Follow us on


An unhealthy trend

Print edition : Dec 03, 2004 T+T-

At a government hospital in Bhopal.-A.M. FARUQUI

The quality of public health care delivery in India remains woeful while the private health care sector attains impressive heights thanks to the government's privatisation drive.

A RECENT story in The Washington Post narrated how 53-year-old Howard Staab travelled all the way from the United States to New Delhi's Escort Heart Institute and Research Centre for a surgical operation that saved him from a life-threatening heart problem. The procedure cost him $10,000, a mere 5 per cent of the fee he would have had to pay back in the U.S. Staab is but one of the 150,000 foreigners who visited India last year seeking comparatively cheap medical solutions. "If we do this, we can heal the world," Apollo Hospitals' founder-chairman Dr. C. Prathap Reddy said. But who will heal the people of India, while the country waits for the crumbs from medical tourism, which is projected to grow into a $2.2 billion industry by 2012?

The United Nations Development Programme's (UNDP) latest Human Development Report (HDR) puts India's public spending on health among the lowest in the world - $4 a person a year or 0.9 per cent of its gross domestic product (GDP). Of the 175 countries documented by the HDR, only four have a lower public spending on health than India.

In sharp contrast, India ranks an impressive 18th in private health care spending (4.2 per cent of GDP). The contrast is so stark for very few countries.

India's health care system, comprising government and private sectors, barely covers half its population. The public sector health infrastructure has about five lakh doctors, 7.4 lakh nurses, 3.5 lakh chemists, 15,000 hospitals and 8,70,000 beds. It is a three-tier structure comprising some 23,000 primary health centres (PHCs), 1,37,000 sub-centres and 3,000 community health centres, serving the semi-urban and rural areas. But, according to Ravi Duggal of the Centre for Enquiry into Health and Allied Themes (CEHAT), private health care accounts for 70 per cent of primary medical care and 40 per cent of all hospital care in India. It employs 80 per cent of the country's medical personnel. In 2002, the outlay of the Ministry of Health and Family Welfare was Rs.5,750 crores (Rs.57.5 billion), while the private sector spent Rs.69,000 crores.

China, with which India is often compared, spends 2 per cent of its GDP on health; even Nepal (1.5 per cent), Bangladesh (1.6 per cent) and Pakistan (1 per cent) spend more on public health than India in percentage point terms. In the matter of basic health care infrastructure and facilities, the country is far behind international standards. It has 94 beds per 100,000 people, compared to the World Health Organisation norm of 333. According to some estimates, there are only 43 doctors for 10,000 people in India; exclude the private sector and it becomes an abysmal 1:30,000. Government hospitals need at least 40,000 more doctors and a large number of paramedics.

The demand-supply gap for public health care delivery is large and on the rise, and this gap is increasingly being filled by private health care institutions. The urban health care industry is booming, with a host of private hospitals offering state-of-the-art services for the rich and the middle class. A 2002 study, "Health care in India: The Road Ahead" by the Confederation of Indian Industry and McKinsey & Company, put the total value of the health sector in India at over Rs.1,500 billion or 6 per cent of GDP. Of this, 15 per cent is publicly financed, 4 per cent is financed through social insurance, 1 per cent through private insurance and the remaining 80 per cent is out-of-pocket user-fees. Two-thirds of all users fall into the last category, and 90 per cent of them are from the poorest sections. National data reveal that 50 per cent of the bottom quintile sold assets or took loans to access private hospital care. An annual interest rate of 1,200 per cent on loans is not uncommon; hence many poor people end up in the vicious cycle of bondedness, from which they do not dream to escape during their lifetime - or even over generations.

Says Union Health Secretary J.V.R. Prasad Rao: "With health funding being so low, the government can either fund doctors or get medicines or provide support services. Not all of these." In its Common Minimum Programme, the United Progressive Alliance (UPA) government has promised to spend 2 per cent of GDP on health. So far, it has not indicated from where the funds would come nor how they would be spent. But a Health Ministry spokesperson has said that the emphasis would be on enhancing public-private partnership to improve health care delivery. Says Dr. Rama Vaidyanathan Baru of the Jawaharlal National University's Centre for Social Medicine and Community Health: "In its 1947 resolution, the government proposed to spend 12 per cent of GDP on health every year. Even in the best of days, it has never been anywhere close to this figure."

The quality of public health care delivery is woeful. The health care system is not only cash-strapped but also fraught with inefficiency; it is prone to misuse, even abuse. According to Dr. K. Nagaraj, Senior Professor, Madras Institute of Development Studies, Chennai, comprehensive public health care system is to be provided with PHCs at the base and referrals to provide secondary and tertiary care. But the system is hardly effective, making comprehensive health care delivery impossible. First, the system of primary health care is only an infrastructural intervention that does not take into consideration the local needs. Second, the referral system almost never works owing to infrastructural problems such as lack of medical professionals, medicines, transport and so on. According to him, the situation is only worsening with the government's privatisation drive.

In a survey of 100 Rajasthan villages, researchers from the Massachusetts Institute of Technology and Princeton University found an absenteeism rate of 44 per cent among medical professionals in public clinics. The absenteeism was cited to be because of meetings and other work-related problems. Apart from that, the PHCs remained closed half the time. Most rural PHCs did not have running water, electricity or emergency medicines, leave alone phones or vehicles. Some did not even have routine medicines to treat children for fever, cough and the common cold. The survey showed that 65 per cent of households in India go to private hospitals for treatment while only 29 per cent use the public medical sector. Even among poor households, only 34 per cent used PHCs. They are increasingly turning to amateur private "doctors" and faith healers, even to treat such infectious diseases as tuberculosis (TB) and malaria.

According to Nirupam Bajjpai, Senior Development Adviser and Director, South Asia Programme Centre on Globalisation and Sustainable Development, Columbia University, the resurgence of communicable diseases such as malaria and TB in India is partly because of the low levels of public expenditure on health care and the commercialisation of medical care. The country accounts for a third of the TB incidence globally and has the largest number of active TB patients. An estimated 20-30 million episodes of malaria occur in India each year; mortality on account of malaria is the highest in India. Profit-oriented curative care is therefore on the rise, 80 per cent of which is in the private sphere. This has resulted in spiralling medical care costs and rural indebtedness.

Tuberculosis is the big killer, claiming nearly 500,000 lives in India every year. This costs the country $300 million (about Rs.1,350 crores) a year of which more than $100 million (about Rs.450 crores) is debt incurred by patients and their families. Says Mira Shiva of the Voluntary Health Association of India: "Medical care has emerged as the second major cause of indebtedness in the country next to dowry."

Public health care spending has been systematically shot down since the early 1990s with health care reforms following the policy of structural adjustment. Even if not explicit, the 2002 National Health Policy's support and encouragement to the private health sector further accentuated the gradual withdrawal of the state from the responsibility of public health care. The state offers subsidies, loans, tax waivers and other benefits for the setting up of private practice, hospitals and diagnostic centres. While about Rs.10 lakhs (at current prices) of public money is spent on the education and training of each doctor, over 80 per cent of those who pass out of public medical schools either joins the private sector or migrate abroad. The country loses Rs.4,000-5,000 million every year as a result of such migration. The private health sector has grown into a giant - in fact the largest in the world - thanks to the support of the state. Its mammoth size notwithstanding, this sector has remained completely unregulated.

Says Ravi Duggal of CEHAT: "All over the world there is a tendency to move towards more organised national health systems and an increased share of public finance in health care. Several countries have universal health care systems where the public sector's share of the fiscal burden is 60-100 per cent. This trend is inevitable in the pursuit of equity and universal coverage."

But what of health care coverage for workers in the organised sector in India? Of the 400 million employed people in the country, hardly 28 million are in the organised sector and covered by comprehensive social security legislation, including social health insurance. The largest of this is the Employees State Insurance Scheme (ESIS), which covers eight million employees; including their family members, it provides health security to 33 million people. In 2002-03, the ESI Corporation spent Rs.12 billion (Rs.1,200 crores) on health care for its member-beneficiaries, averaging Rs.365 per capita. This effectively covers a mere 3.2 per cent of the population. About 0.5 per cent of the population is covered through the Central Government Health Scheme (CGHS), which spends Rs.2 billion (Rs.200 crores) averaging at Rs.450 per beneficiary.

According to Ravi Duggal, while these social insurance plans have been around for a long time, their credibility is now at stake owing to the large-scale outsourcing to the private sector. For instance, in large cities, the ESIS has panels of private doctors, who provide ambulatory care to those covered under the scheme. Similarly, under the CGHS, the beneficiaries have the `choice' of accessing private health care, with the cost reimbursed. A senior bureaucrat can get reimbursement for a bypass surgery up to a maximum amount of Rs.150,000. Totally, less than 5 per cent of the population has some form of social insurance cover for health through employment.

Says Ravi Duggal: "The limited social insurance coverage is also declining and getting privatised. There is a systematic decline in the role of the state in public health finance. This is contrary to the experience elsewhere, which shows that universal access to health care can only be achieved with financing mechanisms that are largely of a public nature such as social insurance, tax revenues or a combination of these." Experts argue that even from the point of view of economics - labour hours lost and productivity decline resulting from sickness and disease - there is a strong case for providing public health care.

Clearly, seen from the social, economic or political perspective, there is an urgent need to universalise access to basic health care and social insurance. This needs appropriate legislation and a constitutional mandate. By generating the political will to achieve this end and activating civil society to demand health care as a right, the country can take positive steps to strengthen public health care services.

Frontline ebook




Living on the edge

They are river people, whose lives ebb and flow with the waters of the Brahmaputra in a timeless rhythm. But now, hydroelectric projects and homogenis