India And Its Public Healthcare – A Comparative Analysis

Posted by Megha Sreeram in Health and Life, Politics
December 15, 2017

“Dengue toll 40 till October 9, 2017: 11,744 cases recorded.”

It is not strange to see newspapers screaming such headlines to draw attention to the condition of hospitals and healthcare in our country.

Dengue is spreading like wildfire in the southern state of Tamil Nadu despite the ₹10,000 crore allocation for public health and family welfare in the current year budget of Tamil Nadu. The state has also allocated ₹43 crores to establish new Primary Health Centres and upgrade the existing centres under the National Rural Health Mission (NRHM). This is in addition to the ₹15 crore allocation towards establishing polyclinics in urban Primary Health Centres under the National Urban Health Mission (NURM).

It is also said that the state government is allegedly hesitating to declare dengue an epidemic, as that would lead to teams from national and international organisations to come down south and investigate, revealing the lack of preparedness and action on the part of the government. One can speculate similar theories all day, but the effect remains the same – people suffer.

Let us first look at the budget allocation for the health sector this year. The amount allocated to the Ministry of Health and Family Welfare for the year 2017–18 is ₹47,352.51 crores. This is a mere 2.2% of the overall expenditure budget of our country for this year. Of this amount, the allocation for Swachchta Action Plan is ₹133 crores, which is about ₹4.58 crores for each state (which has numerous government hospitals based on the size of the state) per year. Having done audits of companies and banks in India, I know how less an amount this is, especially for a hospital.

The National Health Policy, 2017 replaces the previous policy of 2002. This is the first time that Universal Health Coverage has been spelt out in the policy statement. It also places great importance on strategic partnership in building and providing a robust healthcare infrastructure with decent buildings and advanced diagnostic systems. The alternative medicine systems – Ayurveda, Yoga, Unani, Siddha, and Homeopathy – have been given importance to bring them into the mainstream and fill the gap in medical care.

However, healthcare in India has its own challenges. About 62% of the medical expenses are from the pockets of the patients, one of the highest in the world. It means that health insurance plays a minimal role in providing for medical expenses. Studies have also pointed to the fact that medical expenses are one of the primary reasons for people to slip into poverty, since they mortgage property to pay for hospitalisation and treatment. Another important issue is the concentration of doctors in the urban areas, leaving the rural populace without qualified medical personnel.

This might seem like the government has forgotten about villages. But in reality, there are schemes by the government that provide insurance coverage for healthcare for the poor to access healthcare facilities. The Rashtriya Swasthiya Bima Yojana (RSBY), Aam Aadmi Bima Yojana (AABY), Janashree Bima Yojana (JBY) and the Universal Health Insurance Scheme (UHIS) are some of the schemes floated by the Central government, apart from various insurance covers provided to individuals and their families by their employers.

Both the States and the centre establish and run hospitals. While the centre manages tertiary care hospitals, the States are responsible for the establishment of Primary and Secondary Health Centres, community and District hospitals. States like Tamil Nadu and Kerala have better healthcare records than many other states, due to the involvement of the respective state governments to make healthcare affordable and accessible to all.

Tamil Nadu, for example, has 48 hospitals attached to Government Medical Colleges, 1747 Primary Health Centres (PHC) and about 8700 Health Sub Centres (HSC). This does not include the dispensaries and hospitals run by the Employees State Insurance Corporation and alternative medicine centres.

Tamil Nadu also has a state-run Comprehensive Health Insurance Scheme which offers health insurance for people having an annual income of ₹72,000 or less. Thus quality healthcare happens when the centre and the state work in tandem towards a common goal.

Many countries around the world have their own ways of approaching healthcare. Generally, they tie up with insurers and an empanelled set of hospitals to ensure quality and affordable to the citizens.

 

A comparison between countries on their healthcare spending and doctor-patient ratio, from the data available with the World Health Organisation (WHO). (*) based on the data of the year 2011.

Cuba has one of the best public healthcare systems in the world. It has, time and again, mobilised teams of doctors and other medical personnel to various parts of the world for disaster relief and recovery. Cuba enshrined the Right to Health in its Constitution when it was revised in 1976. Hence the Cuban government exercises full control over the healthcare facilities. In fact, the then Director-General of the WHO, Margaret Chan had appreciated Cuba for the research and innovation that goes into its healthcare systems when she visited Havana in 2014.

Similarly, Canada’s healthcare system is also known for its simplicity where the government pays for the care provided solely by the private sector. The system is publicly funded with the doctors getting a share of it for consultation. The rates are negotiated between the province and the medical associations in that particular province. The Canadian government also ensures affordable medicines by regulating the prices and keeping it at the reasonable level.

While the National Health Service (NHS) in England is known for its efficiency, it is not the sole provider of healthcare funding in England. Under the NHS, the government ties up with insurers and private medical practitioners for healthcare facilities. The government then compensates the doctors who provide services under the NHS. Anybody can opt out from the NHS. Some private practitioners do not come under the NHS, especially for niche areas of treatment like HIV/AIDS. Unlike Canada, even dental consultations are funded through NHS for people in need. However, the NHS also has its own share of problems.

“More than half of the Managing Trusts (these control the NHS hospitals in a particular area) are heavily in deficit. There is no mechanism for rationing health personnel by those trusts due to budget issues. Shortage of beds leads to long waiting lists for the patients,” says Nick Nugent, a British National and an Independent journalist.

In the United States, about 60% of the overall amount spent on healthcare is provided by the government through various State insurance schemes. The remaining is out-of-pocket expenses by the people seeking medical aid. The US is one of the countries that do not guarantee access to health care to its citizens. A major portion of the facilities are owned and operated by the private players with the remaining administered by the States themselves. The Federal government does not own or operate hospitals making Obamacare, which makes affordable health care possible, the subject of contentious debate in the Republican Congress and the Trump administration. Most of the hospitals have very little scope for outpatient treatment.

To be fair in comparison, Brazil, which is also a rapidly expanding economy, administers health care in a ‘payor only’ mode thereby expecting the private players to cater to the needs of the patients. Almost the entire population insurance coverage in Brazil and the health spending by the government has gone up when compared to the previous years. Similarly, Thailand also has a social health insurance coverage scheme which lets the State handle the cost of healthcare, and the South Korean government assumes the role of being the sole payor to the private players who provide medical aid to its people.

This does not mean that the countries mentioned above are the perfect role-models to follow. They also face challenges, like quality in healthcare and regulation of the private sector, in the implementation of their respective schemes. Also, there is always scope for improvement when it comes to healthcare and medical ethics. Governments must strive towards an ethical practice of medicine along with compassionate care. India must look to the design and implement a social healthcare scheme which reaches the people in need. This can only be achieved through a continuous commitment to the cause of universal healthcare.

Let us put all this aside and focus on what India can do to be anywhere close to ensuring quality, affordable and accessible healthcare for all. Prime Minister Narendra Modi has an ambitious plan to increase the healthcare spending to 2.5% of our GDP by 2025, which roughly amounts to ₹3,39,000 crores, based on the GDP of 2016.

This is a long-term plan and quite steep, given the present allocation. However, the short-term action plan should include filling up vacant posts in government hospitals and primary health centres, ensuring supply of medicines according to the demand, increasing accountability of the hospital administration and doctors and ensuring that the environment is free from vectors and is hygienic.

Apart from the above, our government must ensure higher absorptive capacity for the funds disbursed from World Health Organisation to achieve our goals of better public healthcare. We do not need another Gorakhpur or a dengue-infested Tamil Nadu in the country. It is time to focus on what is necessary and work on war-footing.