The sorry state of public health
With India’s dysfunctional primary healthcare system severely impairing its human capital, the government needs to rise above the rhetoric of its grandiose plans and policies, says Raghu Dayal
With India’s dysfunctional primary healthcare system severely impairing its human capital, the government needs to rise above the rhetoric of its grandiose plans and policies, says Raghu Dayal
While US President Barack Obama has given top legislative priority to health insurance reform to enable Americans to have quality and affordable healthcare, Indians have little hope of deliverance from an increasingly-unaffordable health regime.
Indias primary healthcare system is based on primary health centre (PHC) and its attached sub-centres, each of which covers 3-4 villages. The Economic Survey, 2009-10, highlights a shortage of 20,486 sub-centres, 4,477 PHCs and 2,337 community health centres (CHCs) based on 2001 population norm. Only 13% of rural residents have access to a PHC, 33% to a sub-centre, 9.6% to a hospital and 28.3% to a dispensary or clinic. About two-thirds of countrys registered hospitals are private.
A recent countrywide survey of PHCs revealed average vacancies at 18% for doctors, 15% for nurses and 30% for paramedics. Absenteeism rates in this sector average 40% across the country. A study on competence level of doctors in the PHCs found, in treating diarrhoea, that a typical doctor often recommended harmful therapies. According to a 2005 Transparency International study, healthcare services account for 27% of the bribes paid for public services in the country. Again, if public doctors miss their clinic opening timings or render poor service, they still get their salary.
The National Rural Health Mission, launched on April 12, 2005, with an annual allocation of Rs 12,000 crore – increased by Rs 2,057 crore in 2009-10 – aims at providing accessible health services to the poorest households in the remotest regions of the country. The Rashtriya Swasthya Bima Yojana claims to have covered 4.5 million below-poverty-line families by issuing biometric cards. In reality, the programmes deliver far short of their avowed claims. Public health services suffer from widespread absenteeism and indifference among doctors and paramedics in the PHCs, shortages of medicines, unhygienic conditions, complaints of rude health workers, patients compelled to make informal payments, lack of supervision and accountability, and rural folk compelled to gravitate to local private practitioners, many of them unregistered and unqualified.
Against such a pathetic supply side, the demand for medicare is enormous. Over 17 lakh children in the country die annually before reaching their first birthday. India accounts for a fifth of the global disease burden: 23% of child deaths, 20% of maternal deaths, 30% of tuberculosis cases, 68% of leprosy cases and 14% of HIV cases. Tuberculosis kills around 2 million people a year around the world; in India, the disease takes a toll of 4,21,000 lives.
The spread of Malaria was brought down to negligible proportions in the 1960s, but it struck back with 6.47 million cases in 1976; and still accounts for 2-3 million cases annually. India has a disproportionately high per-capita rate of acute respiratory infections and diarrheal diseases than the rest of the world. The infant mortality rate (IMR) per 1,000 live births was 80 in 1990, which dropped only to 66 in 2000 against proportionate Millennium Development Goals (MDG) target of 57.
With almost a third of the country’s population living in cities – more than half the number in 23 metropolitan areas – the healthcare infrastructure is far too inadequate. While there is need to raise the availability of doctors from 6,00,000 to 20,00,000 and nurses from 16,00,000 to 44,00,000, some 165 medical colleges annually turn out only about 16,000 doctors in the country.
The number of physicians per 1,000 population for the world is 1.5; for India, it is 0.6. Against a world average of 3.98 hospital beds per 1,000 population, Russia has 9.7, Brazil 2.6, China 2.5, and India 0.9. Per-capita per-year in-patient admissions for India aggregate 1.7 compared to 9 for the world and 5.5 in low income countries.
A clear message in these depressing figures is of serious sickness afflicting the country. The UN Human Development Report, 2007, brings to the fore the countrys abysmal record in education and health; here, India is in the same league as Ethiopia, Burundi and Chad. India remains mired in hunger and poverty, home to a third of the worlds poor, its human capital severely impaired by grossly inadequate healthcare infrastructure strained by steady urbanisation, epidemiological transition to chronic and non-communicable diseases, poorly regulated private sector and poor management of public sector facilities.
Total annual per-capita state and Central government spending on public healthcare services is $2-3. A sub-group on healthcare financing and insurance recommended public expenditure on health to be not less than 2.5% of GDP. The UPA government had us believe that this will be raised to 3%. Public health expenditure in the country has been only about 0.9% of GDP – central government 0.29% and state governments 0.61% – which is below the low-income countries average of 1%, and even sub-Saharan Africas 1.7%. These are distressing figures.
As much as 63% of the entire spending goes to wages and salaries, leaving meagre resources for drugs, supplies, equipment, infrastructure and maintenance. Moreover, there are significant inter-state differences in per-capita spending on health services: in 2004-05, it ranged from Rs 100 in Bihar and Rs 156 in Uttar Pradesh to Rs 448 in Tamil Nadu and Rs 354 in Kerala. The countrys health system is afflicted with inequities. An NCAER study reveals that the richest 20% enjoy three times the share of public subsidy for health.
A working paper by the Centre on Globalisation and Sustainable Development (CGSD) terms Indias primary healthcare system dysfunctional: the system has failed to deliver basic health services to the poor, notwithstanding numerous schemes launched with fanfare, including the Rashtriya Swasthya Bima Yojana and Health For All. Amidst its emphatic avowals of a new deal for aam aadmi, the government has a challenging task to face, rising above the rhetoric of grandiose plans and policies.