Identifying the structural challenges of the Indian healthcare systemUsha Manjunath
Growth on the health sector front in India is at best a mixed bag. Even as India continues to struggle on many indicators of morbidity, mortality, and malnutrition, the health sector is rapidly growing. We carry a disproportionate burden of the world’s illnesses, the country accounts for 20% of the global burden of diseases with 17.5% world’s population. Over the 25 years, India’s population increased by 450 million by 2016. Even though the proportion of people living poverty has fallen by half, ‘dual disease burden’ marked by the continuous rise in communicable diseases and spurt of non-communicable ‘lifestyle’ diseases have rendered the system ineffective to meet the demands.
Healthcare delivery system:
Rural Health Statistics 2015 indicates that at least 6 large states had nearly 40% shortfall of Community Health Centers with Bihar having the highest shortfall at 91% and many of those states also are falling short significantly in terms of number of PHCs, the backbone of public health! Compared to 2005, during which we had one Government hospital bed for every 2336 persons, currently, we have one bed for every 1833 person. However, State wise disparities are too high to be happy with averages. For e.g. small state like Goa has one government bed for every 614 but Bihar has one for every 8789 people. National Health Policy envisaged a strong partnership with private providers and medical colleges; their role in primary health care is yet to make a significant mark. Meeting needs of changing epidemiological spectrum, regulation in quality, price and other aspects of service delivery is no easy task. Excess commercialization of private sector and inefficiencies of the public sector has created mistrust among people.
Skewed distribution of skilled human resources:
Critical factor like manpower in the sector shows an imbalance in terms of competencies, rural-urban distribution, and shortages even though the number of MBBS and nursing colleges has increased. KPMG report estimated that 74% of the doctors provide services to a third of the urban population. Many states face the challenges of filling vacancies in the ‘specialty care’ in the public health whereas private hospitals have excess capacities in urban areas. From Gujarat to West Bengal, the shortfall of specialists exceeds 80%. The Recent attempt by Karnataka State to fill specialist vacancies by on-line bid system is a case in point.
India has not done very well on public spending on healthcare which has been around 1% of GDP for so many years even though the National Health Policy 2017 has promised to increase it to nearly 3%. Expansion of public health services funding with NRHM and the recent NHM is laudable. In real terms, we have the lowest funding in public and private sector with nearly 60-70 percent of health expenditures from personal savings-out of pocket expenses’. We have one of the lowest per capita health expenditure in the world. Our Government contributes to roughly 32 percent for insurance while the UK spends 83.5 percent.
Essential medical products and technologies:
Increasing use of high-end technology in everyday practice is further pushing the healthcare costs up. At best patchy implementation of schemes like Jan Aushadhi and variability has not been able to reduce the burden of spiraling cost of medicines. Corruption, hidden charges, and short-term gains increase irrational use of technology, drugs, and commissions (kickbacks or cuts!!) on the purchase of medical devices further creates a vicious cycle. Government’s intervention in price regulation of stents and other products are welcome but they are not enough to reduce the out-of-pocket burden.
Health Information System:
At best our health system is fragmented and so is its information system. IT revolution and streamlining of information across several levels in the health system is yet to be realized. Data accuracy, completeness, quality and integration of various health data are yet to reach the status of a maturity model despite the presence of many agencies ranging from NSSO to the Registrar General of India to disease-specific program-based systems to survey malaria to HIV. The Swastha Bharat mobile application for information on diseases, symptoms, treatment, health alerts and tips; ANMOL-ANM online tablet application for health workers, e-RaktKosh (a blood-bank management information system) and India Fights Dengue are in pipeline. However, we have a long way to go in using HIS for evidence-based public health programs, measuring of outputs/outcomes, EMR and Clinical Information Systems.
Leadership & Governance:
In the end, leadership and governance, a foundation of any well-functioning system at best is a talking point. There is probably more politics, both in private and public sector than governance. We are yet to talk about ‘clinical governance’ even though some, again both private and public hospitals are able to achieve very good clinical outcomes. A number of factors like transparency, due diligence and good governance in financial, HR, System performance and practices need a thorough overhaul of the system. A recent CAG report indicated gross irregularities in government hospitals and equipment purchase. Also, most private hospitals evade taxes. As per CAG report, the data on non-filers of income tax was available in only three states (West Bengal, Assam and Gujarat) and no such process trackers were found in Tamil Nadu, Kerala and Delhi. A lacuna in Leadership from political to organizational levels across public and private health sector is hindering all aspects of health system functioning in the country.
The road may be rough and long for health system reforms but the Odyssey has begun, we have no choice but to buckle up and strive hard.