Times of India
10 June 2011
By Rema Nagarajan

Poor facilities and rising cost of healthcare even at government hospitals are pushing people towards more expensive private setups. As a result, large sections are bankrupted or go without treatment
Fifth largest economy in the world it might be, but India’s health profile is closer to countries in sub–Saharan Africa reeling from persistent civil war and underdevelopment than to countries it likes to compare itself with such as Brazil, South Africa or China.

Chronic underinvestment in health has resulted in the country witnessing an increase in suffering and death from various diseases, accounting for about 20% of the world’s disease burden. Almost half our children (46%) are malnourished and plagued by ill health associated with chronic undernourishment. More than half the women (56%) in the 15–49 year age group are anaemic.

Significant progress was made in controlling infectious diseases such as diarrhoea, diphtheria, tuberculosis (TB), malaria and other vector borne diseases in the early decades after Independence. However, since the late 1980s, with the weakening of the public and preventive health system, there has been a resurgence of many of these diseases like malaria, drug resistant TB, chikungunya, dengue and diphtheria.

Even as the battle against infectious diseases gets tougher, non–communicable diseases such as cardiovascular diseases, diabetes, hypertension, cancers and mental disorders are becoming leading causes for morbidity and mortality. This double burden of infectious as well as non–communicable diseases has meant an even greater demand for healthcare and increasing pressure on the existing health facilities.

Priced Out
Today, the private sector accounts for 80% of a person’s expense on health. Inadequate funding of public health and consequent deterioration of public facilities has led to a decline in the share of public health expenditure. The public sector’s share of hospitalised care dropped from 60% in 1987–88 to just 40% in 2004. Even government health facilties have started charging user fees and asking patients to buy expensive drugs and diagnostics from private outlets citing nonavailability of these in the state setup.

With healthcare more expensive, more and more people are forced to forego treatment. Financial reasons account for over a quarter of untreated ailments in rural areas, and over 20% of untreated ailments in urban areas, a sharp rise from 15% and 10% respectively in 1986–87.

Healthcare has become a foremost reason for impoverishment of people. It is estimated that 39 million people are pushed into poverty every year due to expenditure on health. Almost 80% of a person’s expenditure on health is on drugs. Ensuring access to good quality cheap drugs can reduce the economic burden of healthcare substantially. Yet, prices of drugs have been going up steadily with little effort from the government to regulate them, unlike most developed countries where governments intervene to regulate drug prices through various measures such as bulk procurement and supply.

Studies have shown that even if the government were to provide free healthcare for the poor, accessing it would still be expensive as they would have to spend on travel to the facility, expensive in the absence of affordable public transport in most of the country. Plus, duration of treatment would also mean loss of daily earnings, something few poor families can afford.

Inadequate Facilities
Even with the NRHM boost to the public health infrastructure and enhancement of the health budget, most public facilities continue to be underutilised as they fail to provide basic services. The lack of service stems from inadequate infrastructure, diagnostic and medical facilities and the problem of persistent vacancies in government health setups at all levels from health workers and nurses to laboratory technicians and specialist doctors.

The last survey conducted by the health ministry reveals that there is a shortfall of over 20,500 sub–centres, 4,500 primary health centres (PHCs) and 2,135 community health centres (CHCs). This shortfall means that in many states a CHC meant to cater to a population of about 1.2 lakh might have to cater to as many as 10.6 lakh as in Bihar or 3.3 lakh in Andhra or 2.6 lakh in Uttar Pradesh. Similarly, PHCs meant to cater to populations of about 30,000 end up bearing the burden of over 65,000 in Jharkhand, 62,000 in West Bengal or 41,000 in Bihar.

Even as several facilities are stretched due to the size of the population they have to cater to, matters are worsened by the fact that many of these facilities don’t have the requisite staff in place as the government finds it difficult to get people willing to work in health setups in in the rural hinterlands. There is a shortfall of over 12,000 specialists – surgeons, gynaecologists, paediatricians – and physicians even at the CHC level.

About 10% of the PHCs have no doctors at all. A third of the PHCs do not have a lab technician making it impossible for the doctor to order any investigation and forcing the patient to get tests done at private labs. Almost a third of sub–centres and about 10% PHCs have no electricity or water.

With such handicaps, it is hardly surprising that patients are forced to shift to the private sector. However, various reports of inspection tours by the health ministry and independent experts to different districts document how PHCs and CHCs with the requisite staff and facilities show substantially increased utilisation of the facility by local people. This proves that there exists a demand for credible and affordable health services. Mobilising local communities to demand better services from their public health facilities have been found to be successful in ensuring better service delivery and improved accountability.

More than any great pull factor of vastly better care or facilities in the private sector, it is the push factor of a non–functional public sector that is forcing a majority of the people in our country to bankrupt themselves seeking healthcare in private facilities.