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India’s health check: It’s bad news

Public health system. Attribution: <a title="Hellfire20 [Public domain], from Wikimedia Commons" href=""><img width="512" alt="AIIMS slum" src=""></a>
Doctors of the All India Institute of Medical Sciences (AIIMS) educate the community about mosquito-borne diseases in a Delhi slum.
In August 2016, a tribal man in Odisha walked ten kilometres from the hospital where his wife died. He carried her body with him – in the presence, no less, of his twelve-year-old daughter. He was forced to do so because the state hospital could not provide an ambulance. 

The incident served as a graphic and visceral reminder of the challenges many Indians face in availing treatment from the country’s public health system. It highlighted issues such as shortages of doctors, nurses and even hospitals.

It has been almost two years since. In that time, has the situation really improved?

India still experiences massive shortages of personnel and resources. This is grimly reflected in the country’s latest health check – the National Health Profile (NHP) for 2018. 

The NHP reveals, among other statistics, that India has just one government doctor for every 11,082 citizens. This gap is eleven times more than what the World Health Organization (WHO) recommends. The WHO says there should be one doctor for every thousand people. However, just ten lakh doctors service India’s 1.3 billion-plus population. To meet WHO standards, India would need to recruit an additional five lakh allopathic physicians.

Public health system, India. <em><strong>Nagarjuna Hospital in Vijayawada, Andhra Pradesh. India is home to 710,761 beds across 23,582 hospitals - servicing a 1.3 billion-plus population. </strong></em>
Nagarjuna Hospital in Vijayawada, Andhra Pradesh. India is home to 710,761 beds across 23,582 hospitals – servicing a 1.3 billion-plus population. 

A public health system in crisis?

The shortage of doctors is just one factor of many ailing India’s public health system.

Severe shortfalls exist in public health infrastructure. In total, India has 710,761 beds across 23,582 hospitals. Urban areas account for 431,173 of India’s hospital beds. However, they account just 3,772 of the country’s hospitals. Rural areas – which are home to almost 20,000 hospitals – have just 279,588 beds.

This disparity reflects broader inequality within India’s public health system. As reported by Health Issues India earlier this year, the improvements made by India on its health indicators are tempered by the unevenness of healthcare systems between states.

The 2015 Healthcare Access and Quality (HAQ) Index found a 30.8 point difference between the scores of Goa – India’s highest ranked state – and Assam – and its lowest ranked state. In 1990, the difference between the highest and lowest scoring states stood at just 23.4 points. This indicated that healthcare is improving in India at the national level. However, it is also becoming more unequal at the state level.

Inadequate healthcare infrastructure and staffing shortages fuel this inequality. The NHP highlights this.

India’s poorer states tend to suffer greater staffing shortages. In Bihar, for example, there is one doctor for every 28,391 people. In Delhi, there is one doctor for every 2,203 patients.

The polio vaccine being administered in India, which has been declared polio-free since 2014. However, infrastructural problems within India’s public health system and inequality between its states has resulted in many disease eradication targets since being missed.

Frustrated by inequality

This inequality frustrates the ability of states to manage their disease burden. A Lancet study published last year observed significant disparities between India’s states in terms of their epidemiological transition level (ETL).

A state’s ETL refers to ‘the ratio of DALYs [disability adjusted life years] from communicable, maternal, neonatal and nutritional diseases (CMNNDs) to those from noncommunicable diseases (NCDs) and injuries combined.’  This gulf was as wide as 24 years between some states. According to the study’s leader, Professor Lalit Dandona, “this has resulted in wide inequalities in the magnitude and progress against various diseases and their causes.”

This frustrated progress is discernible in missed targets for eliminating diseases such as kala-azar. In addition, India continues to experience a high prevalence of communicable conditions such as tuberculosis and malaria. The Centre has pledged to eliminate both diseases, by 2025 and 2030 respectively. The likelihood of realising these goals has polarised opinion among India’s medical and scientific communities.

A dual burden of disease

Noncommunicable diseases (NCDs) are increasing sharply in prevalence in India. They now account for the majority of deaths in India and, according to the WHO, ‘pose one of the biggest threats to health and development globally.’  This is already taking shape in India, which could lose as much as 6.2 trillion USD to NCDs by 2030.

Public hospitals will have to cope with increased numbers of patients in the coming years. Many of these will require prolonged treatment for chronic conditions. As the National Health Profile shows, public hospitals are ill-equipped to meet such increased demand. 

Many patients turn to private healthcare providers for treatment. This leads to them paying their health expenditures out-of-pocket. Many are left impoverished and in debt as a result. As many as 55 million Indians are pushed into poverty every year by healthcare costs.

Prime Minister Narendra Modi, whose flagship National Health Protection Scheme seeks to provide health insurance coverage to around 100 million economically vulnerable households. Could this help make healthcare in India more affordable and accessible?

The driving force: Low spend on health?

The manifold shortfalls of India’s public health system stem from a multiplicity of complex causes. Arguably the most prominent of these is India’s chronically low public health spending.

The annual figure is Rs 1,112 per capita, according to the NHP. This equates to three rupees per person per day. As IndiaSpend points out this is “less than the cost of a single consultation at the country’s top private hospitals.”

India’s health spending equates to 1.02 percent of its gross domestic product (GDP). This is a lower proportion than that spent by many countries at similar or lower levels of economic development. India spends less on health than Sri Lanka, Bhutan and the Maldives.

Modicare: A potential solution?

The Centre has pledged to raise the country’s allocation towards healthcare. The Budget earlier this year included an eleven percent increase in the healthcare budget. However, this was significantly less than what India’s Ministry of Health and Family Welfare (MoHFW) requested.

Health Minister J. P. Nadda sought a “bare minimum” of almost 10 billion USD to finance India’s public health system in the 2018-19 period. The Centre allocated 8.2 billion USD instead. This came despite the requests for additional funds and the Centre’s target of raising public health spending to 2.5 percent of GDP by 2025.

The allocation provoked the ire of MoHFW officials. One of the officials, speaking to Reuters anonymously, asked “What’s the point of having a GDP target? With this funding, it still looks like a herculean task.”

The National Health Protection Scheme (NHPS) could improve the accessibility and affordability of healthcare in India. Also known as Ayushman Bharat or ‘Modicare’, the NHPS aims to provide health insurance coverage to around 500 million Indians. However, rollout of the NHPS will have to overcome shortages of medical staff and inadequate healthcare infrastructure. As such, unless improvements and investments are made into the public health system, India’s poorest citizens will likely continue to bear the brunt of the consequences.

The National Health Profile can be accessed here.

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