A country boasting one of the cheapest healthcare costs in the world, yet a vast swathe of its population fears any experience with its public healthcare system as it currently is. A country with far fewer than the UN-mandated 1 doctor per a 1,000 population, yet also one where the medical tourism market is estimated at around 8 billion USD with thousands of patients flying in from around the world to get themselves treated! A country often referred to as the world’s pharmacy, with some of the world’s most advanced and innovative healthcare companies, yet one struggling with the most basic of health outcomes for its vast populace. Classic India, isn’t it?
Even before I begin, I’d have to admit that a lot of my views here are informed by two of my most recent career stints – a year in the parliament, and two months immediately preceding it at the National Health Authority, Government of India, the (genuinely amazing) institution which runs and administers the Ayushman Bharat Yojana. I’ve benefited a lot from some excellent writing/reportage on the subject as well, a lot of which, along with all references, I’ll be linking towards the end. With that out of the way, let’s dive in!
Healthcare. Everyone seems to be talking about it, it is everyone’s business (rightly so) yet there’s such a whole lot of nuance about so important a subject that gets lost in a deluge of information we’re bombarded with day in and out. Whenever someone speaks of healthcare as this one singular state of being in India, I inevitably end up digging into the more detailed aspects go how India is home to states with health metrics corresponding to both, Sweden and Sub Saharan Africa in this one same country. Plus, oh god, some of the sector’s evolution since independence mirror that of education so, so linearly. Which brings me to the first set of focus areas -
The four divides:
Rural-urban divide - In India, around three-fourths of the total healthcare infrastructure is concentrated in urban areas where only about a third of the total Indian population dwells. Only one allopathic doctor is available for every 10,000 people and one state-run hospital is available for around 90,000 people. According to Dr Prabhakar DN, former president of the Karnataka branch of the Indian Medical Association, 40% of doctors in Karnataka are in Bangalore. “In rural areas, there is still a shortage. Bangalore is totally saturated, even for specialists. So they don’t get jobs. Doctor salaries are coming down.” This is a near-criminal mismatch.
Source: TOI, September 2nd 2018
Even with PMJAY- Ayushman Bharat, one of the main ideas for the program has been to bring scale for healthcare providers so as to bring down costs, allow them to expand, create infrastructure and hence set into motion this virtuous cycle of a kind. One obstacle facing this vision is the fact that most specialists, the most vital resource for any tertiary healthcare service providing institution, are reluctant to live and work outside of the few major Indian metropolises with a certain quality of life. The rural-urban divide goes even deeper, most high-quality medical education institutions in India are concentrated in urban areas with a mere 4.6 per cent of the total seats belonging to the institutes located in rural areas, 4.6% yep!
Inter-State divide - As I mentioned earlier, India houses unbelievably different and varying healthcare services and provision standards within its borders depending on which state one is talking about. This divide shows up rather clearly in health outcomes as well – Kerala has a life expectancy of 74.9 years – 12 years more than in Madhya Pradesh 62.4 years. Likewise, be it the risk of death during pregnancy or levels of infant mortality, Kerala is fourfold lesser than MP. The 2030 Sustainable Development Goal target for neonatal mortality rate is 12 neonatal deaths per 1000 live births. Kerala and Tamil Nadu have already achieved it. But Bihar has 27 deaths and Uttar Pradesh has 30 deaths per 1000 live births, in 2017-2018.
Source: WHO report, 2016
Even as governments cite a shortage of doctors, interestingly enough, six states — Delhi, Karnataka, Kerala, Tamil Nadu, Punjab and Goa — have more doctors than the WHO norm of one for 1,000 people. The density of doctors per 1,000 people in Tamil Nadu is as high as 4, almost at the same level as Norway and Sweden, where it’s 4.3 and 4.2 respectively. In Delhi, the density is 3, higher than the UK, US, Canada and Japan, where it ranges from 2.3 to 2.8.
Moreover, just the five states of Andhra Pradesh, Karnataka, Kerala, Maharashtra and Tamil Nadu have 55% of all medical colleges in India, while Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, having around two-fifths of India’s population account for just about 15%, for comparison. Jharkhand, which annually produces about 300 doctors, will take at least 87 years to meet the doctor-patient ratio of 1:1000 set by World Health Organisation(WHO), says a Medical Council of India (MCI) study. These differences are beyond stark.
Monetary dividing lines: Well, this is simple, those with the means to pay can avail of world-class healthcare here in India and the rest are at the mercy of public healthcare systems. Simple, right? There’s a whole lot more nuance to it, for which we’ll have to briefly delve into the quality of growth that the Indian economy and policymaking has delivered over the past couple of decades.
As per a study by the Pew Research Center, even while India’s poverty rate fell from 35% in 2001 to 20% in 2011, the population that could be considered middle income saw a puny increase, going from around 1% to just 3%. Hence, unlike China, instead of a prosperous, swelling middle class, India saw a movement of its population from poor to low-income earners at max.
The same study also showed that “these were people hovering closer to $2 than $10 in daily income, and thus still a ways from the transition to middle-income status.” At such a precarious income threshold, a vast majority of Indians are literally at the edge of the global poverty line, just one economic/health shock away from slipping back into poverty, undoing the gains of years and decades. This is why the provision of quality, public healthcare is critical more than ever in India.
The tertiary, primary and secondary divide - Healthcare delivery in India is classified under three categories – primary, secondary and tertiary care. Primary healthcare is where we go for the most basic of healthcare needs, the first line of defence of sorts. These comprise of basic clinics, sub-centres, Mohalla Clinics in Delhi are an example, and primary health centres (PHCs). Secondary care is about the more advanced, evolved healthcare needs wherein we are talking about district hospitals, community healthcare centres, sub-divisional hospitals etc. Tertiary healthcare refers to the most advanced, specialised tier of healthcare needs which are mainly provided by medical colleges, PSU hospitals, ESI hospitals etc.
Sources: Dun and Bradstreet – “Sectoral risk outlook – Hospitals” October 2014, via Thomson Research, accessed January 2015; “Rural Health Statistics in India2012”, Statistics Division Ministry of Health and Family Welfare Government of India, 30 April 2013
An often overlooked divide is the one which exists even amongst these three tiers of healthcare needs and services in India. To me, it seems like the classic Indian sectoral evolution, because something similar has played out in education as well. We’ve some of world’s best technology and management schools, at the sheer neglect of the most basic and primary of educational attainments by a vast swathe of our school-going population. Similarly in health, we’ve globally renowned hospital chains, pharmaceutical companies and even a few specks of good tertiary level public sector institutions as well, at the expense of the most basic of primary and secondary healthcare facilities for which even today a huge chunk of the spending, if accessible at all, is done out of pocket by individuals themselves. I’m sure most of us are aware of how swathes of primary healthcare centres across this country lack access to electricity, running water, permanent structure etc. Therein lies the most under-discussed a disparity, one which is equally damaging to overall health outcomes.
One of the key components of PMJAY has been the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres, with the goal of delivering Primary Health Care. As Dr Indu Bhushan, CEO of PMJAY-AB recently mentioned in an interview to the economic times, “There is this false dichotomy that we should be supporting primary care and public healthcare. But if you do more primary care, you will also need more secondary and tertiary care…Once people know that there is a linkage to treatment, they will be keener to go get themselves screened. Secondary and tertiary care facilities also incentivise people for using primary care. Also, this (public provisioning) is what we’ve been doing for 70 years. Now because of the ageing of the population, because of environmental concerns that we have, because of the shift from communicable to non-communicable diseases, the need for secondary or tertiary care is going to increase. Of course, if you have strong primary care, it will prevent some diseases. But the impact of that will come with a lag…When it comes to poor people, they don’t have a choice. They will just die because they can’t afford treatment. Supporting these people who can’t afford it is a very legitimate public policy question that we can’t ignore. “
What about funding?
Let’s dive into how healthcare is funded in India – If someone’s healthcare is funded by the government, it comes primarily via two streams – free healthcare provided in public healthcare centres across the country both by the union as well as the state governments, and publicly provided insurance coverage for government employees, and, in a radical departure, for more than 500 million of India’s most underprivileged after the introduction of Ayushman Bharat.
As far as Private means of funding healthcare needs go, again, the two primary streams are Out of Pocket expenditure as well as medical insurance.
I’d like to bring into focus three points here -
First: Healthcare in India suffers from chronic underspending by the public sector, amounting to just about a third of the total amount spent on healthcare in the country. For perspective, this amounted to just about 1.2% of GDP, woefully lesser then what most of our much poorer neighbours spend, let alone the world’s fifth-largest economy and its second-most populous country. Private spending accounts for nearly 70% of the spending on health in India.
Second: It is very interesting that Public + Private, i.e. total amount spent on healthcare in India comes to around 3.6% of GDP, a far cry from around the US (16.9%), Germany (11.2%), France (11.2%) and Japan (10.9%), for perspective. But, a great thing to take note of is that the total per capita spending on health in India has nearly doubled in just the last five years alone – from ₹1,008 per person in FY15 to ₹1,944 in FY20, and it’s a trend which needs to be consolidated and accelerated going forward, especially given the emerging challenges we face.
Graphic: Sarvesh Kumar Sharma/Mint
Third: It’s crucial to remember that Out Of Pocket expenditure contributes to close to 86% of private expenditure and 60% of overall healthcare expenditure. As a consequence, and as already discussed briefly earlier, nearly 40 million people in India are in debt because of out of pocket expenditure on health and it’s estimated that nearly a third of the population requiring healthcare services are pushed below the poverty line owing to lack of insurance coverage and Out Of Pocket expenditure. Thankfully, with increasing awareness and traction, Ayushman Bharat is steadily changing that for good! Moreover, Universal Health Care access is something we’ve legally committed to under SDGs and it remains a political imperative as well: this, again is where Ayushman Bharat aims to reach eventually and it’s a goal NHA has been working towards steadily as well.
What fascinates me the most about healthcare in India and certain trends going ahead:
- A classic case of the application of Goodhart’s law in India: again exactly mirroring education, is our focus on outputs and not outcomes. Remember RTE’s excessive focus on the size of windows in classrooms, ceiling height, size of playgrounds etc. and not on the wider context and policy steps necessary to ensure quality educational outcomes like learning? Quoting from a report published earlier in the leap journal, as per regulations, “a hospital should ideally have 80 to 85 sq.m of plinth area per bed; there should be a toilet for every six beds; and one operation theatre for every 50 beds in the general ward. The standards for district hospitals requires 300 district-hospital beds per million population, five to ten% of the total beds in a district-hospital should be ICU beds and each ICU bed should have a ventilator (amongst other equipment) etc.” C
The idea here is not to diss the importance of minimum standard requirements, but the fact remains much of our fixed, persistent focus on outputs comes at the cost of critical outcomes instead, basics like quality and reliability of healthcare services delivery.
- Evolution in the disease profile: This is not so much in the garb of future but a living reality already, that the profile of diseases most prevalent in India has shifted decisively over the years from mostly communicable diseases like tuberculosis, chickenpox etc, to more and more Non-Communicable Diseases (NCD) rooted mostly in lifestyle and environmental concerns: for example Cancer, diabetes, heart stroke etc. This required a shift in policy and allocation of resources over time. This shows up within states as well, for example Bengal faces more risk of communicable diseases while more prosperous states like Punjab struggle with more NCDs and lifestyle-oriented ailments.
But the current pandemic, for example, a communicable phenomenon through and through, makes me wonder if some of the focus would shift back from NCDs on a more permanent basis going forward, given the increasing frequency of similar outbreaks over the years, most of which we learn to live with eventually. The HIV virus epidemic, for example, we know how it spreads and transmits from one individual to another, and it has infected millions of Indians ever since its cases were first reported in 1981 in the US.
- What long-term impact will COVID19 have on healthcare in India? This is honestly as much a question as it is a speculation, for now at least. We know there is increasing political capital building up over necessary improvements in the state of healthcare in India, people are more aware and concerned, especially since the well off couldn’t just pay their way out of a crisis this time around most shiny private institutions have been requisitioned by the state for COVID duties as well. This idea of we are all truly in this mess together is slowly dawning upon people across classes, at least in this regard is what I feel. However, will we stop paying doctors working in district hospitals 30-40,000 a month after this, valuing their skills and demand for what it is? I can only be hopeful.
But coming back to the main issue here, which is how much of this ad hoc augmentation in medical capacity being done in view of the pandemic is going to stay with us once the pandemic is over? I have tried all I could to put together some numbers, but the fact remains a lot of this ad hoc creation of bed/hospital capacity is temporary plus mostly in semi-permanent structures, at the expense of other routine medical procedures, and not sustainable at all once the complete shift is focus happens over time. Yes, some states indeed have come up with new hospitals, new wards/buildings have been inaugurated, so there has been some augmentation of the capacity of course, but it is still at the margins I feel, and this is something which will start to get clearer over the next year or so.
- Two policy errors which stood out for me during the current crisis: First was definitely not leveraging our existing Primary Heath Care centres at all to augment our capacity in tackling the virus. For example, Delhi has this set of rather renowned Mohalla Clinics, essentially better run, better equipped and better funded Primary Healthcare Centres all across the city. Reports indicate how they were basically closed off for the first month or so during the lockdown and that the healthcare staff there hasn’t been roped in to help augment capacity in their respective local levels just when it’s needed the most at all.
Speaking of the capacity of the system, the second but equally puzzling such oversight seemed to be the decision of not allowing more than 20,000 Indian doctors/medical students, who’ve earned their degrees in medical schools abroad, of joining hospitals in India and helping massively in alleviating the existing capacity constraints we are operating with despite them wanting to.
- This is just a thought bubble: Okay so according to WHO: health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is, de facto, the quality of human health upon which the realisation of life goals and objectives of a person, the community or nation as a whole depends. Health is a multi-dimensional phenomenon. It is both an end and a means of development strategy. The relationship between health and development is mutually reinforcing- while health contributes to economic development, economic development, in turn, tends to improve the health status of the population in a country.
My point here is to ask you that what do you think, what the emergent and upcoming challenges within the broader ambit of healthcare are that we’d have to face up to sooner rather than later? The above tweet and news link bring to my mind this set of thought. For example, in some regards health and safety of a population is being weaponised by some states. There is this whole swathe of a newer, equally important set of the phenomenon we are to tackle as a society, be it mental health, greater need for preventive care, awareness on hygiene, increased immunisation, managing patient data and privacy since more and more is being generated and recorded with every passing day, increasing geo-politicisation of healthcare (hydroxychloroquine being the best example for this), the unbounded potential that biotech holds to completely alter our fundamental assumptions about our anatomical functioning etc.
I’d love to hear your thoughts on this essay more broadly, and this concluding set of questions more specifically. Also do let me know if you’d want me to write on any of these in greater details sometime soon.
Thank you for reading!
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