What ails India’s healthcare system

The right to good health is of paramount importance. It’s sad that we, the world’s most populous democracy, can’t guarantee that to our citizens. India has the most inequitable healthcare scenario feasible. On one hand, our country is fast becoming the hub for medical tourism where people from other countries flock to get good quality, affordable medical treatment.  On the other most of these facilities are simply not available to the natives.

So how did the situation get so bad?

Healthcare was never a top priority after independence. The initial onus was on agriculture, infrastructure and military. This led to social sectors like health and education being neglected. In fact, it wasn’t until 1982-83 that the National Health Policy was endorsed by parliament.  Most of the services provided thereon were preventive (vaccinations against various ailments) and very few curative healthcare services were provided. Preventive services were mostly provided by the private sector. Medical education too was neglected, a case in point being that there are no superlative medical institution brands like the IITs or the IIMs.

Here are some of the major issues we need to tackle if we hope to one day become the nation that our freedom fighters and forefathers thought we’d become:

1. Woeful rural healthcare

Mahatma Gandhi had a dream that India would be a land of self-sustaining villages.  ‘The true India is to be found not in its few cities, but in its seven hundred thousand villages. If the villages perish, India will perish too.’ The health scenario in rural India would’ve caused him great pain.  The basic problem in this case is the lack of resources – human or otherwise. Initiatives like the National Rural Health Mission (NRHM) or a compulsory Bachelor of Rural Health Care (BRHC) course haven’t made much headway.

Here are some of the stark facts about the lives of our rural brethren:

• 50% of all villagers have no access to healthcare providers.
• 37% are chronically starved
• 10% of all babies die before their first birthday
• 50% of all babies are likely to be permanently stunted due to lack of proper nutrition
• 33% people have no access to toilets, while 50% defecate in the open

Source:  Indiafacts.in and India Development gateway

2. Women’s and Children’s Health

According to a poll by Thomson Reuters, India is the worst place for women among G20 nations. Female foeticide, unequal rights, dowry killings, poor maternal health and lack of sexual education are just some of the reasons for the same. Here are  few stark realities about women in India:

• 12 million girls were aborted in the last three decades in India
• Child marriage has a domino effect since this also leads to lowered education levels and lower levels of awareness
• 45% Indian women are married before they turn 18. This results in early pregnancies, higher morbidity and mortality rates.
• A mother dies every ten minutes in India

The children’s healthcare situation is equally bad. While some diseases have been controlled to a large extent others continue to wreak havoc.

• Over 1.25 million children die annually in India.
• 48% of all children have stunted growth due to malnutrition.

Source: Lancet 2011 and Save the Children

• Only 7% children in India receive the minimum acceptable diet set by the WHO. The other countries we share such a dubious honour with are sub-Saharan African countries and Pakistan.

Country	Pakistan	Nigeria	Congo	Mali
% of children who receive minimum acceptable diet	4%	3%	4%	7%

Source: Save the Children

3. Low government spending, high out-of-pocket expenses and lack of insurance

 As we mentioned before, the government spending on healthcare is grossly inadequate. It spends about 1% of the nation’s GDP on healthcare. This has led to very high out-of-pocket (OOP) expenditure for the general public. This means that 78% of all spends on healthcare are paid by the people and 72% of this is on drugs alone. Estimates suggest that 39 million people are forced into poverty because of medical expenditure. Here’s a breakdown of total % of GDP spent on healthcare, percentage spent by individuals and per capita spent by the governments of various developed, developing and under-developed countries.

Country	Total % of GDP spent on healthcare	Private Expenditure %	Per capita spent on healthcare (US $)	Per capita government spends on healthcare (US$)
India	4.1	70.8	132	39
USA	17.9	46.9	8362	4437
UK	9.6	16.1	3480	2919
South Africa	8.9	55.9	935	412
China	5.1	46.4	379	203
Brazil	9	53	1028	483
Pakistan	2.2	61.5	59	23
Nigeria	5.1	62.1	121	46
Russia	5.1	37.9	998	620

Source: WHO

As we can see we’re nowhere near the top bracket US or UK. We don’t even spend anything close to what our BRICS (Brazil, Russian, India, China and South Africa) counterparts spend. In fact, our spends are even lower than a country like Nigeria’s.

Because of the centre’s negligent attitude, most of the resources lie with the private sector. It currently has 80% of all doctors, 26% of nurses, 49% of beds and 78% of ambulatory services and 60% of in-patient care. It seems audacious not to exploit those resources. To this effect, the Planning Commission had suggested that the public sector tie-up with the private sector to improve the country’s healthcare scenario. However, the proposal was vehemently opposed by health activists who felt that it would ‘corporatize’ healthcare.

Another big issue is lack of medical insurance. Only 243 million of India’s 1.2 billion citizens are covered under Govt health insurance schemes and a total of 300 million (25% of total population) don’t have health insurance at all.

Source: Planning Commission Health Division report for the 12th Five Year Plan

4. Medical Education and Healthcare Human Resources

India has some top quality medical institutes which provide quality education and a huge number of medical professionals are added to the task-force every year. While that is indeed a huge number, most of them are based in urban centres resulting in deficit of healthcare services in rural and semi-urban India.

Health HR	Doctors	Specialists	AYUSH*	Nurses	ANM**	Pharmacists	Total
Numbers graduating annually	30,000	18,000	30,000	54,000	15,000	36,000	163,000

*Practitioners of Ayurveda, Yoga, Unani, Siddha and Homeopathy

**Auxiliary nurse middle-wife (for childbirth)

Some stats to ponder about:

•  Urban India has four times more doctors and three times more nurses than rural India.
• Only 193 of India’s 640 districts have medical colleges. This has a domino effect on the local community with doctors moving away, either to urban centres with medical colleges or abroad.
• Almost 80% of the medical colleges are located in South and West India creating a dearth of professionals in Central, Eastern and Northern India.

To bridge these issues, various steps have been suggested –

• Giving AYUSH docs the right to prescribe allopathic drugs after a one year course.
•  A compulsory Bachelor of Rural Health Care course
• AIIMS-like institutions in various parts of the countries. They are going to be located in Patna, Bhopal, Bhubaneshwar, Jodhpur, Raipur and Rishikesh.
•  A compulsory bond that will force the docs to return to India after completing their medical education abroad.
• Setting up of a centralised National Commission of Human Resources and Health which will have all other medical bodies in the country under its jurisdiction.

However, most of these initiatives met vehement criticism and have experienced opposition from the medical community.

Source: Planning Commission Health Division report for the 12th Five Year Plan

5. High number of avoidable deaths

Avoidable deaths refer to those that could’ve been avoided extremely easily with either the most basic or cheap medication or treatment. Some of the more common avoidable diseases are malaria, tuberculosis, kala azar and Japanese Encephalitis. Deaths from conditions like nutritional deficiencies or perinatal deaths are also considered in this list. A rough estimate suggests that over 2.1 million people died in India from conditions that could’ve been avoided. Here’s how we arrived at the number.

Diseases	Estimated deaths in South  East Asia (2008)	Est. deaths in India* (2008)
Tuberculosis	405974	357257
Malaria	43200	38016
Diarrhoea	1141586	1004596
Dengue	7064	6216
Japanese Encephalitis	11313	9955
Kala Azar	10130	8914
Nutritional deficiencies	84,123	74028
Perinatal conditions	8,72,676	767955
Maternal conditions	80620	70946
Total	26,56,686	2337884

 *Assuming 88% of these deaths were in India, since it accounts for 88% of the population in this region.

Note: It’s extremely hard to track deaths due to avoidable diseases. WHO estimates over 2.6 million people died in South East Asia in 2008 from these conditions. However, official records show the numbers to be far lesser. For example, India had only around 1000 reported malaria deaths in 2008. However, when the entire SE Asian region is taken the number of estimated malaria deaths is 43,200. Now this region has a total population of 1.3 billion and India had an estimated population of 1.15 billion in 2008. So it’s clearly implausible that despite having 88% of the population it only accounted for 2 percent of malaria deaths. So we’re assuming that 88% of all deaths caused by these diseases are in India. We’re assuming of these 2,656,686 deaths, 2,125,348 occurred in India.

It’s extremely sad that so many Indians are losing their lives to diseases and conditions that could’ve been easily avoided with the most basic of healthcare services.

Read more about causes, symptoms, diagnosis and treatment of diabetes.

Rise of Lifestyle diseases

While rural India battles third world diseases like malaria and dengue, rising urbanisation has led to the middle and upper classes being afflicted with ‘developed world’ lifestyle diseases like diabetes and obesity. A fast food culture, increased smoking and alcohol consumption has led to a rise in obesity related diseases like diabetes and cardiovascular ailments.  To read a more comprehensive report about lifestyle diseases click here.

The road ahead 

Most of our healthcare woes could be vanquished if we as a nation simply worked together for it. When I say nation, I mean everyone – doctors and other medical professionals, rural and urban citizens, bureaucrats and politicians, the state and central governments.

It’s a travesty that 66 years after Independence we still can’t make even the basic healthcare services accessible to everyone. Most of us reading this probably haven’t experienced the grim grip of poverty, malnutrition or ill-health. We’ve probably never gone to bed hungry or lost a loved one because we couldn’t afford a drug. Sixty-five years ago we freed ourselves from colonial rule; it’s about time we sent ill-health packing.

Imagine a country where healthcare is accessible to all. Or as Tagore would say, ‘Into that heaven of freedom my father let my country awake.’  Jai Hind.

Read more about causes, symptoms, diagnosis and treatment of dengue.