India’s Public Healthcare System Needs Urgent Overhaul: Are Those In Authority Listening?

"The enjoyment of the highest attainable standard of health is one of the fundamental Rights of every human being without distinction of race, religion, political belief, economic or social condition” – the preamble of WHO, declaring health as fundamental right.

In the history of Independent India, no setback of the state comes even close to the spectacular failure the government-run “public healthcare” has been in every aspect of planning and execution.

However, it wasn’t like it was destined to be so. In the final days of British rule, the Sir Joseph Bhore-led committee, set up in 1943, prepared its comprehensive set of recommendations and submitted them in 1946. This could have been the document upon which our nation’s healthcare delivery system could have been built. Here is a highlight of the essence of Bhore Committee recommendations:

1) Integrate preventive and curative systems at all administration and execution levels

2) Development of primary health centres (PHC) in two stages (remember this is for 1946)

• a) Immediate short-term measure: One PHC for a population of 40,000, manned by two doctors, one nurse, four public health nurses, four mid-wives, two sanitary inspectors, two health assistants, one pharmacist and 15 other class IV employees. A secondary centre was planned to provide support to a cluster of PHCs, to coordinate and supervise their functioning.
• b) Long-term plan: Setting up of PHCs with 75-bed hospital for every 10,000-20,000 people and secondary units with 650-bed hospital supporting a cluster of PHCs and regional hospitals to support secondary units with huge 2,500-bed hospital infrastructure.

The report was a very farsighted vision and execution document which, if and only if, the governments of Independent India adhered to, the country would probably be today boasting of a healthcare system far superior to any in the world. It is available in three volumes and can be downloaded here.

Reading the above (for preparing India public healthcare vision document – 2030) along with other available records in relevant government departments and planning commission, left me thoroughly disillusioned; that, such a fundamentally strong and pragmatic ‘vision plus execution’ document prepared so early in the life of our Independent nation, did not find any takers until now among our political leaders and policy-makers. The inability of the political leadership to even recognise healthcare as an important aspect of human life is exposed by the fact that even in the latest National Health Policy (NHP) of 2017, the current regime is not willing to declare “right to health” as a fundamental right of citizens of India. Lack of political leadership and political will is a disease affecting all parties across all ideologies.

Subsequent governments, post 1946 formed different committees: the Mudaliar Committee of 1962 (Government of India, 1962), and the Shrivastav Committee of 1975 (Government of India, 1975, 1976). The Mudaliar Committee (1962) concentrated on medical education and development of training infrastructure for static medical units. The Shrivastav Committee (1975) urged the training of a cadre of health assistants to serve as links between qualified medical practitioners and multipurpose workers (eg school teachers, post masters, gramsevaks, etc.). However, none of them were visionary and comprehensive like Bhore Committee report. They were as short sighted as the political leadership of those times.

The NHP 1983 declared a lofty resolution of taking health services to the doorstep of people and ensuring fuller cooperation of community, however; it failed to declare health care as a fundamental right of the people, and neither did the NHP of 2002 do it.

Both the NHP of India 1983 and 2002, failed to even confer the status of a ‘right’ to health. Both had some worthwhile proposals, no doubt, but the major social thrust and vision to convert their commitment into ‘health as a right’ was lacking. This was due to poor awareness amongst the ruling politicians, wherein Ministry of Health was/is treated as a reward to loyalists instead of being seen as place which needs committed planning and execution with efficient people. Planners and bureaucrats with no hands-on experience in healthcare delivery to masses/patients and having zero knowledge of ground realities were/are in-charge of planning and execution of such an important aspect of human life as healthcare. Truant demands from a community unaware of its fundamental rights, a private medical establishment which sought to drown itself in short-sighted profiteering strategies and business of scale, further complicated matters, making Indian healthcare rank among the lowest (154 among 195 countries) in the world, performing much worse than our 2000 ranking of 112.

Worldwide, the goals of medicine have undergone a paradigm shift from curative to preventive, preventive to social and social to community medical intervention strategies aimed at improving healthcare. The ultimate purpose is not to just to achieve a disease-free state but also to improve overall quality of life. Whereas India, which could have been a beacon holder for all developing countries, had it simply followed Sir Joseph Bhore committee recommendations, has still to reap the benefits of this original philosophy which was handed to them in 1946 on a platter, to any significant degree.

Let us further analyse the havoc that has been perpetrated by successive governments in the name of healthcare.

Comparative analysis: India, whose gross domestic product (GDP) is at $ 2.264 trillion, spends 1.04 per cent of its GDP, equivalent to $ 267 per capita (2014 data) on healthcare; whereas US, with current GDP of $ 18.54 trillion spends 18.57 per cent of its GDP equivalent to $9990/-per capita. If you understand the population base effect difference between the countries, you will appreciate the inadequacy of the amount allocated to our large public healthcare needs by subsequent governments in India, thereby destroying the efficiency of our public healthcare system.

Each year, more than 40 million people in India, mostly rural folk and urban poor are impoverished, get entangled in financial crisis and run into massive debts to access secondary/tertiary/quaternary care (Reference: 4) Marten R, McIntyre D, Travassos C, Shishkin S, Longde W, Reddy et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China & South Africa (BRICS). Lancet 2014; 384: 2164-71).

This is mainly because the government does not want to spend on health services (in the name of fiscal prudence), forcing the people to spend out of their pockets leading to personal and family disasters. This out of pocket payment (OOPP) is the single most common cause of sudden emergent financial crisis among rural folk and urban poor.

India loses 6 per cent of GDP annually due to premature deaths of economically productive citizens, expenditure on preventable illness, non-communicable diseases (NCDs) and accidents (Reference 5). NCDs and accidents/injuries account for 52 per cent of deaths in India and will keep increasing with decrease in deaths due to communicable and infectious diseases (Reference 6: Burden of NCDs policies and programmes for prevention and control of NCDs in India. Indian J Community Medicine 2011; 36 (suppl 1): S7-12).

The above two studies (Reference 5 and 6) are proof that successive governments have been asinine in their approach towards healthcare expenditure. Had the governments made up their mind to increase healthcare expenditure to just 5 per cent of GDP, the country would be richly rewarded back with increased economic productivity of its healthy citizens. The global average expenditure on healthcare is around 9.981 per cent of world GDP. India spends around half of that figure, around 4.7 per cent of its GDP. In this, the government of India currently spends only 1.14 per cent of its GDP on healthcare. The balance 3.56 per cent comes from the pockets of citizens, leaving them at the mercy of profiteering and burgeoning corporate healthcare providers and unregulated private players in healthcare. This OOPP has led to increased incidence of sudden financial crisis especially among the rural folk and urban poor. According to the World Bank and National Commission's report on Macroeconomics, only 5 per cent of Indians are covered by health insurance policies. Government of India does not make any efforts to increase insurance coverage among the lower middle class and middle class or any class of its citizens, who can purchase the same thereby reducing the instances of OOPP and financial crisis.

Sometimes looking at the GDP numbers and the amount of money involved ($81.88 million in this case (back of cover calculations, figures need to be authenticated further)), to my fertile imagination, it appears like a healthcare scam is waiting to be unearthed/exposed.

Analysis of healthcare with respect to: current inherited healthcare status of nation, failure to meet accepted Millennium Development Goals by 2015, adaptation of United Nation's Development Programme's (UNDP) Agenda for Sustainable Development and release of National Health Policy 2017.

The quintessence of Bharatiya Janata Party’s (BJP) manifesto regarding healthcare is captured in NHP 2017. The “goal” as described by NHP 2017: “The policy envisages as its goal the attainment of the highest possible level of health and wellbeing for all at all ages, through a preventive and promotive healthcare orientation in all developmental policies, and universal access to good quality healthcare services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery. The policy recognizes the pivotal importance of Sustainable Development Goals (SDGs). An indicative list of time bound quantitative goals aligned to ongoing national efforts as well as the global strategic directions is detailed at the end of this section”.

Personally, I admit here that, post Bhore committee recommendation in 1946, NHP 2017 is the most comprehensive and extensive document the public healthcare leadership, planners and bureaucracy has produced; however, there is a curative bias in approach which needs to be addressed for achieving better far-reaching results.

Public health infrastructure inherited (Data as of 31 March 2017):

• 208,596 sub centres
• 31,938 primary health centres
• 7,541 community health centres
• 648 district health centres
• All India Institute of Medical Science other autonomous institutions

Total number of beds owned by public health infrastructure as per data published by government in June 2014 is 628,708. Urban health infrastructure holds 432,526 beds and rural beds are 196,182, which is a little less than a third of urban bed strength. As per population statistics, there is one bed for every 1,946 people in urban areas, whereas in rural areas it is one bed for every 4,639 people. Population distribution statistics indicate that 70 per cent of population stays in rural areas, making this more skewed than it appears to be.

This brings us to the “Jinx of 70” we face in healthcare (Reference Rule of 70: Derived from Central bureau of Health intelligence “National Health Profile 2016”):

• 70 per cent of people stay in rural area with little access to healthcare
• 70 per cent of people pay from their pockets (actually it is 75 per cent)
• 70 per cent of expenditure is on medicines alone

To overcome the existing infrastructure deficiencies, requires imagination, out of the box search for solutions, innovative implementation methods and supra-optimal use of existing infrastructure. It requires political will and leadership – the question is can the Health Minister and Prime Minister provide the same?

India’s political and public health leadership in the past, has led innovative schemes and translated the best of those into policy, made substantial contributions for bettering population health. Since the launch of the National Rural Health Mission in 2005, over 157,000 personnel have been employed to health sector. The infant mortality rate (IMR) has declined from 68 to 42 per 1,000 live births between 2000 and 2012. The Janani Suraksha Yojana was successful in ensuring delivery of more than 120 to 130 million women in government facilities and more than 600,000 new-born babies are receiving care in neonatal care nurseries in district hospitals each year through Janani Shishu Suraksha Karyakram.

Polio has been eliminated from the face of the country, yaws eradicated, kala-azar, endemic filariasis, leprosy and measles on their way to eradication. This is exciting, but is not enough; failure to achieve UNDP’s Millennial Developmental Goals by 2015 which were signed in 2000 is a sobering lesson to the government, healthcare planners, administrators and managers. It requires much more capacious hard labour, purposeful action, thorough planning and execution to achieve goals with respect to healthcare monsters like tuberculosis, malaria and HIV-AIDS. UNDP’s sustainable development goals and NHP 2017 are the right way forward. The question is “Is India’s present political leadership willing to put its political capital and political will behind public healthcare and bring it from existing lower than third world status (rank 154) to first world levels?”.

This article is the intellectual property of Dr Jagadish Hiremut and will appear on his personal blog; those wanting to quote from it should do so with permission and due credits.