INDIA UNDER THE LENS: How far are we from Equitable Access to Healthcare?
Similar to any other element of life, health care sustains the human race and should always be made affordable, and more importantly accessible for the masses. Health care should be available for all — when they need it and where they need it, without any discrimination and interruptions. Regarding India, easily accessible and affordable health care for all in the public sector can reduce the dependence of the public on private healthcare institutions, thus reducing the cost of health care for the general public. However, the present state of management in the public healthcare sector is rather asymmetrical and ill-managed, leaving no choice for the masses but to shed out a high out-of-pocket expenditure for treatment in private institutions. But as India struggles with its public health care, only one question arises.
How far are we from equitable access to health care?
Serving a mammoth population of almost 1.3 billion people, India’s health care system is far from unrestricted access, a concept which birthed with the system itself. Even though the health care system is considerably vast when compared to the private healthcare sector, but the disparities across a number of parameters is where it is lacking. These disparities are the reason the general populace has had a shift of focus from the public health care system to private in the past few decades.
Where Are We?
The report ‘Global Burden of Disease Study’ published in May 2018 ranked India 145th out of 195 counties on the basis of health care access. Even though the results show that India has improved over the past decades, the results are still quite dismal. While the list featured Iceland, Norway, Netherlands and Luxembourg as the top countries, the countries with the lowest scores were Central African Republic, Somalia, Guinea-Bissau, Chad and Afghanistan. Interestingly, the likes of Bhutan, Nepal, Sri Lanka and Bangladesh outranked India. The study highlighted the fact that India’s health care system was quite weak in handling life-threatening ailments such as tuberculosis, testicular cancer, stroke, colon cancer, rheumatic heart diseases and chronic kidney failures among others (Source: India Times, 2018).
While the figures are quite disappointing, the 13th ‘National Health Profile’ report by the Central Bureau of Health Intelligence (CBHI) paints an even clearer picture of the dismal state of public healthcare in India. The report states that India has a measly 1.04 million qualified doctors serving a population of 1.3 billion.
Moreover, roughly 11% of these doctors work in the public sector — which takes it to a ratio of 1 government allopathic doctor for just about 11,082 people.
In Uttar Pradesh for example, there are 10,754 allopathic doctors for a population of over 21 crores, taking the ratio of doctor to patients to 1:19962. In Bihar on the other hand, things are even worse as the ratio worsens to 1 doctor per 28391 people. Similar stories are seen in Maharashtra, Jharkhand and Chandigarh as one doctor is available for 16696, 18518 and 12624 respectively (Source: CBHI, 2018). As per WHO standards, one doctor should be available for every 1,000 people, which is a distant dream in case of India.
The public health care system also falls short when it comes to infrastructure. As of 2017, there are 23,582 government hospitals in the country with 710,761 beds. On an average, each bed serves a population of 1844. The numbers worsen in multiple states, where the ratio dips to frightening levels.
In Bihar for example; one government hospital bed is available for over 8600 people, the worst in the country.
In other states such as Haryana, Andhra Pradesh, Uttar Pradesh, Maharashtra and Rajasthan, each government bed serves 2496, 3819, 2904, 2306 and 2291 people respectively. These disparities regarding workforce and infrastructure reflect the asymmetry in public healthcare sector, which hinders equitable access to health care (Source: CBHI, 2018).
But on the other hand, it is essential to understand that public healthcare in India works upon a referral system. It begins with the basic sub-centres, moving up towards the primary health centres (PHC), community health centres (CHC), general hospitals, government-affiliated medical colleges and at the top of the chain is All India Institute of Medical Sciences (AIIMS).
While India has seven functioning AIIMS institutes currently, the current government has planned to open as many as 22 AIIMS institutions across the country, which will be constructed in Bihar, Punjab and Assam among other states (Source: Times of India, 2018). While this is a commendable step, many believe that India does not have a massive lack of doctors, but the shortage of doctors in the public sector. Even though such initiatives will augment capacity building, there still exists the need for a bridge to help them choose to work in government hospitals.
The Divide
Even though India faces a dearth of doctors and infrastructure in public health care, the sector is even more wounded when it comes to the divide between the rural and urban populace. The ‘Report on Healthcare Access Initiatives’ by Klynveld Peat Marwick Goerdeler (KPMG) in association with the Organisation of Pharmaceutical Producers of India (OPPI) clearly highlights the divide. According to the report, over 80% of doctors and 75% of dispensaries are located in urban areas, while rural areas hold the rest. It is indeed thought-provoking as rural India holds just about 72% of the population of the country. Moreover, only 35% of people in rural areas have access to in-patient departments within a radius of 5 km, while just over 65% people can access an OPD (Source: KPMG, 2016). The disproportionate figures are the primary reason for an increasing out-of-pocket cost of health care for people in India, especially in the rural areas.
Healthcare Expenditure
Out-of-pocket expenditure can be termed as the payments made to health care service providers while getting health assistance. As the public health care system becomes more accessible and affordable, the out-of-pocket expenditure of a country decreases. Low out-of-pocket expenditure is a sign of a robust government health care system. In India however, the out-of-pocket expenditure has been increasing over the past few years, showing an increased dependency on the private healthcare sector.
According to a report titled ‘Health and Morbidity in India’, the highest out-of-pocket expenditure was recorded in Kerala, with private spending of 84%. What is ironic is the fact that the State Government spends a significant amount on health care when compared to other states. While the Kerala government has a per capita expenditure of INR 1,070, Bihar has INR 348, the lowest in India. The state of Himachal Pradesh showed the maximum per capita expenditure at INR 1,830 (Source: Brookings India, 2016).
According to a press release by the Ministry of Health and Family Welfare, the average medical expenditure per hospitalisation has increased dramatically in the past few years. For urban areas, the cost had increased from INR 8,851 in 2004 to INR 26,455 in 2014. On the other hand, the rural population had to shed out INR 5,965 per hospitalisation in 2004, and INR 16,956 in 2014 (Source: Press Information Bureau, 2017). The increase can be attributed to the move from public to private health care. The private healthcare industry has become such a booming venture that it has helped India become one of the top countries for medical tourism. It is estimated that over 500,000 tourists come to India every year for medical purposes (Source: Federation of Indian Chambers of Commerce and Industry, 2017). This is because India offers affordable pricing for various major health care procedures. For example, a heart bypass surgery costs nearly $123,000 in the USA, $26,000 in South Korea, $14,800 in Colombia but only $7,900 in India (prices subjective to health care centres). Putting things into perspective, the surgery costs just over 15 times in the USA, in comparison with India. Similar price differences are evident in other major health procedures such as Heart Valve Replacement, Knee Replacement and Dental Implant, turning India into a medical tourism destination (Source: Medical Tourism, 2018).
The Case of Corruption
In August 2017, an incident in Fortis Hospital, Gurugram, Haryana rocked the nation. In an extreme turn of events, family members of a girl hospitalised with dengue shock syndrome received a bill with a whopping amount of INR 16 lakh. The incident was not taken lightly by the public, and the hospital had to face the ire of the masses. The government launched a probe only to find a number of malpractices going on. Following the findings, the license of the blood bank was revoked, along with its license to sell drugs. This incident was one of many episodes that have been unearthed in the recent past, showing the malpractices done by the private healthcare institutions to skim off money from its patients.
These malpractices can be attributed to the fact that the healthcare sector which started as a social service, has now turned to a money-making industry, paving the way for corruption. Corruption in the medical industry is now persistent at all levels, ranging from the grants to open medical institutions, admissions and even health care. Hundreds of cases, both big and small have come to light which put doctors under the radar, as they continue to make an unregulated and illegitimate profit from gullible customers.
Doctors have often been caught prescribing expensive medicine with questionable quality to maximise their profits as many companies offer these doctors kickbacks to prescribe their drugs.
Moreover, a large number of private doctors recommend unnecessary diagnostic tests to be undertaken from their partner labs, which provides them with a cut on the final bill of the patient.
What Does the Future Hold?
To guarantee minimum corruption and a set standard of services by healthcare establishments, there have been some initiatives by the current and previous governments. The Clinical Establishments Act (CEA) and the Ayushman Bharat Yojana are two of the biggest and key initiatives in the past decade. The CEA was enacted in 2010 in a bid to put a halt to immoral practices that went on in private instructions while reshuffling the healthcare services in India to streamline the sector. The act was passed by the Parliament in 2012 and included all the clinical establishments in the country, except those run by armed forces. But even though over six years have passed since the act was enacted, there are only a handful of states which have implemented the act, and it remains mostly on paper. Even though the Union Health Ministry is constantly urging all states to implement the act, not much seems to change and private institutions continue with their malpractices.
On the other end of the spectrum is the Ayushman Bharat Yojna, announced by the current government. The programme contains two initiatives, namely the National Health Policy and the National Health Protection Mission. The National Health Policy’s vision is to establish wellness centres to create a focal point in the public health care system. To promote equitable and affordable health care for all, the policy proposes free emergency care services in all government hospitals, along with free drugs and free diagnostics. Moreover, the policy even suggests that the health budget of the country should be at least 2.5% of the GDP of the country. But the budget allocation for 2018/19 sketched a different scenario.
The health budget was increased from INR 50,079.6 crore in 2017/18 to INR 52,800 crore for 2018/19, marking an increase of just 5%, rather than the required 20% year-on-year to stay in tandem with the policy.
But the budget allocated INR 1,200 crore for the wellness centres, which the government believe will bring health care closer to the homes of people (Source: Business Today, 2018).
The second initiative is the National Health Protection Mission, which comes into effect to provide a health insurance cover of INR 5 lakh to every family below the poverty line (BPL), every year. The scheme targets just about ten crore BPL families and will provide for almost all mid-level and low-level health procedures. This programme is the largest health care programme in the world if implemented correctly, and on 23rd September 2018, Prime Minister Shri Narendra Modi launched the scheme and dedicated it to the wellness of the nation (Source: Times of India, 2018). But as the scheme unfolds and the public benefits, many experts are questioning about the capital requirement of the scheme and how the government plans to allocate such a high value of funds every year.
For instance, to cover ten crore families with an insurance cover of INR 5 lakh crore every year, a sum of INR 50 lakh crore is required.
Even though the scheme looks pitch perfect on paper, it will take some time to quantify its benefits to the common man.
Conclusion
Taking everything into account, India’s healthcare sector is at a critical point in time, where the need for equal and affordable health care is important. When many new states are in the process to implement the CEA, the nation’s health care can only be made robust if all the states and UTs implement the act to work together. Only if all the states and respective governments work together to eradicate the malpractices done by the private healthcare industry, and solidify the public health sector, then only we can achieve what we call equal access to health care.
