Public Health in India: A journey from patients to clients
Shashank Chaganty is a medical student currently studying MSc in Clinical and Therapeutic Neuroscience at the University of Oxford 2019/2020. His research interests pertain to Neurosurgery and Public Health.
India’s health policy over the years has achieved an improvement in life expectancy, reduction in infant mortality, maternal mortality, disease burden of malaria, tuberculosis, and lately, human immunodeficiency virus (HIV).However, the health quotient of the nation as a whole remains much to be desired- globally, India consistently ranks as one of the worst demographics for nutritional status, poverty and access to adequate sanitation and drinking water. The country has a massive non-communicable and infectious disease burden and a health-system that is rife with low-quality care, rampant corruption, overcrowding in hospitals and barriers to access. Hereby, we explore some three major drawbacks of Indian health policy which has hampered health status of India whilst recommending solutions to ameliorate the current situation.
One of the key issues with Indian health policy is its limited focus. Since the turn of the millennium, various government health missions have been launched, spear-headed by The Ministry of Health and Family Welfare (MOHFW). Three major initiatives of the MOHFW are as follows1:
1) Immunisation: India today continues to have a high communicable disease burden, with an alarmingly high prevalence rate for conditions such as tuberculosis and diarrhoeal illness.2To tackle this, Mission Indradhanush (MI) has been a cornerstone project undertaken by MOHFW, due to which we have seen an increase in national immunisation coverage (NIC) from 62% in 2015 to 83% in 2018.3,4Despite this progress, such a health policy is predicated on technocratic solutions and has disregarded the root cause of disease. Simply sustaining safe drinking water and sanitation can lead up to a 70-80% reduction in the burden of communicable diseases.5This is pertinent to India where two-thirds of the population don't have access to drinking water and adequate sanitation, and over a third are malnourished.
2) Health-insurance: Various health-insurance schemes have been launched both centrally and regionally under National Health Protection Scheme (NHPS) aka “Modicare”.This has provided a modest degree of financial-risk protection from catastrophic out-of-pocket payments in both government and private-sector hospitals. Such health-insurance schemes incentivise curative Western-oriented model of health rather than a preventive health-care system which ensures the highest possible health status for the population of India.1
3) Medical Education & Capacity Building: India faces a shortage of around 600,000 doctors and 2 million hospital beds.6,7To address this, the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was launched in 2003 with the aim of building 20+ new AIIMS-like teaching hospitals by 2022.1Again, such policies that look to bolster the current deficit in human resources and infrastructure, inherently view medicalisation as some sort of panacea to the nation’s ill-health, and thereby is promoting a curative rather than preventive health-care model.
Figure 4: Overcrowding atrium of government hospital in India8
In England, the provision of adequate housing, a reduction in overcrowding and improved nutrition drastically cut tuberculosis (TB) disease burden, and only then where drugs for TB widely introduced.9,10Health policy in India however almost exclusively views health through a biomedical lensrather than in the context of its social determinantsi.e living conditions, nutrition, safe drinking water, sanitation and education. For advocating immunisation, health-insurance policies and capacity building without ameliorating the determinants is futile, akin to internal finishing of a house without setting its foundation.
Various programs working on improving the social determinants are in operation, including Anganwadi (nutrition), Beti Padhao Beti Bachao (women empowerment),Sarva Siksha Abhayan (education) and Swach Bharat Abhiyan (clean water, sanitation & waste disposal). These initiatives have a direct impact on the social determinants but are run by various ministries outside the jurisprudence of the MOHFW. Greater consultation and shared incumbency must be sought between the various ministries running preventive public health programs and MOHFW which is tasked with building the health status of the nation. Such inter-departmental collaboration is necessary to generate better designed public health policies that are able to monitor how health status improves commensurate with bettering of social determinants and implement strategies in accordance with the needs of the target population.5,11
Communitisation is based on the principle of promoting greater participation of local stakeholders in formulation and implementation of local health policy. Indian health policy has made attempts at exercising communitisation with the ASHA [Accredited Social Health Activist] workers and formation of patient welfare committees (Rogi Kalyan Samiti). However, greater decentralisation of power is required to transform their current role from isolated advisors to proactive participants in policy making and priority-setting. Such empowerment is necessary to mobilize the community towards health planning that targets key issues pertinent to the local demographic. This can be realised through community primary health centers, local support groups, primary prevention via screening, and inducting patient representatives to health policy committees.
When oxygen ran out at BRD Medical College, 42 children died within the following 72 hours, and 290 over the month due to acute encephalitis.12,13The essence of the rebuke directed at government focused on their incapability in ensuring oxygen supply rather than the importance of prioritising access to water and adequate sanitation (which is said to have contributed significantly to the epidemic). The narrative of mainstream media and the dominant outlook on health in the Indian mind needs to shift from one that is curative-oriented to one centered around preventive healthcare. When the public consciousness starts re-prioritising social determinants of health, we will transcend the phenomenon of normalising deviance, whereby the vast majority of Indians will stop seeing unsafe water and poor sanitation as a daily part of life and instead a serious issue that needs urgent repair. In doing so, quick technological fixes for grave health issues will be substituted for more long-term sustainable solutions.
Figure 5: India public & private healthcare statistics, National Statistical Survey 201414
Following neo-liberalisation in early 90s, vast swathes of those in the higher socio-economic strata eviscerated themselves from the social contract and opted for privatisation. Henceforth, we have witnessed an inexorable burgeoning of the private sector in healthcare, to the extent that today the private sector conducts 70% of outpatient services, 60% of inpatient services, and has 80% of technology.11The privatisation agenda has been further bolstered thanks to the government’s provisioning aforementioned health insurance schemes. Maintaining these policies for a number of years has type casted the government into the role of a financier to the private sector.
So how is privatisation a threat to public health?
1) Health commodification: Ideologically, it is a threat. Fundamentally, providing public goods services like water-treatment, waste disposal, access to nutrition and works on other determinants of health are outside the interests of private agents due to non-profitability. As the government increasingly outsources health provision to the private sector, India’s health policy has become more corporatised. Hence, the national health narrative and the common social consciousness sees healthcare as a commodity rather than a human right to be achieved via fixation of social determinants.
2) High-costs: With privatisation, India has been drastic rise in costs of healthcare delivery which has fostered a culture of health neglect in many low-income families as they delay seeking care and apply for discharge against medical advice.15Health insurance in part shoulders the burden of paying for healthcare, however, only 20% of India is insured, with high-income urban-based government employees receiving most benefit, rather than rural-based low-income labourers in the informal sector, who arguably need it most. Therefore, the majority without insurance have had to bear hefty out-of-pocket payments- this solely is responsible for an increase in the poverty rate from 31.1% to 34.8%.15,16
3) Reduced access: The privatisation agenda has led to proliferation of health services in industrialised areas- more than 75% of healthcare facilities and doctors are found in urban areas.11 Rural areas in India, where social determinant status is dire and patients have a low-paying capacity, have been neglected by the privatisation agenda due to their low profitability. It is paradoxical, that ruralites which form 70% of the population and make up 86% of medical visits in India are having to travel more than 100 km to an available health-care facility, only to endure exorbitant out-of-pocket payments which land them in poverty.17
The Indian government must adopt strategies that aim to improve the status of social determinants of health, particularly in rural areas. One such transformative strategy, would be to place a temporary (2-3 years) moratorium on gross health spending in urban areas and redirect the money towards public health spending in rural areas.11 This would ensure investment is earmarked for development of social determinants in rural areas, which in turn can financially incentivise NGOs, not-for-profit organisations, social enterprises, and even the private sector to get involved. Easier said than done of course, however such a bold strategy can be effective as demonstrated by Thailand, where a moratorium was placed between 1995 and 2000 and two years later the country launched its universal health coverage (UHC) policy.18
In 2003, the central government launched a heavily subsidised health insurance scheme targeted for economically-backward ruralities, however thus far the enrollment-rate has been low.15To tackle this, one of the strategies the government can adopt is making health insurance mandatory and run a program pushing for universal health insurance coverage (UHIC).19As long as the mission towards UHIC is undertaken as aggressively as MOHFW’s pursuit for universal immunisation coverage, such a policy would increase the take-up rate of what has so far been voluntary health insurance, and in doing so reduce bankruptcy induced by healthcare costs.
Consumers must recognise the unbridled growth of the private sector in health has contributed significantly to the externalisation of our locus of control as we have developed a mindset whereby we feel ill-health warrants external technological fixes rather than an exploration of the root cause of disease. To reverse this trend, health promotion programs that look to increase our sense of agency over our health must be encouraged, especially in rural areas. This may include community-workers education sessions, social prescription and observing days such as ‘Heart Day’ and ‘Diabetes Day’.
The Indian government’s prioritisation of public health is grossly inadequate. The following areas can be seen as major impediments that stand in the way of India achieving universal health coverage:
- Underfunding:Since neo-liberalisation, health spending as a proportion of total government spending has fallen and for the past couple of years the health spending has hoovered at a dismal 1-2% of GDP.15,20 This lack of funds for health represents a missed opportunity when we consider the profound shortfall in social determinants, human resources and infrastructure that characterises the health landscape of India.15,17
Figure 6: National Health Spending, National Health Profile, 201820
- Low prioritisation of health: Unfortunately, the little funds that are allocated are commonly misallocated and simply withheld following fiscal devolution to the state level. When we consider the NHM funding, 18 states spent only 32% of allocation which was already 36% short, and in some states the unspent balance ranged between 40% to 76%.21In six states, Rs 36 crore was diverted towards non-NHM projects. Today, states pay for about 75% of the public healthcare system but such insufficient state spending has neglected strengthening of social determinants in India.
- Poor governance:Even when commissioned funds are eventually allocated, it has to face the inexorable wrath of an administrative environment devoid of government supervision, accountability, transparency and regulation. In the public sector, this has paved way for numerous cases of corruption: in 2011, a regulatory audit found ₹100 billion (US$1.4 billion)had been siphoned from the NHM finances in Uttar Pradesh. Whilst this was being investigated by the CBI, the Minister of Health was sacked, the health secretary imprisoned and 5 potential witnesses were murdered.22,23 Lack of governances has in a way indirectly incentivised corruption in the private sector in the form of rising health-care costs, proliferation of commission based referrals, dispensing of unlicensed drugs and a myriad of other malpractices in private hospitals. Lack of governance in both public and private sectors can be seen to have worsened public health status.
Fundamentally, health authorities and policy makers must reprioritise improving health quotient of the nation and only then will we see a greater proportion of the nation’s GDP being allocated towards improving public health infrastructure. The following strategies can be used to generate funds which must be earmarked specifically for public health spending: sin taxes, medical tourism tax, mansion tax, co-payment i.e. an obligation for patients to pay a subsidized amount when utilising healthcare. In order to tackle the phenomenon of funds being diverted and mis-spent at the state-level, the devolution of funds must be outcome-based staged-release rather than a one-time bulk release- this would improve the likelihood of funds being utilised exclusively for public health missions.
Apart from the standard requirement of greater law enforcement, a robust system that combines the potential of information technology (IT) and utility of social auditing must be in place. For MOHFW to launch social auditing schemes, region-specific data can be collated using beneficiary satisfaction feedback forms, social determinants performance metrics, cost-surveys and medical records. Using IT, a digital platform could be established where this information would be published on a benchmarking network, allowing for states to compare and contrast their data with each other. With such a network being made available for public perusal, this would improve transparency, provide insight into the progress of public health missions and allow for identification of low-performing areas where there is potential for intervention.
Political rhetoric often reflects aspirations of the electorate. Hence, a major stakeholder that has the power to shape public health policy is the end-consumer. It is the electorate that must inculcate a sense of incumbency and make the neglect of public health an election issue and demand its repair. Only then politicians and policy makers alike are to initiate discussion and work towards bolstering capacity of social determinants. Until then, the privatisation agenda will continue to be advanced at the detriment of the national health quotient as a whole.
“We shall not defeat any of the infectious diseases that plague the developing world until we have also won the battle for safe drinking water, sanitation, and basic health care.”
– Kofi Annan, Former Secretary-General United Nations.
Any system is a reflection of ideals of the people it represents as well as those it serves. From the minister of health to the grass-roots patient, a willingness to change amongst all stakeholders is sine qua non for any improvement to be realised in the Indian health-care system. India today is seen as an emerging superpower poised with a mushrooming youth- so called ‘demographic dividend’. Without major reforms in health policy to place public health works on social determinants of health at its centre, India’s health-care system will remain curative rather than preventive and promotive in nature. In years to come, continued neglect of India’s public health will render even more health inequity, and realising India’s potential will remain a grandiose rhetoric.