India’s healthcare needs life support

By Moin Qazi

Poor quality of health-care services, a lack of public hospitals and a shortage of doctors are common problems in India’s health-care system. India has a laggardly record in its healthcare coverage. In per capita terms, adjusted for purchasing power, the public expenditure on health is $43 a year, compared to $85 in Sri Lanka, $240 in China and $265 in Thailand. European Nations spend ten times more and the United States spends twenty times. According to the Insurance Regulatory and Development Authority (IRDA), the Indian Government’s contribution to health insurance stands at roughly 32 percent, as opposed to 83.5 percent in the United Kingdom. India’s high rate of out-of-pocket expenses for health stems from the fact that 76 percent of Indians do not have any health insurance.

Government’s hand in healthcare

The country has a similarly low ranking on several important health indices.The dwindling budget allocation for public health care in one of the fastest-growing populations of the world starkly reflects the misplaced priorities of the Indian government. These are all really depressing statistics but this year’s budget and health-related policy reforms is some good news.

In a major step towards providing universal health coverage, the government announced a National Health Protection Scheme, popular as Modicare, covering ten crore poor and vulnerable families, which is around 50 crore people- about 40 percent of the population. The healthcare plan would offer up to 500,000 rupees or about $7,860 of coverage per family each year. The move is revolutionary as most people have no health insurance. The healthcare trajectory that Modicare is plotting is to free people from the worry of medical costs. In recent years, the government has also capped prices of critical drugs and medical devices and increased health funding.

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. The plan would require an estimated 110 billion rupees ($1.7 billion) in central and state funding each year. The government estimates the cost of insuring each family under the new scheme at about 1,100 rupees ($17.15). The government could also partly use the funds raised from a newly imposed one percent health cess on taxable incomes, and the health scheme would also benefit from the planned merger of three state-run insurance firms announced.

The problems with public healthcare

The biggest disease burden sits on the bottom pyramid of 500 million people. They don’t have access to reliable diagnosis or proper treatment. If they get diagnosed, they find it hard to get treatment. The government-run hospitals are free for everyone, but the access is difficult, quality is abysmal and corruption is endemic. The government’s health policy does little to prevent poor health in the first place. Unsafe water, poor sanitation, malnutrition, and lack of proper housing undermine health. Poor people are dying from diarrhoea, pneumonia, under-nutrition, malaria tuberculosis and this is the result of poor hygiene and sanitation. Preventive and curative services need to go together.

Experience shows that health programs pay enormous economic dividends. Good quality and affordable health care is the foundation for individuals to lead productive and fulfilling lives and for countries to have strong economies. For every dollar invested in childhood immunization, developing countries realize $44 in economic benefits. But funding is not the only difficulty, says Drèze. “There are issues of management, corruption, accountability, and ethics and so on. The main problem is healthcare is way down the political agenda.”

How insurance affects healthcare

India’s low levels of insurance penetration are a potential damper on its growth, with as many as 70 million people slipping into poverty each year due to sickness. 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 government’s interventions for alleviating poverty. According to the ‘India State-level Disease Burden Report and Technical Paper’, there has been a massive increase in disease burden on account of non-communicable diseases. It also showed a Disability Adjusted Life Years (DALY) rate increase from 1990 to 2016 for diabetes at 80 percent, and ischemic heart disease at 34 percent. DALY measures years of healthy life lost due to premature death and suffering. The average Indian’s life expectancy is about 68 years which definitely shows some improvement as compared with the past, but globally the progress is still dismal.

Around 70 percent 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–not oral rehydration salts and zinc–for diarrhoea in young children). There is also an indiscriminate use of antibiotics. The focus is on the immediate relief of symptoms rather than the most effective treatment. This entails avoidable expenses and also leads to long-term health complications. Several unscrupulous medical professionals have, of late, brought a bad name to a fraternity respected for its humanitarianism, tarnishing the image of doctors and instilling doubt in the minds of common people.

According to WHO’s findings last year the density of doctors at the national level was 79.7 per 100,000 population. This is very poor in order to accommodate the needs of 1.3 billion Indians. In an attempt to find relief from misery and pain, patients are left with little alternative than to turn to the costly state-of-the-art private hospitals.

Healthcare process in villages

The apathy of the government is reflected in a rather poor prognosis for the health system. Primary Health Centres (PHC) in villages are supposed to screen and feed medical cases to specialized hospitals in districts and further on to state-level specialized hospitals, but PHCs do not exist in many villages, only about one for every twenty villages, and wherever present, they are so acutely undermanned that the “access” system is broken at the first mile.

There is a massive network of sub-centres (SCs), primary health centres (PHCs) and community health centres (CHCs) in rural India. SCs serve as the first point of contact between people and public health system. They provide public health services such as immunization, curative care for minor ailments and maternal and child health and nutrition. They employ one male and one female worker with the latter being auxiliary nurse and midwife. The only redeeming feature turns out to be the committed cadre of Auxiliary Nurse Midwife, ANM, at PHCs and their sub-centres along with Accredited Social Health Activists, ASHAs – the frontline health workers.

There are around 734 district hospitals across the country which provide secondary health care. Additionally, there are around 300 other women’s hospitals at the district level which are powerful nodes in India’s healthcare network and can be revitalized to boost the health infrastructure. PHCs serve as referral units for six SCs and have a qualified doctor and four to six beds. CHCs serve as referral units for four PHCs. They have four doctors covering different specialities, 21 paramedical and other staff, 30 beds, an operation theatre and X-ray room. Population norms per centre for the plains are 5,000 for SCs, 30,000 for PHCs and 1,20,000 for CHCs. With 1,56,000 SCs, 25,650 PHCs and 5,624 CHCs as per the Rural Health Statistics, 2017, we are currently within striking distance of these norms.

The system is well designed and should normally deliver good services. However, due to a shortage of resources, the SCs, PHCs and CHCs have had less than adequate infrastructure, overworked staff and inadequate incentives for the staff. It ought to be strengthened with public investment by supplementing their services from the private sector with a contractual mechanism that reviews the performance periodically. India also needs to reform the governance of public healthcare. There must be a transparent and seamless ‘continuum of care’ across the spectrum from village to sub-health centre, primary health care, sub-district hospital and the district hospitals.