Saturday 14 September 2013

Need for Health care reforms in India

In 2012, India spent 4.1% of its GDP on Healthcare. This is equal to $75.4 billion marginally higher than some of the poorest Sub-Saharan African countries. China on the other hand spent about 5.1% of its GDP on healthcare (mind you China's GDP is 4.6 times higher than India). Between 1990 and 2013, Indian population increased by 42% with an annualized growth rate of about 7.3% to reach 1.24 billion in 2012. On the other hand, China's population grew by 19% during this period at an annualized growth rate of about 3.5% to reach 1.35 billion in 2012. As in 2012, per capita spend by India government on healthcare was $39 as against $203 in China. I am not even going to bring in statistics from US and other developed nations for the health coverage in those countries are far better (though concerns remain and i will speak about those in my future posts) than what it is in emerging economies. Many economists and so did i believe that this relatively low spending has vastly resulted in poor healthcare facilities in the country. However as i say this, in his paper - "It's broken: Health Policy in India" - Jishnu Das points out there there is virtually no correlation between Public spending on healthcare and health status of the population. In addition, he also points out that availability of nearby government healthcare facilities has no bearing on the health status of the population. In addition to his findings, It seems that the average primary healthcare providers per 10,000 people (2011) across the globe is 14 however the case in Kerala was 2.4 and in Tamil Nadu was 3.1 and in Gujarat was 4.8. These three states have health statistics on par with some of the developed nations. So if additional public spending is going to improve health status, these three states should be spending more on healthcare to bring the ratio closer to the Nation's average of about 12 healthcare providers for 10,000 people. These are interesting findings particularly when the Prime Minister last year announced the Universal Health Coverage (UHC) program indicating access to healthcare for all. In fact soon after Prime Minister's announcement, a series of ministerial meetings lead to announcement of two ambitious programmes - National Urban Health Mission (NUHM) and Free Essential Medicines. When implemented, the programmes would cost the government Rs 22,000 crore and Rs 28,560 crore respectively. The combined cost is equal to about $8.5 billion per year at an exchange rate of RS 60 per USD. 

So what is the missing link?

There are a few issues broadly and i am going to cover only a few key ones in this post - the composition of the providers is one of the important aspects. 59% of the healthcare providers in India have no formal training and 44% of this 59% have just an high school education and another 44% of this 59% have little more than high school education and the remaining 12% of this 59% have barely been to school. 26% of the healthcare providers in the country are Privately trained physicians and only 10% is being offered by the public healthcare providers. This means that if the government is aiming at providing universal healthcare in the country, it has to take over 10 times the market it currently serves! Just moving on this subject - does supply and demand ratio really provide any solution. I mean does it make any sense to talk in terms of ratios (health status to public spending, etc). Professor Jeff Hammer (Princeton University) in his profound speech provided statistics that the ratio of public healthcare spending to health status is not relevant at all so he concluded that the supply and demand analysis does not work in this case and in particular the Healthcare sector. Another scaring detail is that the average amount of time the primary care physician spends in the health center is just 39 minutes per day (Thankfully in Tanzania, it is 29 min). This is a larger level corruption than the so called 2G or Common wealth games - If a doctor is paid a salary for at least 40 hours per week of service and the practitioner spends on an average 6 hours per week. Finally most of these physicians have low capability and make very little effort to bond and create a trust with the people. So much of it boils down to trust and bonding that the people have to set with the physician. It is in fact striking that 80% of the people in India first make a visit to a private practitioner. So this broadly concludes that even if government were to increase spending on healthcare, the results may not be cor-relational. However this evidence still does not help us conclude if spending in general will not help improve health status.

So what is lacking in India - unlike many developed and developing economies which have social welfare organizations that cater to basic amenities such as water and sanitation, India has few besides a few NGOs that work on this ground (India has about 8 lakh ASHA (Accredited Social Health Activists) in the villages with very poor training and knowledge). India suffers from basic sanitation facilities so much so that about 30% of the population that lives in cities have sewage water seeping in to their homes at some point in time in a year. So first of all, Indian cities are still not ready to the so called urbanization. Second, as per the Economist magazine, nearly half of India's small (under five) children are malnourished and this is one of the highest rates of underweight children in the world and in fact higher than most of the countries in the Sub-Saharan African continent. About 48% of Indian Children under 5 are stunted (under height for their age) and about 43.5% of Indian children are under weight. Third, right from 1946 till 2012, we have been talking about universal healthcare however we failed to understand that if we can take care of primary healthcare (essential healthcare), more than half of the bottleneck at the secondary and tertiary healthcare is resolved. As against this, we want to step in everywhere. Part of this illusion is also stems back to low capability of the physicians in the public health particularly in the villages. If a person in a village goes to a primary care physician in a village complaining about heart burns, without any diagnosis or questions, the individual is directed to undertake tests for a probably heart attack. As a result the public claims with respect to healthcare has increased from Rs 750 to Rs 1100 - 1200. So probably the government is mislead on this front that it has to tackle at all levels of healthcare and if we improve the quality of primary care, this misconception could be alleviated. The above are just a few infrastructural issues facing the country besides grueling issues such as increasing maternal mortality rates, growing infant mortality rates (in comparison to developed economies), shortage of doctors because we have so many constraints if one wants to start a medical school, regulatory dimensions towards other healthcare specialists such as Nurses providing primary care, and out of pocket personal healthcare spending as against government spending in India (ratio is 3:1). 

The RSBY (Rashtriya Swasthya Bheema Yojan) has as on date enrolled about 120 million people and the government is wanting to expand the horizon to cover the entire population not just the poor people. If this has to be achieved, then the per capita expenditure is likely to reach Rs 1500 and I am not sure if we have enough money to fund this expansion. In addition, an average cost of operating a primary healthcare center in a village in India is about Rs 3 crore as against Rs 12 lakhs for many of the private health care centers in the same region. Besides in the year 2012, India spent Rs 21000 crore on essential medicines but at least 25 to 30% of the drugs and equipment that government procures as part of the free essential medicine program is wasted because of lack of adequate storage capacities. So even if we want expansion plans provisioned, implementation of the strategy is largely at stake besides poor infrastructure.

So what can the country do now - 
  • Move away from the combined healthcare provision to concentrating on the primary healthcare as this will alleviate burden on secondary and tertiary care which are largely managed by private healthcare set ups. In fact much of the government's proposed spending should be in this area while improving the quality of care with better infrastructure, qualified professionals who can bond with the local population, and adequate monitoring systems to ensure value for care.
  • Providing adequate drinking water (non availability of adequate drinking water results in 200 million cases every year in the secondary healthcare centers) and sanitation as this can lessen the burden on primary healthcare centers
  • Remove regulatory constraints towards other medical specialists such as nurses from providing primary care. This to a large extent will alleviate the shortage of doctors concern.
  • Finally move towards privatization of the healthcare (government can just fund the initiative through the insurance schemes and pay for performance schemes but give the onus to private healthcare providers who can manage the health centers - In fact this could bring in a revolution in the Indian Medical educational system), and improve the standard of the social health activists as it will not just bring in more education and awareness in to the system but also will improve the care provided by the 59% of the healthcare providers - non-trained segment. 


However as i write, there has been very little progress (the two ambitious programmes have been shelved for almost two years now) that has happened on implementing any of these healthcare programs partly because as a country, politically we are yet to move to a stage where healthcare is on the agenda to buy votes. We are yet to see advocacy groups persuade governments to include specific healthcare programs as part of their political agenda. But it is not very far that we will see this change and the government will have to redefine the UHC (Universal Health Care) program.

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