Healthcare: No country for the sick and ailing
The collective woes of the Indian healthcare sector won’t be solved unless our budgetary allocation for the public healthcare system goes up drastically
Union Health Secretary, Chandra Kishore Mishra, does not really pull his punches or mince his words. After working in different capacities in Bihar and at the Centre, he knows intimately about the high-cost illnesses can extract from families and the economy. When Hardnews met him a few days before the 2017 Union budget was presented, he shared his views on the importance of increased funding to the health sector and how public health needs to be given primacy over creating infrastructure for the tertiary sector. Public health had the first right over resources rather than hospital care, as better public health could ensure lesser hospitalization. The strongest argument, in favour of increased investment and emphasis on public healthcare is that 7 crore Indians relapse into poverty whenever ill-health takes hold of their families.
A few days later, when Union Finance Minister Arun Jaitley presented the budget, the health sector found just a passing mention in his protracted speech. However, a few salient points were readily apparent: the 27 percent jump in the budgetary outlay for this year and the government’s intention to eradicate kala azar, filariasis (2018), and tuberculosis in the country by 2025. The minister also announced plans to create 5,000 postgraduate seats in medical colleges every year. This is a welcome step, but still a far cry from the mandated and necessary Indian Public Health Standard (IPHS) norms. India currently has an abysmal ratio of 0.7 doctors per 1,000 people. Try to visualise that statistic: if 1,000 Indians were to collectively fall ill, they would not have access to a single doctor because their doctor is actually a fraction.
Post-budget analysis indicated that some of the ideas that were shared by the health secretary with Hardnews found prominent space in the annual budget. But a lot of ground still needs to be covered. The National Health Policy of 2015 envisioned a 2.5 percent allocation of the GDP, which is closer to about Rs. 3.5 lakh crore. In terms of GDP spending, our budgetary allocation for health is far lower than Sri Lanka, which has invested 5 percent of its GDP in the healthcare sector and has been amply rewarded by its sterling performance on the Human Development Index (HDI), perhaps one of the most important development metrics. This parsimony in investment in public-funded healthcare shows in every possible health indice. One can’t wantonly dismiss these disturbing statistics, like the one which says that 37 percent of children below the age of five years in our country are stunted. The probability is that the figure could be higher. A major chunk of these children lives in Madhya Pradesh and Bihar, but it is possible to find many of them in UP, Rajasthan and Gujarat. Here’s another alarming statistic to chew on: 29 percent of children in our country are underweight, and 55 percent of our women are anaemic.
Compounding these worrying figures is the fact that our country has an alarmingly high rate of maternal and infant mortality. In the budgetary speech there was a proposal to bring down infant mortality from 39 per 1,000 to 28 per 1,000, but that would only be possible if there is an upgradation of infrastructure.
Prof Santosh Mehrotra, an economist with Jawahar Lal Nehru University (JNU), is of the view that without increased spending it is impossible to sort out many of these issues, no matter how efficiently we use our resources. In an interview with Hardnews, he strongly advocated the strengthening of the public health system and provided figures that suggested that India’s healthcare was the most privatised in the world, with people spending Rs 70 for every Rs 100 needed out of their own pockets when dealing with ailments in the family. He also talked about the National Health Mission (NHM) which aims to promote a rights-based approach to health services and also strengthen the system for delivery of these services. Prof Mehrotra believes that certain targets have to be met before the NHM can give meaning and credence to its vision of providing universal access to quality public health services. He appreciated the increased allocation for postgraduate medical study in the budget, but was quick to caution that most doctors who finish their MDs do not like to work in rural areas. According to him, this problem has been successfully addressed in Tamil Nadu where doctors posted in rural areas are mostly sourced from the local talent pool. Prof. Mehrotra again brought up the example of our tiny neighbour, Sri Lanka, where medical students have to spend time in what he chose to describe as the “boondocks” before they are granted permission to practise after they obtain a degree. This policy has had a salutary impact on the health of the nation.
Prof Mehrotra believes that India will need an upgradation of infrastructure to deliver health services 24/7. According to him, barely 50 percent of government health facilities function 24/7, which is necessary if their functional capacities are to be fully utilised. A heart attack can occur at any time of the day and not necessarily during office hours.
Capacity building remains a huge challenge. He did not agree with vertically driven programmes to fight diseases like kala azar, tuberculosis and the like. The better approach, according to him, is to strengthen the public healthcare system. Ironically, the need to have a State-funded public healthcare system does not find approval from the chairman of Niti Aayog, Arvind Panagariya, who wants the public healthcare system to become a public-private partnership-driven health insurance system. The health ministry has been resisting these suggestions and even told Panagariya to ascertain for himself the need to have a public healthcare system in a country with so many desperately poor people.
Prof. Mehrotra was in agreement with the Union Health Secretary C K Mishra that there was little merit in creating infrastrucuture for tertiary health sector as there were not enough quality professionals to man their various departments. The Health Secretary,, though, has been a strong votary of setting up Medical colleges in District Hospitals that have excess land around them. The cost of setting up these medical colleges is around Rs. 400 crores, far lower than setting up a single AIIMS. This suggestion of the Health Secretary has found space in the annual budget.
Though there has been a 27 percent hike in the budgetary outlay; it is still inadequate to meet the challenge of providing universal and equal access to quality healthcare for millions of people. What compounds health investment decisions is India’s complex demography: there is a bulging population of adolescents as well as of the old. While the young need preventive healthcare, the old need more hospital beds. However, what really happens when someone falls ill is that the first person to be contacted in the village is a neighbourhood quack. The health secretary has suggested that Ayush or ayurvedic doctors be trained to meet the growing needs of senior citizens. This proposal has been aggressively opposed by the Indian Medical Association (IMA) which does not want to yield space to doctors who practise alternative medicine. The net outcome of this gap in medical care is that, during epidemics, hospitals are clogged with patients who could easily be treated at home. What is apparent is that there is no one-size-fits-all formula to fix India’s complex healthcare sector.