Healthcare in India: An Overview (Part 1)

By Mohammad Anas Wahaj; MBA, University of Illinois at Urbana-Champaign, 2000, USA; BS in Mechanical Engineering, Aligarh Muslim University, 1993, India
Dated: 15 September 2018

Brief Introduction

India's large size with huge population (1.25 billion), substantial part of which resides in rural and underdeveloped regions, brings both challenges and opportunities for implementing healthcare policies and initiatives, both public and private. Over the years ineffective implementation of such initiatives at various levels, has created lopsided infrastructure and uneven development in healthcare. Although there are more advanced healthcare facilities in large cities, but villages and remote areas lack even the basic healthcare services. In 2018 budget Indian government recently announced the National Health Protection Scheme (NHPS) to provide government-sponsored insurance to nearly 40% of India's population. An announcement was also made by government to create 150000 wellness centers across the country as Ayushman Bharat Program.

Health is associated with the overall wellness of the citizens. Good health reflects on the productivity and growth of the nation. More so in the case of India as substantial population is young. India has more than 50% (about 662 million) of its population below the age of 25 and more than 65% below the age of 35. By 2020, the average age of India's population is expected to be 29 years. Aging of this large population will happen at the same time. Having adequate infrastructure is key to avoid a massive health catastrophe for this elderly population in future.

Health is also a key issue in the public policy sphere. In the public policy context healthcare issues are often related to accessibility, affordability, socio-economic disparities, healthcare delivery mechanisms, illness and diseases and their impact on society etc. Government policy should ensure universal healthcare at basic and primary level with affordability and quality, proper laws for smooth functioning of heathcare system and sufficient competency level of healthcare providers. Moreover, there should be an effective policy framework that emphasizes better healthcare to vulnerable groups like children, women, differently abled and senior citizens.

India have a conceptual universal health care system run by the constituent states and union territories. The biggest challenge is to make it accessible and affordable for the overall population. Although both public and private sector provide healthcare services, but at present times, healthcare policy is designed to give more impetus to private sector involvement alongwith PPPs (Public-Private Partnerships). Healthcare education sector too has both public and private insitutions providing services alongwith corporates that mostly focus on allied services and training.

Historical Aspects: Evolution of India's Healthcare - Past and Present

As with most of the old civilizations, healthcare in India too has gone through many iterations. Lot of experimentations and trial and errors have happened. One of the oldest developed form of healthcare practice in India has been Ayurveda and Siddha. And then through the advent of Muslims they brought with them the Unani Medicine (Greek) and Tibbi system alongwith the latest practices of that time. The coming of the British and Europeans after the renaissance brought modern medical practices into the country. Alopathy, homoeopathy, and modern surgical procedures evolved with interactions from other countries and civilizations. Now all healthcare streams co-exist in India. Some have expanded more while some others have taken a back seat, depending on the government's patronization and public demand. The more government policy initiatives and budgetary allocations, the better is the growth of that particular system.

In ancient times, health and illness were interpreted in a cosmological and anthropological perspective. Religious beliefs and magical practices were the dominant forces through which medicine and cure of diseases were often derived. Food and medicinal plants were the main component of health and disease management. In 5000 BC (Vedic Times), the medicine was intermingled with superstition, religion, magic and witchcraft. Siddha and Ayurveda are the most ancient Indian origin medicine systems. Ayurveda encompassed most parts of the Indian peninsula while Siddha was mostly concentrated in South India particularly in the present state of Tamil Nadu. Sowa Rigpa System of Medicine based on Tibetan Medicine is another form of indegenous Indian medicine. Hygiene was an important aspect of ancient Indian medicine.

Medieval times had influx of muslims from central asia and middle-east bringing the prevalent Greek and Tibbi system. 1453-1600 AD is considered as period of 'revival of medicine' globally - inclination towards medicinal research, theory of contagion and art of surgery. 17th and 18th century had Harvey's discovery of circulation of blood, Leeuwenhoek's microscope, Jenner's vaccination of small pox etc.

The era of modern medicine came in 19th century with the dichotomy of medicine between preventive and curative medicine. After 1900 AD medicine moved towards specialization and expert oriented healthcare. Modern science ushered in discovery of synthetic insecticides, discovery of drugs, sanitary awakening and concept of disease eradication. 20th century also saw development of screening for the diagnosis of disease in its pre-symptomatic stage. This period includes the development of family, social and community medicine.

India's National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. Some important milestones regarding healthcare in Independent India are - Primary Health Centers (1952); Family Planning (1952); Green Revolution (1967-77); National Health Programs (1957); National Health Policy (1982 & 2002); Health for All 2000 - Primary Healthcare; Millennium Development Goals (2000); National Health Policy 2003; National Rural Health Mission - NRHM (2005); Public Health Foundation of India - PHFI (2008).

The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a particular focus on 18 states with poor health indicators and that lacked adequate infrastructure.

The High-Level Expert Group (HLEG) on Universal Health Care (UHC) was constituted by the Planning Commission of India in October 2010 with the mandate of developing a framework for providing easily accessible and affordable health care to all Indians defined as Universal Health Coverage. The recommendations of the HLEG on Universal Health Coverage encompass the area of health financing, health services norms, human resources for health, community participation and citizen engagement, access to medicines, vaccines and technology and management and institutional reforms.

The long term objective of the Twelfth Five Year Plan (2012-2017) strategy was to establish a system of Universal Health Coverage (UHC) in the country. In the Twelfth plan period entire Below Poverty Line (BPL) population was expected to be covered through Rashtriya Swasthya Bima Yojana (RSBY) scheme. The National Health Policy had been worked upon further in 2015.

Now the Planning Commission has been replaced with NITI Aayog (National Institution for Transforming India) and 12th Five Year Plan was the last one. NITI Aayog envisages a bottom-up approach to policy making as compared to the earlier top-down approach under Planning Commission. Medical education reforms are on its agenda.

NITI Aayog recently released its first comprehensive Health Index report titled, 'Healthy States, Progressive India', that ranks states and Union territories innovatively on their year-on-year incremental change in health outcomes, as well as, their overall performance with respect to each other. Health Index has been developed as a tool to leverage co-operative and competitive federalism to accelerate the pace of achieving health outcomes. Linking this Index to incentives under the National Health Mission by the Ministry of Health and Family Welfare underlines the importance of such an exercise.

The Ministry of AYUSH was formed on 9th November 2014 to ensure the optimal development and propagation of AYUSH systems of health care. Created in March 1995, the Department of Indian System of Medicine and Homeopathy (ISM&H) was renamed as Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November 2003, with focused attention for development of education and research in these fields.

Swachh Bharat Abhiyan, launched on 2nd October 2014, is also an important ingredient of assuring better health through cleanliness and hygiene and prevention of related diseases and disorders. The program is run by Government of India and as one of its main aim intends to achieve an Open-Defecation Free (ODF) India by 2nd October 2019, the 150th anniversary of the birth of Mahatma Gandhi, by constructing 90 million toilets in rural India at a projected cost of Rs. 1.96 lakh crore (US$ 30 billion).

In 2018 budget Indian government recently announced an ambitious plan called the National Health Protection Scheme (NHPS) to provide government-sponsored insurance to roughly 500 million people or nearly 40% of India's population. In addition, an announcement was also made by government to create 150000 wellness centers across the country by 2022 as Ayushman Bharat Program. The first center under the Ayushman Bharat Scheme was inaugurated by the Prime Minister of India at Jangala in the tribal district of Bijapur, Chattisgarh.

Health Statitistics and Healthcare Data

• World Health Organization's (WHO) 2000 World Health Report rank India's healthcare system at 112 out of 190 countries.
• India is ranked a lowly 154th on Healthcare Access and Quality Index 2015, making it among the biggest underachievers in Asia.
• India has a life expectancy of 68.3 for both sexes, 66.9/69.9 years (m/f) - (WHO, 2015)
• Infant mortality rate (IMR) of 34 per 1000 live births. The total number of estimated infant deaths have come down from 930000 (9.3 lakhs) in 2015 to 840000 (8.4 lakhs) in 2016. (SRS Bulletin, 2016)
• Total health expenditure as percentage of GDP is 4.7%. (The World Bank, 2014)
• Public health expenditure as percentage of GDP is 5.0% (The World Bank, 2014)
• National Health Policy 2017 (NHP) aims to double the government spend - from the existing 1.15% of the GDP to 2.5% by 2025, the budgetary allocation of Rs 52800 crore for health in 2018-19 was merely 5% higher than the revised estimate of Rs 50079.6 crore, in 2017-18.
• India's new National Health Policy envisages health systems strengthening by increasing public health expenditure to 2.5% by 2025 and increasing state health spending to more than 8% of their budget by 2020.
• India’s total health expenditure as percentage of GDP is around 4.7%, with out-of-pocket spending accounting for around 63% of this spend.
• Each year, 63 million people - close to the population of the United Kingdom - are pushed into poverty because of catastrophic health expenditure.

Malnutrition

• 38% of children under five are affected by stunting - children too short for their age due to lack of nutrients, suffering irreversible damage to brain capacity.
• About 21% of children under 5 are defined as 'wasted' or 'severely wasted' - meaning they do not weigh enough for their height.
• Over half of women of reproductive age - 51% - suffer from anaemia - a serious condition that can have long term health impacts for mother and child.
• More than 22% of adult women are overweight, a rising concern as women are disproportionately affected by the global obesity epidemic.
• In India, 16% of adult men and 22% of adult women are overweight.

Diseases & Doctors

• Nearly 61% of deaths in India are now attributed to non-communicable diseases, including heart disorders, cancer and diabetes. Almost 23% are at risk of premature death due to such diseases. (WHO Report, 2017)
• In India, a total of 5817000 deaths were estimated from diseases like cancer, diabetes and heart problems in 2016. (WHO, 2017)
• Cardiovascular diseases (coronary heart disease, stroke, and hypertension) contribute to 45% of all NCD deaths, followed by chronic respiratory disease (22%), cancer (12%) and diabetes (3%). (WHO Report, 2017)
• Cancer, diabetes and heart diseases alone account for 55% of the premature mortality in India in the age group of 30-69 years. (WHO Report, 2017)
• New infections from HIV, the virus that causes AIDS, have almost halved in India over the past decade, but decline has to be greater to end AIDS by 2030. India had 2.1 million people living with HIV at the end of 2016, with new infections falling to 80,000 in 2016 from 150000 in 2005. Of these, 9100 infected were children under age 15 years. (UNAIDS Ending AIDS Report, 2017)
• Viral hepatitis has been recognized as a serious public health problem in India by the WHO with over 52 million people infected with chronic hepatitis in the country. Latest assessment by WHO shows that in India, 40 million people are chronically infected with Hepatitis B and 6 to 12 million people are chronically infected with Hepatitis C. (WHO, 2016)
• In India, there is one government allopathic doctor for every 10189 people, one government hospital bed for every 2046 people and one state-run hospital for every 90343 people. India has a little over one million modern medicine (allopathy) doctors to treat its population of 1.3 billion people. Of these, only around 10% work in the public health sector. (National Health Profile, 2017)
• Only one in five doctors in rural India are qualified to practice medicine, found a WHO report on India's healthcare workforce, highlighting the widespread problem of quackery. The WHO report, published in 2016, said 31.4% of those calling themselves allopathic doctors were educated only up to Class 12 and 57.3% doctors did not have a medical qualification. (WHO Report, 2016)
• Doctors of Allopathy 1022859, Dental Surgeons 197734, AYUSH practitioners 771468, Auxiliary Nurse Midwife (ANM) 821147, Allopathy Doctors in public hospitals 113328.
• India has 1 million doctors of modern medicine (allopathy) to treat its 1.3 billion population. Of them, just 1.1 lakh work in the public health sector, to which India's 900 million rural population turns for treatment.

Infrastructure

• Modern Medicine (Allopathy) Hospitals in India 14379, Beds 634879; Urban 3325, Beds 425869; Rural 11054 Beds 209010.
• Whereas 58% of the doctors in urban areas had a medical degree, only 19% of those in rural areas had such a qualification (Unqualified Medical Practitioners Report 2017)
• AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) - Dispensaries 26405, Hospitals 3639.
• Medical Education - Colleges 462, Students 56748; Dental colleges (BDS) 309, Students 26790; Dental MDS 242, Students 6019, Nursing Colleges 3123, General Nurse Midwives 125764; Pharmacy Colleges 777, Students 46795. (National Health Profile 2017, Ministry of Health and Family Welfare)
• A Comptroller and Auditor General (CAG) report in June revealed a 27.21% shortage for clinical equipment and 56.33% for non-clinical equipment, of which oxygen supply is a part. The report found critical medical equipment had not been used for more than five years because there was no annual maintenance contract.
• Another data shows, there are total 439 Medical Colleges in the country out of which 212 are government run and 227 are private. Total 59883 MBBS seats of which 30790 are in the private sector. Total of 26390 PG seats in the country.

Healthcare Today - Policy, Infrastructure, Finance and Insurance, Challenges and Opportunities

At present, India's healthcare is the mix of various systems. It includes Ayurveda, Siddha, Unani, Alopathy, Homoeopathy, Naturopathy etc and of course the large number of quacks, who find their patients in the illiterates and ignorant poor and rural population. India's large population with a sizeable rural percentage, makes it challenging to provide uniform healthcare to all. There is also existence of public and private healthcare facilities and hospitals, nursing homes, clinics etc. Corporates are also entering into the fray and developing modern healthcare infrastructure. Although they mostly serve the rich and well off and are concentrated in the metros and big cities.

Healthcare Policy

Health sector is the responsibility of the state, local and also central government. Service delivery is state responsibility. Center is responsibile for healthcare in union territories without a legislature. It is responsibile for developing and monitoring national standards and regulations, linking the states with funding agencies, and sponsoring numerous schemes for implementation by state governments. Both the center and the states have a joint responsibility for programs listed under the concurrent list.

The 14th Finance Commission (Est. 2013), operational duration 2015 to 2020, increased the State's share from central taxes from 32% to 42% of divisible funds. The share of health expenditure in total public expenditure peaked in the Indian States in 1987, but it has been more or less secularly declining thereafter. According to the constitutional division of expenditure responsibilities, the principal burden of health expenditure has to be borne by the States. In recent years, the Center has stepped up healthcare expenditure through various schemes. Nevertheless, the States' share in health expenditure remains above 70%.

India's Planning Commission used to create monitorable timebound goals for healthcare within the 5-year plan system. For example, some of the basic goals of the 11th 5-year plan (2007-2012) were - Reducing Maternal Mortality Rate to 1/1000 live births; Reducing Infant Mortality Rate to 28/1000 live births; Reducing Total Fertility Rate (TFR) to 2.1; Providing clean drinking water to all by 2009; Reducing malnutrition among children of age group 0-3 to half its present level; Reducing anemia among women and girls by 50%; Raising the sex-ratio for age group 0-6 to 935 by 2011-12 and 8950 by 2016-17. Moreover, the long term objective of the Twelfth Five Year Plan (2012-2017) strategy was to establish a system of Universal Health Coverage (UHC) in the country. It aimed to provide health insurance for all the population that was below poverty line (BPL). The present government has now dissolved the Planning Commissions and substituted it with NITI Ayog.

NITI Aayog recently released its first comprehensive Health Index report titled, 'Healthy States, Progressive India'. Health Index has been developed as a tool to leverage co-operative and competitive federalism to accelerate the pace of achieving health outcomes. Linking this Index to incentives under the National Health Mission by the Ministry of Health and Family Welfare underlines the importance of such an exercise.

National Accreditation Board of Hospitals and Healthcare Providers (NABH) committee's purpose is to make provisions for access, assessment, care of patients and protect patient's rights. Clinical Establishment Act (2006) established to promote low cost and good quality healthcare. It is a policy decision on easy provision of 'medical visas', increased foreign investments in various healthcare segments such as insurance, development of competent technology and have well trained personnel.

India's universal health plan that aims to offer guaranteed benefits to a sixth of the world's population will cost an estimated Rs 1.6 trillion (US$ 25.73 billion) over the next four years. Government of India had earlier launched the National Deworming initiative aimed to protect more than 24 crore children in the ages of 1-19 years from intestinal worms, on the eve of the National Deworming Day.

Under the National Health Assurance Mission, the government would provide all citizens with free drugs and diagnostic treatment, as well as insurance cover to treat serious ailments. The Center's Rs 160000 crore National Health Assurance Mission promises more than 50 free drugs, a dozen diagnostic tests and insurance cover to all by 2019. Similar programs have delivered on a smaller scale. The Vajpayee Arogyashree Scheme, which provided health insurance for catastrophic illnesses to households below the poverty line in Karnataka, lowered death by 64% and halved out-of-pocket spending on hospitalizations, found a study of more than 60000 households in close to 600 villages.

Over the past two decades, successive governments at the Center, and lately, the National Health Policy 2017, have promised to raise India's public health expenditure to 2.5% of the GDP, yet the current spend hovers at 1.4%. States account for 0.9% of this expenditure, with Centre's share being an abysmal 0.6% of the GDP.

The Central theme of the Eleventh Five-Year Plan was to deepen the role of the market in healthcare. The principal instrument suggested was Public-Private Partnership (PPP). The main objective of the National Rural Health Mission (NRHM) has been to strengthen primary healthcare infrastructure, but in practice private sector has been the one coming to the rescue. Reviews of the NRHM indicate that its intended objectives are not being achieved. Over 80% of the health expenditure in India is in the private sector, while in most developed societies more than 80% of health expenditure is borne by the state. Our public sector share is around 1% of GDP. One of the basic weakness of the Indian healthcare is the absence of an accessible basic doctor. Even today, 70% of primary healthcare is provided by unqualified practitioners.

Healthcare Infrastructure (Public and Private)

Constitution provides State with a responsibility of strategic directional role for the good health of all its citizens. Public health infrastructure has been the major component of India's healthcare system, although it has never been adequate. It includes delivery of primary healthcare services through primary health centers and sub-centers, hospitals and health centers that comprise community health centers, rural hospitals, district hospitals and centers, specialist hospitals and teaching hospitals. Public health insurance schemes have employee state insurance scheme, central government health scheme alongwith insurance for other departmental employees like defence and railways.

There has been an increase in rural health facilities from 725 to 163000 during the period 1950-2000. But, there is a shortfall by 16% in Primary Health Centers (PHC) and 58% in Community Health Centers (CHC). Public health infrastructure is not satisfactory with many lacunae - policy and management issues, shortage of health staff, weak referral system, inadequate funds and overall lack of accountability in providing quality care.

Private sector plays a substantial supporting role in the healthcare infrastructure and includes private hospitals, polyclinics, nursing homes, and dispensaries. Moreover, there are general practitioners and their small private clinics. Although majority of healthcare services are provided by private sector, the government has recently taken initiatives to institutionalize PPP in healthcare. During the last decade there has been deliberate policy focus on privatization of healthcare to reduce public expenditure and fiscal deficits. This shift towards privatization has further deteriorated the condition of public health services and put general public in dilemma to seek healthcare. Choice for the public is between weak and inefficient public services and expensive private healthcare delivery. At times people even forego care entirely except in life threatening situations, that often results in indebtedness.

Universal Health Care (UHC) is not achievable without substantial participation of private sector. Government should increase public spending, but at the same time also partner with the private sector. Such partnerships may include subsidizing facilities for a section of people in private hospitals to increase access; incentivizing private hospitals to operate in rural areas; using technology widely to improve penetration of healthcare such as through telemedicine.

Health human resources are major component of healthcare infrastructure. Rural health infrastructure consists of over 5 lakh trained doctors working under plural systems of medicine and a vast frontline force of over 7 lakh ANMs, MPWS and Anganwadi workers besides community volunteers. As part of rural primary health care network alone, a total of 1.6 lakh subcenters (with 1.27 lakh ANMs) and 22975 PHCs and 2935 CHCs (with over 24000 doctors and over 3500 specialists to serve in them) have been set up. To promote Indian systems of medicine and homeopathy there are over 22000 dispensaries 2800 hospitals. Besides 6 lakh angawadis serve nutrition needs of nearly 20 million children and 4 million mothers.

Data from the the National Family Health Survey (NFHS) 2015-16 shows that public sector doctors are often unavailable or offer poor quality care. 55% of households reported not using government health facilities when sick, and 48.1% of such households cited poor quality of care as one reason for avoiding public health facilities. Data shows that there is a broad correlation between quality of care and usage.

For general public that can't afford private health services, government policy and initiatives come to the rescue and play an important role to enhance the healthcare infrastructural capacity. Government provides tertiary hospitals with concessional land, customs exemption and liberal tax breaks and in return they have to reserve beds for poor patients for free treatments. In the current health system, there are no regulatory and accountability procedures to ensure compliance of such agreements - the disclosure systems are far from transparent, redressal of patient grievances is poor and allegations of cuts and commissions to promote needless procedure are common.

Corporate tertiary hospitals are run as businesses and use business strategies to attract patients, often those at the top of the pyramid, those with sufficient health cover through insurance or general emergency cases of those that rely on loan or charity to pay for treatment. The standards of these hospitals are world class and have best experts and specialists on the payrolls.

Most of the noncorporate private entities such as nursing homes are run by doctors and doctor-entrepreneurs and remain unregulated either in terms of facility of competence standards or quality and accountability of practice and sometimes operate without systematic medical records and audits.

Healthcare Finance and Insurance

Healthcare affordability is an essential component of healthcare systems. It is related to the availability of finance when it is needed to avail healthcare services. In most health systems, insurance is the prevalent form of financial planning. Indian health system lacks effective payment mechanism and has a high out-of-pocket expenditure (roughly 70%). India's poor provision of healthcare and low insurance cover leads to very high out-of-pocket expenditure on health, leading many households into penury. Adverse health events (health shocks) have considerable impact on India's overall poverty figures, adding about seven percentage points.

Public health spending accounts for 25% of aggregate expenditure, the balance being out of pocket expenditure incurred by patients to private providers. Public spending on health in India has itself declined after liberalization from 1.3% of GDP in 1990 to 0.9% in 1999. Central budget allocations for health have stagnated at 1.3% to total Central budget. In the States it has declined from 7.0% to 5.5.% of State health budget. A good chunk of health funds remain unutilized by states. Share of funds unspent in total grants under the health department increased in 2016-17 (DHFW-10.09%) after declining in 2015-16 (DHFW-3.2%), 2014-15 (DHFW-19.76%). Even where funds are channelled, quality of care remains poor. 47% of the people who visit a public hospital do so because they have no choice. And while private clinics are more popular, doctors in such clinics are often inadequately qualified.

Notwithstanding a significant rise in allocation to the health sector in the 2017-18 budget over the previous year, the Union government’s spending on health and family welfare amounted to merely 0.3% of GDP (gross domestic product), budget data shows. Even after including states, the overall government expenditure on health remains extraordinarily low. India's disease burden is higher than most peers while its spending to combat such diseases is lower than most peers. (Public Health Expenditure 2014 - 1.41% of GDP, US 8.28%, UK 7.58%, South Africa 4.24%, Brazil 3.83%, Russia 3.69%, China 3.1%).

According to the World Bank and National Commission's report on Macroeconomics, only 5% of Indians are covered by health insurance policies. But now health insurance is one of the fastest growing sector of the health business. The government is also a major player in the insurance sector and also regulates the private insurance markets. It also runs several safety net health insurance programs for the high-risk population. Some of the programs in this regard include Community Health Insurance program for the population below poverty line and Life Insurance Company (LIC) policy for senior citizens. General Insurance Corporation (GIC) monitors and controls most of these programs. In these programs people pay upfront cash and then get reimbursed by filing a claim. Government employees too have specifically designed insurance programs.

In India, the share of healthcare expenditure borne by insurance companies is now less than 3%. But, policies are now designed to bring insurance into the mainstream healthcare finance. Insurance covers only the cost of hospitalisation and not expenditure on outpatient care. NHA statistics show that close to 70% of the out-of-pocket expenditure of the household is for outpatient care, which will not be covered by insurance. Even in the U.S. about 50 million persons (over 15% of the population) do not have any health insurance cover as they do not have employers to pay their premium. In the Indian situation where a majority of the people are self-employed, universal coverage will be difficult to achieve desired and effective results. Healthcare infrastructure is not upto the mark. Villages and small towns don't have modern healthcare facilities and rural public have to travel distances to get care. Without standard health infrastructure health insurance will not work.

Government insurance is one of the ways to provide equitable health care to those who can't afford healthcare. Employed population and those who can afford it there are private voluntary health insurance cover. For the unorganized sector sector there can be community based health insurance. Government's recent announcement to publicly fund 40% of population under NHPS and earlier program of Rashtriya Swasthya Bima Yojana (RSBY) meant for the poor is unlikely to serve its purpose due to infrastructural shortcomings.

The recent opening up of the general Insurance sector to foreign companies brings dynamism to the market and necessary competition that potentially benefits the consumer.

India's Healthcare Challenges and Opportunities For Improvement

The current state of India's healthcare delivery system is not upto the mark and lacks overall consistency and uniformity. Some regions have better healthcare facilities available while others are deprived of even the basic health infrastructure. There are also successfully implemented models of healthcare in various pockets and this gives a positive outlook as these models can be replicated in more areas and best practices applied at a larger scale. Opportunities are many and need is for strategic commitment by all the stake-holders - government, public and private players, ngos and even public.

India's healthcare system faces substantial challenges, from the need to improve physical infrastructure to the necessity of providing health insurance and ensuring the availability of trained medical personnel. Some of the problems with Indian healthcare include - Poor availability and access to healthcare; Inefficient public health services; Lopsided health infrastructure; Shortage of health professionals; High out-of-pocket expenditure; Low insurance coverage; Low use of public health data; Inadequate monitoring and surveillance system; Vulnerability to infectious diseases; Large urban-rural gap in facilities; High burden of diseases; Challenge of diabetes, malnutrition, child and infant mortality.

Public health infrastructure is insufficient and inefficient for the population that requires it. Poor often have to avail private health services which are not only costly but also not readily available due to locational issues. Only 20% of OPD and 45% of inpatient care obtained from government health infrastructure while the rest is from the private sector. There is a wide urban-rural gap in the availability of medical services leading to inequity in health delivery. There are below par facilities even in large government institutions compared to corporate hospitals. Some issues that government facilities face include lack of funds, poor management, political and bureaucratic interference and lack of leadership in medical community.

Access and affordability remain the biggest challenges of India's healthcare. Large portion of the population cannot afford private healthcare while the public healthcare infrastructure is in shambles and is overburdened with excessive input of patients. Economic deprivation in substantial segment of India's population has cascading effect. It results in poor access to healthcare and lack of education, further leading to non-utilization of health services and increase in health risks that otherwise would have been avoided. These factors combine to impact life expectancy and IMR (Infant Mortality Rate). Human development indicators are longevity, literacy and per capita GDP. Longevity is a measure of state of health, and is linked to income and education. Logevity is adversely affected by weak health sector. This is visible in India's low rank of 131st amongst world nations on the basis of HDI.

India has high out-of-pocket expenses in healthcare and according to the National Sample Survey Office (2014) they are about 70%. This causes impoverishment to nearly 7% of the population. When it comes to public expenditure of healthcare in proportion to GDP, India ranks disappointingly low. Other BRICS countries perform much better than India in this regard.

Intrastate disparities are prominent and there are wide gaps between the better performing and other states. And in some cases these gaps are observed to be increasing during the nineties. Large differences also exist between districts within the same better performing states. There are visible differences in health outcomes between urban and rural areas, with urban areas better equipped and have effective health delivery. But this is not the case with urban slums that have different demographics. Data shows that urban slum population will grow at double the rate of urban population growth in the next few decades. This will further create challenges in urban health delivery system.

India has overall shortage of doctors and health professionals. But the shortage of doctors and primary health centres in rural areas is another major problem. Medical services are available in a lopsided manner and are more concentrated in urban areas that almost 70% of the doctors in India provide their services in urban centres. There is also shortage of trained nurses in all regions. The need for skilled medical graduates continues to grow, especially in rural areas which fail to attract new graduates because of financial considerations. A sizeable percentage of the graduates also go abroad to pursue higher studies and employment.

India faces high burden of disease due to many reasons - high growth of population, lack of education, lack of environmental sanitation and safe drinking water, under-nutrition, poor living conditions, limited access to preventive and curative health services, and gender inequality.

Analysis of Global Burden of Disease (GBD) study focusing on age-specific morbidity during 2000 in ten most common disease (excluding injuries) shows that 60% of morbidity is due to infectious diseases and common tropical diseases, about 25% due to life-style disorders and 13% due to potentially preventable pre-natal conditions. Domestic R&D has been lacking in efforts with only Rs. 1150 crore going towards it out of the total health expenditure of Rs. 80000 crores. As global focus on R&D on infectious diseases is nominal, India has to make special effort towards it. Data shows that only 11 drugs were indicated specifically for tropical country diseases out of total 1233 new drugs that came into market between 1975 and 1997.

There is a visible and necessary demand for improviding and consolidating the basic primary healthcare and infrastructure. India faces a growing need to fix its basic health concerns in the areas of HIV, malaria, tuberculosis, and diarrhoea. Additionally, children under five are born underweight and roughly 7% (compared to 0.8% in the US) of them die before their fifth birthday. One of the other major concern is lack of access to quality sanitation for large section of the population. This further excacerbates the existing health issues. Out of the total healthcare budget Indian government allocates only 30% towards primary healthcare.

Addressing malnutrition and communicable diseases is another major public healthcare challenge which if addressed can cause a huge reduction in burden on healthcare in India. Challenges also include a shift in the pattern of diseases towards an increased burden of lifestyle diseases. Irony of the health situation is that on one side India has deaths due to under-nutrition while on the other side there is an increasing burden of morbidity and mortality due to lifestyle diseases related to excessive food intake.

Another major health catastrophe pounding on India's door is diabetes and is one of the main challenge at present. Approximately 65-70 million Indians live with diabetes with half of them unaware about their condition. The number is expected to touch the figure of 100 million by 2030. Some of the causes of diabetes include of rapid urbanization, lifestyle, poor diet choices and increasing sedentary lifestyle patterns. To tackle diabetes effectively requires planning and work on both prevention and management.

Some of the other worrisome trends on India's health scene includes cancer, cardiovascular diseases, renal conditions and neglect in regard to mental health conditions. Studies by WHO show that by 2026 with the expected increase in life expectancy, cancer burden in India will increase to about 14 lakh cases. Cardiovascular (CVD) and diabetes cases are also increasing with an 8 to 11 % prevalence of the latter due to fast life styles and lack of exercise. Traumas and accidents leading to injuries are often offshoots of the same competitive living conditions and urban traffic conditions. Data shows one death every minute due to accidents or more than 1800 deaths every day. In Delhi alone about 150 cases are reported every day from accidents on the road and for every death 8 living patients are added to hospitals due to injuries.

India stands to lose US$ 4.58 trillion before 2030 due to NCDs and mental health conditions. Cardiovascular diseases, accounting for US$ 2.17 trillion, and mental health conditions (US$ 1.03 trillion), will lead the way in economic loss. All these diseases can be prevented if managed in time. But lack of trained medical professionals and ignorance on the part of patients make it difficult to treat them efficiently.

According to the Global Nutrition Report 2017, India faces a serious burden of three forms of under-nutrition. These include childhood stunting, anaemia in women of reproductive age, and overweight adult women. Female health issues of prominence include breast cancer, malnutrition, stroke, polycystic ovarian disease (PCOD) and maternal mortality. India faces the twin epidemic of continuing/emerging infectious diseases as well as chronic degenerative diseases. The former is related to poor implementation of the public health programs, and the latter to demographic transition with increase in life expectancy.

The issue of infant and child mortality is a mojor one. 70 out of 1000 children die in the first year and 98 before five years and there is low birth weight (22% UW at birth ands 47% EJW at below 3 years). Most mortality occurs from diarrhoea. Death of newborns in India is much higher than even Bangladesh, and preventable illnesses such as diarrhoea kill more than a million children every year. Deaths from acute encephalitis syndrome (AES) and Japanese encephalitis (JE) are higher in India than neighbouring Thailand because the disease is poorly managed, with most children reaching hospitals for treatment after convulsions have set in because of swelling in the brain.

Lack of adequate data and monitoring is also one of the main reasons for the poor quality of public health services in India. The NFHS report is published once in 10 years. And the health ministry's real-time health management information system (HMIS) suffers from poor quality and data gaps. A 2017 Comptroller and Auditor General (CAG) report showed that 18% of health facilities did not even report basic infrastructure data in the HMIS portal in 2015-16. CAG report also found discrepancies in what the HMIS system reported and the physical records.

The lack of adequate monitoring threatens India's disease surveillance system. The integrated disease surveillance programme (IDSP) initiated by the health ministry in 2004 with funding from the World Bank is inadequately managed. According to a 2015 World Health Organization (WHO) field study, only 41% of 70 district hospitals visited had a district surveillance committee in place. And of the 117 district laboratories under IDSP, many fail to conduct recommended tests. The World Malaria Report 2017 shows India has among the weakest malaria surveillance system with only 8% cases detected, lower than countries such as Zimbabwe, Nigeria, Pakistan, Indonesia, etc. India’s reporting of tuberculosis cases is also not efficient.

India can achieve much better health outcomes through prevention and thus reducing the load on already burdened healthcare infrastructure and facilities. Prevention alongwith early diagnosis and treatment are the most cost-effective strategies for most diseases. Creating awareness about healthy lifestyle at the early stage of human development like in schools and colleges can bring substantial change towards personal hygiene and healthy living. As regards childhood diarrhoea, deaths are totally preventable through simple community action and public education. There should be identification of children having low birth weights and early detection of children at risk from malnutrition by applying low cost screening procedures.

Focus on preventive measures of maternal and child health particularly on improvement in nutrition will give a boost at the developmental stages of the new population that later on becomes a part of demographic dividend. The young adult population of 340 million has to be healthy and remain so to contribute positively to the development of the country. Efficient, effective and intensive utilization of existing rural health facilities can prevent the maternal deaths. Policy and implementation should target key areas such as improved institutional deliveries, better trained birth attendants and timely antenatal screening to eliminate anaemia and at the same time isolate cases.

Rational drug use can prevent emergence of anti-microbial drug resistance, and reduce drug toxicity, adverse drug reactions, and the cost of treatment. Coordinated approach is required to achieve it - patient and physician education, antibiotic policy, hospital infection control team, regional and national antibiotic resistance surveillance.

Health should be perceived as an investment and receive greater budgetary allocation. The objective of National Health Policy is to increase healthcare expenditure from 1.04% of GDP to 2.5% by 2020, with 70% of this being dedicated to primary health care, is a welcome step. The draft policy also lays down plans to provide essential and generic drugs and diagnostics free of cost for all primary health care needs. A few other commendable measures have been with regard to setting up dialysis centres in each district and plans to provide a basic insurance cover to poor people. Education, safe water and sanitation need priority.

Utilization of technology in all areas of healthcare can be transformative to India's healthcare. Use of high tech diagnostic, therapeutic and preventive interventions in the field of medicine and surgery results in physicians spending less time in history taking and physical examination. This improves physician effectiveness and assist them to make better and informed decisions for their patients.

Healthcare should become a primary concern of all elements of Indian society - the government, private sector, nonprofits and people. Although there are many challenges but the opportunities too emanate from them - developing new infrastructure, providing medical equipment, delivering telemedicine solutions, conducting cost-effective clinical trials, developing new drugs and medicines, streamlining health delivery mechanisms and more. Government should make policies keeping in view the present status of healthcare and looking into the future and avoiding silos and lopsided interventions. It should also strengthen regulatory mechanism to keep the sector in check for any abuses. Private sector should consider itself as partner in all aspects of the healthcare development and improvement of the country.

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