Healthcare is the budget’s biggest winner?but the health service is still failing the poor

By Moin Qazi

India’s economy is soaring but its healthcare system remains an Achilles’ heel. For millions of people, the high cost of treating illness continues to undermine their economic progress. This is largely on account of India’s abysmal and chaotic healthcare system. India now ranks close to the bottom of the pile in international rankings on most health indices. Things had reached such a desperate state that the government can only afford to ignore the state of healthcare in the country at great peril. The government’s latest budget is ample proof that it now means business as far as healthcare reforms are concerned.

Budget contributions

The budget announced a National Health Protection Scheme that will cover over 10 crore poor and vulnerable families, which is around 50 crore people, and would make it the world’s biggest state funded healthcare programme in the world. It will provide each family with a yearly coverage of up to Rs 5 lakh for secondary and tertiary-care hospitalisation. Comprehensive health care, including for non-communicable diseases and maternal and child health services, and free essential drugs and diagnostic services, are to be provided at health centres. These two plans are part of the ‘Ayushman Bharat’ scheme to address health holistically, in the primary, secondary and tertiary care systems.

Illnesses are a severe risk and can shave off most of the hard-earned savings in low income communities. They are the primary route to bankruptcy. The Ministry of Health has found that a quarter of all people hospitalised were driven to penury by their hospital costs—and that does not include the cost of missed work—even as the country struggles to adapt a rickety system to handle a wave of ailing people who cannot afford healthcare. The government has acknowledged in the National Health Policy (2017) that every year 6.3 crore people fall into poverty due to health-related expenditure, which is partially undoing the achievements of the government’s poverty alleviation strategies.

The problem in numbers

Universal healthcare in India remains a distant reality, because healthcare still continues to rank very low on the government’s priority list. Yet no one wants to talk about this elephant in the room. There are presently three popular models of universal health coverage. While facilities in Indian metros are competing with the world’s best, the situation beyond the urban conglomerations is quite distressing. The demand and supply in healthcare services still shows a significant disparity in urban and rural areas. Here is a snapshot of the challenges:

• 30% of Indians do not have access to primary healthcare facilities.
• About 39 million Indians fall below the poverty line each year because of healthcare expenses.
• Around 30% of people in rural India do not visit hospitals due to fear of the expenses.
• 47% of healthcare needs in rural India and 31% of the need in urban areas are financed by loans or the one-off sale of assets
• About 70% of Indians spend all their income on healthcare and drugs.
• Out-of-pocket spending on healthcare in India—which makes up 69% of the total expenditure on health—is among the highest in the world, and is much more than the rates in Thailand (25%), China (44%), and Sri Lanka (55%).
• Nearly 75% of dispensaries, 60% of hospitals and 80% of doctors are located in urban centres.

A lack of doctors

Nearly 30,000 doctors, 20,000 dentists and 45,000 nurses graduate from medical colleges across India every year. However, the doctor-to-patient ratio in India is only six for every 10,000 people. This is far below the rate in Australia (1 for every 249), the UK (5 for every 1,665) and the US (9 for every 548). The global ratio stands at 15 doctors for every 10,000 people. Across India, there is one government hospital bed for 1,833 people, while one government hospital serves 61,000 people.

The government’s apathy is reflected in the rather poor prognosis for the health system. Primary health centres (PHC) in villages are supposed to screen and feed medical cases to specialised hospitals in districts and further on to state-level specialised hospitals. However, PHCs do not exist in many villages (about 1 for every 20 villages), and where present are so acutely undermanned that ‘access’ to the system is broken at the most local level. Moreover, as many as 18% of PHCs are entirely without doctors. This impacts not only the filtering of patients into the system but also deeply impairs prevention and early detection, which is a must if costs in the whole system are to be contained. The only redeeming feature is the committed cadre of the Auxiliary Nurse Midwives (ANM) at PHCs and their sub-centres and accredited social health activists (ASHAs).

India’s healthcare facilities have grown significantly in terms of numbers and expertise, but this growth has largely been in the private sector. The government’s failure to deliver quality care has led to a rapid expansion of private hospitals, which today account for 93% of all hospitals (up from 8% in 1947), 64% of all beds, and 80-85% of all doctors. But mass access continues to remain a challenge. For the private sector, affordability in Tier 3 cities and rural areas is a critical limiting factor to further expansion.

Growth in the private sector

Around 70% of healthcare in India is provided through the private sector, comprising both legally trained and illegal doctors. People perceive that quality is better at informal providers, even though the latter often mishandle common ailments—for example, prescribing antibiotics rather than oral rehydration salts and zinc for diarrhoea in young children. There is also an indiscriminate use of antibiotics. The focus is put on the immediate relief of symptoms rather than the most effective treatment. This entails avoidable expenses and also leads to long-term health complications.

There are 734 district hospitals across the country which provide secondary healthcare facilities. In addition, there are around 300 other hospitals, such as women’s hospitals, at the district level. These are powerful nodes in India’s healthcare network and can be revitalised and ramped to boost the health infrastructure. The government ought to strengthen them with public investment and supplement their services from the private sector.

Future reforms

India needs to reform the governance and management systems of its health care system. The approach to service delivery has to establish a ‘continuum of care’ from village to sub-health centre to primary health care, sub-district hospital and the district hospitals A system of universal health coverage should pay for health services from a pooled fund, consisting of tax-fund revenues like employer-provided insurance, government-subsidised social insurance programmes like RSBY (Rashtriya Swasthya Bima Yojana) and some of the Arogyashree programmes. And a single-payer system at the state level should purchase services from private healthcare providers.

The government has demonstrated that it wants to address the issue with urgency.  The direction of travel is right but must be accelerated. For reforms to be successful, hard-coded timelines and needed and those who are tasked with administration must be held accountable. Now is the time for the policy experts to collaborate with professional doctors and use their ingenuity to find solutions which are affordable and practical.

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