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Dr Mukesh Batra
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Despite an incredible growth in recent times, the Indian healthcare sector can be described as a paradoxical one. On the one hand, the country boasts of ‘best in class’ healthcare delivery attracting medical tourists from across the world, while on the other, there is a near absence of accessible and affordable quality healthcare for a large part of its population, especially in the rural areas.
The challenges the sector faces are substantial, from the need to improve infrastructure to ensuring the availability of trained medical professionals and from the necessity of providing health insurance to increasing health awareness amongst people. Let us analyse these challenges first to understand the future roadmap for better healthcare.
Low spending on health: a major reason for severe health consequences
India’s health system failures can be majorly attributed to low levels of health spending. Despite increased spending in recent years, according to the statistics of the World Health Organization (WHO), in 2011, India has spent only 3.9 per cent of gross domestic product (GDP) on the health sector which is the lowest amongst the BRICS (Brazil, Russia, India, China, South Africa) member countries. Even countries like Pakistan and Bangladesh spend more on healthcare than India.
Moreover, amongst the BRIC nations, in 2011, Russia’s out-of-pocket expenses stood highest at 87.9 per cent closely followed by India (86 per cent), China (78.8 per cent), Brazil (57.8 per cent), and South Africa (13.8 per cent). On the other hand, these expenses in developed economies like the US and the UK were comfortably poised at 20.9 per cent and 53.1 per cent respectively.
Low spending on health is the major reason for severe consequences in India where majority of the population lives below the international poverty line and an even greater proportion of the population rely on public health facilities.
Shortage of trained manpower and quality infrastructure
According to a report by the United Nations, 75 per cent of the infrastructure and manpower in India is concentrated in urban areas where only 27 per cent of India’s population lives. The rural population of India is around 716 million people (72 per cent) and yet there is a chronic lack of proper medical facilities for them.
Shortage of doctors and specialists and other support staff is one major reason for poor healthcare delivery in rural India. There is only one doctor per 1,700 citizens in India. The World Health Organization (WHO) stipulates a minimum ratio of 1:1,000. While the Union Health Ministry figures claim that there are about 6-6.5 lakhs doctors available, India would need about four lakhs more by 2020.
While shortage of doctors, nurses and support staff is one problem, their unwillingness to work in the rural areas is another. Though government takes initiative in posting doctors in rural areas, where it fails is in getting it implemented, as doctors take least interest in working in rural conditions.
Furthermore, while China has 30 hospital beds for every 10,000 people, India has only 12. The figures are even more alarming when looking at nurses: there are 98 nurses per 10,000 people in the US, and in India there are only 13. In fact, to reach the WHO’s prescribed standard of 35 beds per 10,000 people, India would need to add six million beds by 2028.
One of the major reasons cited for failure of various government schemes for better healthcare is that to take benefit of government schemes, the beneficiaries have to opt for government hospitals or health centres. However, many hospitals are not equipped to handle critical cases and several hospitals lack even basic facilities. For example, more than half of the primary healthcare centres (PHCs) across the country have less than four beds or a functional operation theatre. Very few PHCs (12 per cent) have an electricity connection and even fewer are equipped to provide emergency obstetric care.
Lack of insurance cover
A widespread lack of health insurance compounds the healthcare challenges that India faces. It has been estimated that only 11 per cent of the population has any form of health insurance coverage. Although some form of health protection is provided by government, the health insurance schemes available to the Indian public are generally basic and inaccessible to most people.
Poor implementation of policies and regulations
The key to success of any regulations and schemes run by the government is implementation. In India, state governments possess primary responsibility for public health and sanitation. As there are several states and diverse health schemes for each state, efficacy of any scheme depends on how successfully it is implemented by different states’ authorities. For eg. Rashtriya Swasthya Bima Yojna (RSBY) may have been exceptionally successful in other states but it seems to have fallen flat on its face in Maharashtra. The Ministry of Labour is contemplating whether to continue the national health insurance scheme in its present form in the state. Thus, implementation plays an important role in success of any scheme.
Poor sanitation and hygiene
According to a survey conducted by Dasra, a strategic philanthropy foundation, over 50 million people in urban India defecate in the open every day. 66 per cent of the women in Delhi slums are verbally abused, 46 per cent are stalked and more than 30 per cent are physically assaulted while accessing toilets. 80 per cent of India’s surface water pollution is on account of sewage alone.
Around 4,861 of 5,161 cities across the country do not have even a partial sewerage network. There is an adverse impact of poor sanitation and hygiene on various aspects including the environment, economics, education and more importantly health.
Diarrhoeal diseases are the primary causes of early childhood mortality. These diseases and several others can be attributed to poor sanitation and inadequate safe drinking water in the country. Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis. India is ranked third highest among countries with the amount of HIV-infected patients.
Lack of awareness and health education
Thus education plays an important role in spreading awareness regarding health, wellness and sanitation. Educating woman in particular is extremely important, as an educated woman can take care of hygiene and sanitary issues of her family.
People also need to be educated enough and aware of the benefits of health services, like institutional delivery and immunisation programmes. Lack of education and awareness has resulted in epidemic of HIV/AIDS which has become one of the greatest social challenges. The Government has mapped out a number of remedial measures for its prevention and treatment, but its outreach and effect has been limited. Sex education and awareness is extremely important in controlling HIV and other related disorders.
India needs to spend more on educational and awareness campaigns. UK spends an estimated two million pounds on its no-smoking campaigns, whereas India spends a dismal amount on such campaigns, which play an important role in health education.
Poor access to medicines
A recent market research showed that only 25 per cent of the Indian population has access to conventional medicine, which is practised mainly in urban areas, where two-thirds of India’s hospitals and health centres are located. Many of the rural population rely on alternative forms of treatment and several do not have access to even basic health amenities.
With so many challenges impeding the growth of Indian healthcare sector, it is evident that though a huge amount of money was spent by the government on various health schemes, they did not perform as expected. To some extent they did help make healthcare accessible to the rural population and eradicate some threatening medical conditions, they failed to deliver intended results, the proof of which is poor physical infrastructure, rising health concerns and inadequate human resources in rural India.
Why did the health schemes fail?
The Government of India launched several programmes to improve the healthcare in the country. Amongst several schemes launched some noteworthy are National Health Mission (NHM), Central Government Health Scheme, National Health Insurance Program and National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. Most of the schemes related to alternative medicine systems had been initiated during the 9th Five year Plan, a majority of which relate to strengthening essential central institutions in medical education, healthcare, quality of medicine and research in complementary medicine.
The failure of many such schemes can be attributed to India’s health policy failures because whatever little is spent on health is not used effectively. It is equally clear that awareness and understanding is a significant challenge when it comes to rolling out large flagship schemes in a manner that the benefits of the scheme reaches those it is meant to.
Over and time again it has been proved that non-transparency; no accountability and bureaucratic failures plague health service delivery in India, particularly in the poor states. Continuous monitoring and audit of health schemes implementation is imperative for better healthcare delivery.
Tough laws on health are required and they need to be effectively implemented. For example, a strong no alcohol and no tobacco policy can help in eradicating health and social concerns due to alcohol abuse and smoking.
Road ahead for better healthcare
Looking at health in its holistic form is important to achieve healthcare objectives. Health problems cannot be addressed in isolation, as they are related to several other factors.
At the individual as well as the national level, it is important to control environment as well as water pollution, as it leads to spread of several threatening health disorders. Mental health awareness can lead to decline in number of suicides due to depression and other reasons. Similarly, physical health awareness and education regarding hygiene and sanitation can help prevent several diseases.
Furthermore, to ensure maximum outcome, policies and regulations should be developed on the basis of the learning of all available systems, the strengths as well as lacunae in existing schemes and needs of individual states. Also, people need to be properly directed towards taking benefit of health schemes.
The policymakers might also analyse how other emerging countries, such as Brazil, have addressed their healthcare needs.
Transforming a healthcare system needs to be driven by consistent political leadership over a sustained period. Creating universal access to medicine has to be the primary focus, with a secondary focus on efficiency or quality.
Government also needs to balance between focusing on increasing funding for programmes such as national insurance, and concentrating on providing better infrastructure, such as more hospitals and clinics, and increasing recruitment. There should be an increased and a far closer partnership between the public and private sectors.
Last but definitely not the least, I would like to suggest adoption of alternative medicine, in particular homoeopathy by the government as a means to reach reliable and cost effective healthcare to rural India. Urban India too needs homoeopathy. Rather than running to separate specialists for each separate part of the body, what we need is holistic healthcare.
What homoeopathy offers is safe, sensible and, cost effective healthcare. For eg., Union Cabinet recently sanctioned Rs 4000 crores for the treatment of Japanese encephalitis in Bihar and UP. On the other hand, during an outbreak of viral encephalitis few years back in Andhra Pradesh, one million people were given doses of the homoeopathy remedy Belladona and not a single person died in the epidemic. Moreover, the cost of treating them was just under Rs 10 lakhs.
A little known fact is that homoeopathic medicine developed its popularity in the US as well as in Europe because of its success in treating the infectious epidemics that raged during the 19th century, much before antibiotics were developed. In 1849, the homoeopaths of Cincinnati claimed that in over a 1000 cases of cholera treated with homoeopathy, only three per cent of the patients died. To substantiate their results they even printed in a newspaper the names and addresses of patients who died or who survived.
The success of treating yellow fever with homoeopathy was so impressive that a report from the US Government’s Board of Experts included several homoeopathic medicines, despite the fact that the Board of Experts had many conventional physicians who despised homoeopathy.
Conclusively, the objective of medical practitioners must not be to profit from disease. Ultimately our attitude towards medicine is defined by what we consider our goal – do we want more doctors, more medicines and more hospitals or simply less disease? In my opinion, this is one case where less is definitely more.