The Focus of Healthcare is Increasingly Getting Skewed Towards the ‘Haves’ of our Society. | 26 Jul 2018

Good health is one of the most fundamental and basic essential needs of all human beings. That is why, third of the seventeen Sustainable Development Goals adopted by the world leaders last year aims to ensure good health for all. Indian constitution also implicitly recognizes good health as one of the fundamental rights guaranteed under the right to life. In absence of good health all of man’s endeavors will be deemed useless. For India to fulfill its dream of becoming a developed and prosperous nation it must take care of the most important of its resources i.e. its human capital. India is on the cusp of demographic dividend with the economically productive (15-59 years of age) portion of its population going above the 60% mark. But India can fully utilize this potential only if it is successful in providing for its population proper education, skills, nutrition and healthcare. Among all this, importance of healthcare is perhaps the highest as only a healthy person can be productive enough to fully utilize his skills. Therefore healthcare is of paramount importance for an individual to lead a fulfilling life and also for the whole nation to progress. However is the Indian healthcare system itself in a healthy state?

India has a disproportionately high share of health problems and diseases like child stunting, diabetes, tuberculosis, cancer etc. In the recent round of National Sample Survey (NSS) it was found that over 80% of Indians do not have health insurance cover and that a majority of people in the rural areas utilize private sector health services. Given the relatively lower levels of per capita income in rural areas of our country all these findings certainly raise a question over whether the healthcare system in India is increasingly getting skewed towards the population that has the means to afford it.

To analyze the nature of the health care sector, we can focus on the three major aspects i.e. accessibility, affordability and quality of the healthcare facilities. On all three fronts Indian health care system has had a mixed record. Accessibility to healthcare facilities is high in urban areas as compared to rural areas. The private sector does not find it viable to increase its penetration in rural areas given the low purchasing power whereas the public sector lacks resources, efficiency and enterprise associated with private sector. This is the reason why as per the NSS survey over 70% of both rural and urban people had to resort to private healthcare facilities despite higher costs associated with them.

Private sector healthcare is more costly as compared to public sector for the obvious reason of absence of state subsidy and the guiding motive of profit and hence scores poorly on the affordability parameter. Even if we go by the stringent parameters of Tendulkar methodology for measuring poverty, over 21% of Indians fail to earn enough to spend more than Rs. 33 per day. In such a situation it would be unrealistic and cruel on the part of state to expect the market driven sector to cater to health care needs of even the marginalized sections of the Indian society. That is why, ‘Financial Restriction’ was the major reason chosen by respondents in the latest NSS survey for not being able to utilize the healthcare facilities, both in rural as well as urban areas.

On the quality parameter as well the Indian healthcare system falls short. India spends less than 1.5% of its GDP on health which is lower than many of the Sub-Saharan countries with GDP much below India. In such a situation public sector healthcare facilities suffer from resource crunch and poor infrastructure as seen in public hospitals, unhygienic conditions, lack of availability of medicines at public dispensaries etc. Doctor to patient ratio in India is below the minimum benchmark given by WHO of 1:1000. Even the quality of doctors available is rendered questionable given the poor status of medical education in India. Medical Council of India (MCI), the institution responsible for overall supervision and regulation of medical education in India, has itself been mired in serious allegations of corruption, nepotism, fraud etc. Private medical colleges with no infrastructure and ghost faculty that exists only on paper are very much prevalent in a number of states. The poor state of medical education and its governance can be gauged from the fact that honorable Supreme Court has had to intervene and ask the government for complete overhaul of MCI. In such a scenario the quality of healthcare, especially in public health facilities is indeed quite low. In private sector even though the quality of healthcare is relatively better, question marks are raised over the mushrooming of unregulated clinics and quacks practicing in semi-urban and rural areas.

Therefore, over all three parameters, Indian healthcare system fails to give satisfactory performance. This clearly affects the poor or the marginalized or the ‘have-nots’ section of the society more as those who can afford to spend on the expensive private health care and live in urban areas or nearby, do have access to good healthcare facilities. In fact medical tourism is an upcoming sector of the Indian economy as costs of the private Indian healthcare system are relatively lower when compared with the first world and without any compromise on quality. Hence it is the ‘have-nots’ that the government should prioritize its focus on for providing quality healthcare facilities on affordable rates.

The government has taken a number of steps to increase the accessibility and affordability of quality healthcare for the weaker sections of society. Infectious diseases which accounted for most of the disease burden 25 years ago have been substantially reduced through mass immunization and vaccination programs and use of other appropriate treatments. Huge strides have been taken in public health in India due to effectiveness of such quality programs. Small pox was eliminated in 2014 and India achieved polio-free status in 2014. Maternal and neo natal tetanus was eliminated by August 2015.

Even though massive vaccination programs in India have been successful, research says the immunization coverage has only been 65% again putting it out of reach of the ones who probably need it the most. With the introduction of new vaccines and programs like Mission Indradhanush, India rightly aims to increase the immunization coverage to 90% in next few years.

Tax deductions for research and development in the pharmaceutical industry and protective regime of favorable Intellectual Property (IP) laws have been instrumental in developing India as a major global player in the generic drugs industry. This has mainly helped in increasing access to low-cost life saving drugs to poor patients, not only in India but many other developing and least developed countries of Asia and Africa as well. However, government needs to continuously safeguard against attempts by strong pharmaceutical lobbies in first world countries to arm twist us into changing our successful and WTO compliant IP regime.

Another way to ensure better health facilities for the ‘have-nots’ is by increasing penetration of health insurance in our country. Rashtriya Swathya Bima Yojana (RSBY) that provides for cashless health insurance at authorized private hospitals for below poverty line families and unorganized sector is one such scheme. Similarly other state run health insurance schemes for central and state government employees, tax incentives announced in Budget 2015-16 related to health insurance etc. are also right steps in this direction. Such schemes if properly implemented can go a long way in bringing quality healthcare within reach for all.

However one side effect of these schemes has been the medical overuse crisis in India. A media report shows that between 2009 and 2015, number of surgeries conducted under government health welfare schemes has shot up remarkably. Surgeries like C-sections, hysterectomies and other emergency surgeries are being performed with abandon and without caring about their side effects on patients. This can potentially lead to a situation in India where the poor have access to complex surgeries but not to basic primary health care. Therefore while the government needs to increase oversight over implementation of its health welfare schemes, at the same time there needs to be a realization that health insurance schemes can only supplement a robust public health setup and not be a substitute for it.

Therefore good health is not only a fundamental right but also a necessity for India in order to augment its human resources capability to emerge as a developed nation. Presently healthcare in India is lagging behind on accessibility, affordability as well as quality especially for the socio-economically marginalized sections of its society. India cannot merely rely on the private sector to provide healthcare to the ‘have-nots’ neither is merely relying on expanding penetration of health insurance a solution. India will need to learn from its own successes in public health intervention in the form of mass immunization programs and its success against a number of infectious diseases. If the poor are to be saved from the vicious circle of poverty and poor health feeding upon each other, focus needs to shift to preventive and curative treatments against non-communicable diseases in the public health sector. India needs to at least double its investment in public health facilities and in the overall health sector as a percentage of its GDP. The availability of medicines and doctors and accessibility to public health centers by opening up new hospitals in rural areas needs to be increased. Such investment will provide tremendous long term returns for India not only by increasing productivity of its workforce and hence that of the nation but also via savings in the healthcare expenses. Only with a world-class health setup that leaves no one behind, can India fulfill its constitutional obligation of ensuring Right to Life in a substantive manner as well as take a leap towards truly earning its place among the developed nations!