Though India may be the world’s healthcare provider, the healthcare system within India is abysmal due to lack of infrastructure and medical professionals in public hospitals and out-of-pocket spending in private sector. To improve the situation, both the sectors need to work together.
Last month, a daily newspaper reported a tragedy that struck Kalawati and Surinder Pal in the small village of Dharnai in the eastern state of Bihar. The poor couple’s only child Reena fell into a hot oil cauldron while playing near her home. The eight-year-old suffered severe burns and was rushed to the nearby primary health centre, where the only doctor was absent. The staff applied first aid and referred her to a government hospital, about 40 km away, but there was no ambulance to take her to the hospital. Somehow, her parents took her in a private vehicle and they reached there three hours after the accident. The same evening, she was sent to another hospital in the state capital, Patna, nearly 100 km away. The child could not survive these frequent transfers and died the next morning.
Few weeks ago, Anil Chough, a service industry professional based in New Delhi met a similar fate despite being in the capital. By the time, he was rushed to Safdarjung Hospital, it was too late to save the 33-year-old. Unlike Reena, Anil was not living in some small village of Bihar, he was in India’s capital.
In both cases, the problem was the scarcity of doctors and lack of health infrastructure. Their lives couldn’t be saved because they could not get the right treatment at the right time.
Despite the implementation of National Rural Health Mission in 2005, the public health system in the country continues to face challenges. A number of government hospitals, meant to cater to the poorer sections of the society, remain devoid of the basic infrastructure and amenities.
According to a study ‘2015 Healthcare Outlook India’ by consultancy firm, Deloitte, the statistics for India’s health infrastructure are below that of other large countries. The US has one bed for every 350 patients while the ratio for Japan is one for 85. In contrast, India has one bed for every 1,050 patients. To match bed availability to the standards of more developed nations, India needs to add 100,000 beds this decade, at an investment of USD50 billion.
The shortage of qualified medical professionals is one of the key challenges facing the Indian health care industry. India’s ratio of 0.7 doctors and 1.5 nurses per 1,000 people is dramatically lower than the WHO average of 2.5 doctors and nurses per 1,000 people. Furthermore, there is an acute shortage of paramedical and administrative professionals. The situation is aggravated by the concentration of medical professionals in urban areas, which have only 30 per cent of India’s population. Many patients, especially those living in rural and semi urban areas, still depend upon unqualified practitioners.
The industry needs an additional 1.54 million doctors and 2.4 million nurses to match the global average.
Though public spending on health needs to increase dramatically, Finance Minister Arun Jaitley barely mentioned health in his budget. Government spending on health is 1.2 per cent of gross domestic product, which forces the poor as well as the rich to seek private care. Add public and private together, and the total spent is still only four per cent of GDP, one of the world’s lowest. “The failure to reach minimum levels of public health expenditure remains the single most important constraint to attaining desired health outcomes,” the finance ministry admits in the Economic Survey.
The vision for the plan period of 2012-2017 is to achieve acceptable standards of health care for the Indian populace. However, India still doesn’t have a central regulatory authority for its healthcare sector. In 2011, a high-level expert group constituted by the Planning Commission of India suggested setting up a National Health Regulatory and Development Authority to monitor both government and private-sector health care providers. The group has also proposed to establish a National Health and Medical Facilities Accreditation Authority (NHMFA) for defining healthcare facility standards.
According to a recent report in Indian Express, the total health spend in the first three years of the 12th Plan has been INR 700 billion, way below the INR 2,680 billion allocation given in the Plan document. In addition, the shortfall of health centres has put immense pressure on the infrastructure. A rural sub-centre is supposed to cater to a population of 3,000-5,000. In India, 152,326 such centres would be responsible for 5,473 people each, as per the 2011 population census. A primary health centre (PHC) is supposed to cover 20,000-30,000 but the average coverage of the 25,020 PHCs in 2014 stood at 33,323. A Community Health Centre (CHC) is supposed to cover 80,000-120,000; India’s 5,363 provide services to an average 155,463. During the entire 12th Plan, 3,960 new sub-centres, 971 PHCs and 530 CHCs came up. The current shortfall is 36,346, 6,700 and 2,350 respectively.
“One way to solve this problem is to address the infrastructure issue by standardising diagnostic procedures, building rural clinics, and developing streamlined health IT systems, and improving efficiency. The need for skilled medical graduates continues to grow, especially in rural areas which fail to attract new graduates because of financial reasons. A sizeable percentage of the graduates also go abroad to pursue higher studies and employment,” a Bangalore-based healthcare management consultant says.
Mounting health bills
To serve the increasing number of patients who are seeking an alternative to India’s low quality public hospitals, private hospitals like Apollo, Fortis, Medanta are growing rapidly. An increasing proportion of people use private healthcare facilities, rather than public, though the costs in the latter are much more affordable. According to a study conducted by IMS Institute of Healthcare Informatics, there has been a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services. About 70 per cent in urban areas had chosen the private sector over the public, and in rural areas, nearly 50 per cent had put their faith in the private sector due to the facilities, quality of service, no waiting periods and availability of doctors, medicine and infrastructure. This has led to a huge spending and private sector hospitals now account for 72 per cent of expenses by patients. Shalini Joshi, whose mother underwent bypass surgery in a super specialty hospital in Delhi, states, “Hospital charges for procedures are not transparent. Hardly any hospitals have standardised packages for high-cost procedures, like bypass surgeries, which include all costs from start to finish. A bypass in a five-star hospital costs INR 400,000 in contrast to INR 150,000 in a smaller hospital. We had no choice because it was a matter of quality of the service.”
The Bangalore-based healthcare consultant informed that the high out-of-pocket expenditure, which is around 70 per cent, means that most Indian patients pay for their hospital visits and doctors’ appointments with straight up cash after care with no payment arrangements. According to the World Bank and National Commission’s report on Macroeconomics, only five per cent of Indians are covered by health insurance policies. “Several large companies also operate employee health policies. While health insurance penetration in India is increasing, it has been proposed that better accessibility to quality health care could be made possible by extending coverage to all employees in the private sector and by offering inexpensive health plans for the poor. This way, people can have full coverage for themselves, their families and elders,” says Charu Sehgal, Senior Director – Life Sciences and Healthcare Consulting at Deloitte India.
“One way to increase India’s health care funding and access is through innovative public-private partnerships. While an appropriate model for partnerships at the primary, secondary, and tertiary levels still remains a distant dream, participation by the government and private sector will help create a blueprint for such partnerships to create an infrastructure for the future. One such example in India is SRL (Diagnostic), which has partnered with the Himachal Pradesh State Government to set up and operate 24 labs in the large state-run hospitals in various districts, thereby bringing superior diagnostics services to the doorstep of people in remote areas,” she adds.
AIIMS – A weak model
Even in the budget 2015-16, the government allocated the highest amount to New Delhi-based All India Institute of Medical Sciences (AIIMS), considered to be India’s premiere public sector hospital, about INR 14.7 billion as against last year’s INR 13.65 billion. The Plan allocation for the institute is INR 5.5 billion and Non- Plan INR 9.2 billion. “A considerable amount of funds will be utilised for the residential accommodation of the faculty staff. For other projects like expansion of the Trauma Centre, separate funds were allocated earlier. The other major chunk of the budget is for paying salaries to the staff,” said Dr M C Misra, Director, AIIMS. In the Budget, the Centre has allocated INR 331.5 billion to set up AIIMS or AIIMSlike institutes in five other states – Jammu and Kashmir, Himachal Pradesh, Assam, Tamil Nadu and Bihar.
Though the government needs to replicate it into five other states, there is a need to give adequate attention to the current form. Patients complain of long queues, unending waits and tiresome paperwork. Thousands of patients travel from distant parts of the country here. The main reason is the near-absence of high quality healthcare in smaller cities and towns. Shweta Shubhdarshini, a dermatology resident at AIIMS Delhi, said to a daily: “There are about five doctors for every 28 beds, though this number varies across departments. But the situation in the OPD wing is out of control,” she says. “Patients wait for hours just to get a token to see a doctor. They often stand in wrong queues and realise that they have to start the process all over again.” Then, cleanliness is not something that AIIMS can score on.
However, for the government, this is clearly a model that is working well. More AIIMS-quality hospitals are a noble idea. But that expansion needs to be done in a planned way.