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India And Its Public Healthcare – A Comparative Analysis

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“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.

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

Read more about his campaign.

Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

Read more about her campaign.

MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Read more about her campaign. 

A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Find out more about the campaign here.

A native of Bhagalpur district – Bihar, Shalini Jha believes in equal rights for all genders and wants to work for a gender-equal and just society. In the past she’s had a year-long association as a community leader with Haiyya: Organise for Action’s Health Over Stigma campaign. She’s pursuing a Master’s in Literature with Ambedkar University, Delhi and as an MHM Fellow with YKA, recently launched ‘Project अल्हड़ (Alharh)’.

She says, “Bihar is ranked the lowest in India’s SDG Index 2019 for India. Hygienic and comfortable menstruation is a basic human right and sustainable development cannot be ensured if menstruators are deprived of their basic rights.” Project अल्हड़ (Alharh) aims to create a robust sensitised community in Bhagalpur to collectively spread awareness, break the taboo, debunk myths and initiate fearless conversations around menstruation. The campaign aims to reach at least 6000 adolescent girls from government and private schools in Baghalpur district in 2020.

Read more about the campaign here.

A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

The Transmen-ses campaign aims to tackle the issue of silence and disregard for trans men’s menstruation needs, by mobilising gender sensitive health professionals and gender neutral restrooms in Lucknow.

Read more about the campaign here.

A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

A Gender Rights Activist working with the tribal and marginalized communities in india, Srilekha is a PhD scholar working on understanding body and sexuality among tribal girls, to fill the gaps in research around indigenous women and their stories. Srilekha has worked extensively at the grassroots level with community based organisations, through several advocacy initiatives around Gender, Mental Health, Menstrual Hygiene and Sexual and Reproductive Health Rights (SRHR) for the indigenous in Jharkhand, over the last 6 years.

Srilekha has also contributed to sustainable livelihood projects and legal aid programs for survivors of sex trafficking. She has been conducting research based programs on maternal health, mental health, gender based violence, sex and sexuality. Her interest lies in conducting workshops for young people on life skills, feminism, gender and sexuality, trauma, resilience and interpersonal relationships.

A Guwahati-based college student pursuing her Masters in Tata Institute of Social Sciences, Bidisha started the #BleedwithDignity campaign on the technology platform Change.org, demanding that the Government of Assam install
biodegradable sanitary pad vending machines in all government schools across the state. Her petition on Change.org has already gathered support from over 90000 people and continues to grow.

Bidisha was selected in Change.org’s flagship program ‘She Creates Change’ having run successful online advocacy
campaigns, which were widely recognised. Through the #BleedwithDignity campaign; she organised and celebrated World Menstrual Hygiene Day, 2019 in Guwahati, Assam by hosting a wall mural by collaborating with local organisations. The initiative was widely covered by national and local media, and the mural was later inaugurated by the event’s chief guest Commissioner of Guwahati Municipal Corporation (GMC) Debeswar Malakar, IAS.

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