What ails the Health system in India?

Note from Jan Swasthya Abhiyan, India

Introduction – visit to a country of paradoxes

Let us take you on a visit to a large and interesting country. While visiting this country, we are especially interested in understanding the health system prevailing there.
We first see that this country has considerable helth care resources -

    * It has the largest number of medical colleges in the world
    * It produces among largest numbers of doctors in the developing world. These doctors are exported to many other countries, and are considered among the best in the world.
    * This country gets ‘Medical tourists’ from many developed countries reflecting the high standard of medical skill and expertise here. They seek care in its state-of-the-art, high-tech hospitals which compare with the best in the world.
    * Turning to medicines, we find that this country is the fourth largest producer of drugs by volume in the world and is among the largest exporter of drugs in the world.

Of course, all these resources require finances. We find that people here do not lag behind in paying and spend a lot on health care – more than many other developing countries, 

Given this situation, what is the health status of the population?

Despite the existence of such impressive health care resources, as we begin to move around and talk to some people in the villages and towns of this country we are surprised to find that –

    * Despite all these resources, the majority of citizens have very limited access to quality Health care, and have poor health indicators.
    * There are low levels of immunisation – in fact less than half of the children are completely immunized (added to this, complete immunization coverage has declined in recent years!).
    * Similarly, the minimum of three checkups during pregnancy remains unavailable for half of all pregnant women.
    * There are massive inequities in access to health care – while the rich avail of most modern and expensive health services, the poor, especially in rural areas do not get even rudimentary health care.
    * Hospitalisation rates among the well off are six times higher than rates among the poor!
    * Despite such a large drug industry which exports medicines across the globe, about two-thirds of the population lack access to essential drugs.
    * This is a country of paradoxes where women from well off families suffer due to unnecessary cesarean operations – in some urban centres close to half of deliveries are done by operation – while their poorer rural sisters frequently die during childbirth due to lack of access to the same cesarean operation at time of genuine need.
    * Although people spend a lot on health care (the poorest spend one-eighth of their total income on health care), the government proportionally spends much less. Of the total health spending in the country, less than one-fifth is made by all levels of government, while the remaining major portion is shelled out by ordinary citizens from their pockets. This makes the health care system in this country one of the most privatized systems in the world.
    * Two out of five hospitalization episodes are paid for by taking loans or selling assets. The proportion of people who are unable to access any form of treatment due to inability to pay is quite large and increasing.

A large private sector leads to high profit motives of private providers. It has been estimated that almost two-thirds of the medicines prescribed here by doctors are irrational or unnecessary. Nearly half of all outpatients receive injections, which are mostly unnecessary.  

Hence we say that this is a country of tremendous paradoxes. And you must have of course guessed it by now – this is the country where all of us live. This paradoxical country is India, where we have really poor health care at high cost, considerable health care resources but very poor health care access for the majority of people. Let alone the poor, even the middle class cannot easily afford major investigations, hospitalisation and operations. Why are we worse off in this respect even compared to other developing countries? How come the proportion of spending on Public health in India is less than even our poor neighbours, Bangladesh and Nepal?
What is the underlying problem?

There seems to be something deeply wrong with our entire Health care system.  It is possible to organise our health care system differently, so that today every community, every family and every person in our country can be assured of decent health care. Some other developing countries have shown the way, and have made universal access to decent health care for their population a reality. Let us try to analyse what is wrong, and suggest a better way of organizing the health system in India.

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