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Four Reasons Why India’s Healthcare Is Not Affordable, Accessible And Available

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This post is a part of YKA’s dedicated coverage of the novel coronavirus outbreak and aims to present factual, reliable information. Read more.

Trigger warning: Covid death

People are howling in emergency wards, asking for the doctor to examine their loved ones’ dropping SPO2. The person next to them has been declared dead and it’s been an hour since anyone came to attend them. Meanwhile, a queue of patients stand outside the emergency ward entrance, waiting for beds that are getting emptied by those passing away.

For a government hospital such as AIIMS in Delhi, this is not a sight in a healthcare crisis. Pandemic or not, this is how government hospitals in India treat the poor. The only thing that the pandemic has brought out are the faultlines to the rest of the world and the upper-class Indians who can be seen running around in private hospitals with a similar desperation.

For a Capital city of a 136-crore-peopled country, 33 Delhi’s state government hospitals had only 348 ICU beds in February 2019 – an abysmal number even on a healthy day. Amid the peak of a national healthcare crisis, Delhi has a total of 6,867 ICU beds (including government and private) for Covid patients – all of which were occupied even in November 2020.

As healthcare systems in urban cities across India grapple with the second wave of COVID-19, smaller towns and villages too are facing devastating consequences. | Picture courtesy: © Gates Archive/Saumya Khandelwal

These numbers go on to show what healthcare in this country has never been: accessible, available and affordable. Article 21 (right to life) and Directive Principles in our Constitution declare access to healthcare as a fundamental part of governance. But today, as we still bid goodbyes to our closed ones, make condolence calls to friends and turn into hypochondriacs ourselves, how do we navigate our country’s health in the future? Let’s open this can of (non-infectious) worms and see all that is wrong with our medical system.

Are We Spending Enough On Healthcare?

India’s expenditure on primary health crossed 1% of its GDP only 2009 onward. In 2017, it was 1.28% of the GDP and after a year in the pandemic, in the Budget 2021, public expenditure on healthcare stood at 1.2%. For reference, the average healthcare expenditure of other BRICS countries is 3.6% of their GDP and the USA spends 18% of its GDP. The Centre plans to increase the 1.3% to 2.5% by 2025, “but it’ll be too late by then,” said Dr Ananya Awasthi, Assistant Director, Harvard School of Public Health, India Research Centre at a webinar on right to health in the context of the pandemic.

But where do we spend this money on, even if India’s budget increases to 2.5%? Currently, Dr Awasthi added, out of every Rs 100 spent on a patient in India, only Rs 35 are incurred by the government, the rest Rs 65 are spent out of the patient’s pocket. This high expenditure on healthcare is what has pushed many people below the poverty line in the pandemic year, while pharma firms and hospital chains were drowning in profits.

There was only one hospital bed for every 2,000 people as of December 2020, with states including Jharkhand, Assam, Haryana, Bihar, Gujarat, Odisha, Madhya Pradesh and Manipur having not even that. “There are a few good hospitals in 2-3 towns of Bihar,” said Professor Manoj Kumar Jha, MP (Rajya Sabha), RJD. The rest of the state depends on district hospitals and Primary Health Centres (PHCs), which only have basic OPD and natal care services, and work as centres to run sanitation and health-related programmes. Even if some district hospitals have high-end equipment, they don’t have an equipped medical staff to operate those machines.

Instead of investing on creative innovation and announcing construction of new facilities, the government should first spend on the existing infrastructure. For instance, establishment of 162 oxygen plants was approved in October 2020, out of which only 33 are up, and before the rest can become operational, a plan of new oxygen plants was announced during the peak of the second wave.

Furthermore, investment on public healthcare has to be proportionally allocated in rural as well as urban areas. Over 60% of hospitals and 80% doctors work in urban India, which only caters to 40% of the population. The rest of the 60% population that lives in rural areas depends on far-off district hospitals and inadequate PHCs and CHCs. To add to their plight during Covid, the Centre even took away their chance to get vaccinated, as only those with smartphones and high-speed internet can get jabs.

 

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But even if the Centre spends on rural hospitals and healthcare centres, most of the medical students in urban colleges aim to set up hi-fi clinics in cities or go abroad. Who wants to work in rural hospitals, asked Dr Awasthi and Dr Bhaswati Bhattacharya, a Master’s in Public Health. They suggest that a mandatory six-month rural internship for medical students can help increase our focus to rural health. The government will still have to spend on stipend, basic infrastructure and security in rural areas for the students.

Not Enough Doctors In The House

Another area of healthcare the government needs to spend on is the country’s health talent. As per the Economic Survey of 2019-2020, India has one doctor per 1,456 population and 1.7 nurses per 1,000. There is a need to fill the vacancy of 20 lakh doctors and with the 30,000 medical graduates from 542 colleges who enter the field each year, this gap won’t be easy to fill for another 40 years. Even among these graduates, many leave for practice abroad. Out of those left behind, the majority are from private colleges whose parents paid under the table to get admission, putting a question on their merit.

“Medical education is only unaffordable due to the state and national medical authorities allowing price gouging in universities. If NITI Aayog announces salary caps and tuition caps on these private institutions, then how will the rich able to make money from education,” said Dr Bhattacharya.

What she is also pointing at is the dominance of upper-caste and upper-class doctors in healthcare. Thus, to make healthcare accessible, affordable and available to all, we must make medical education accessible, affordable and available to all. More government colleges with reservation for people from rural areas and marginalised castes should be opened in non-urban areas and private medical colleges should be regulated. As reported by The Week in 2019, as against the medical graduates from general category who leave for practice abroad, over 70% graduates from Dalit or tribal communities from AIIMS stay in India to practice medicine.

Another way to strengthen health talent from rural areas, Dr Bhattacharya suggested, PHCs in villages can organise health camps to train people in basic hygiene, primary healthcare skills to become primary health workers.

What About AYUSH Doctors?

Talking about filling the demand-supply gap of doctors in India, Dr Bhattacharya raised another point – the lack of recognition of AYUSH doctors practicing in Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy. Considered ancient medical systems that treat the human body through natural ingredients, these practices are often seen with scepticism by modern medicine. While most of this negative perception has come after the preposterous claims made by Hindu-smitten leaders Pragya Thakur, Baba Ramdev and Swami Chakrapani, Dr Bhattacharya, an academic in modern medicine as well as alternative medicine, says that the two fields shouldn’t be seen as exclusionary. “There are many well-trained MBBS doctors who also hold a degree in alternative medicine such as Ayurveda and integrate that knowledge in their practice,” she said.

“India is a model country for health freedom in the world. There are many medical systems followed here including Allopathy, Homeopathy, Ayurveda, Naturopathy and so on, and patients should have the right to choose from them. Allowing these doctors to practice in urban and rural areas can also fill the demand gap in our healthcare system, but unfortunately, the Indian Medical Association (IMA) is apprehensive to get doctors from any other medicine system involved. No legal credibility or infrastructure is made available to these systems,” said Dr Bhattacharya.

She contended that the IMA vs AYUSH issue is a larger political issue as the allopathic medicine system is backed by the practice of big pharma companies, while alternative medicine systems recommend a more home-based treatment.

Responding to people’s apprehension over incompetent practitioners who misguide their followers, she said that there are incompetent AYUSH doctors as there are MBBS doctors in modern medicine. Both of them should be made to clear competency exams every 10 years or so (like in the US) before giving them the license to practice.

Private Hospitals Or Business Centres

Wherever the government finds itself incompetent or too lazy to participate, it happily welcomes big corporates with their big bank accounts, turning essential services such as education and healthcare into money-gobbling monsters.

Banquet Halls Converted Into Covid Care Centre In Delhi
Wherever the government finds itself incompetent or too lazy to participate, it happily welcomes big corporates with their big bank accounts, turning essential services such as education and healthcare into money-gobbling monsters. Photo by Mohd Zakir/Hindustan Times via Getty Images

Medical students are inculcated the ethic of making money right at the beginning – where they have to pay lakhs and crores of rupees to get admission, and then get harassed, corrupted and disrespected by the medical system itself, found Dr Bhattacharya when she talked to many students and practitioners during her research. They then open hospitals where a patient has to make a huge deposit even to get admitted in a general ward.

But to deny private hospitals their rightful space in India’s healthcare, said Mr Sameer Wagle, Managing Director, Asian Healthcare Fund, a venture capitalist firm that invests in companies in healthcare, would be unfair as 62% of healthcare is handled by the private sector. He said that by bringing in innovative technology, efficacy and efficiency that a bureaucratic system can’t often afford, the private sector can take up a complementary role in public healthcare.

A successful example of this was brought up by Krishna Devrayalu Lavu, MP (Lok Sabha), YSRCP, from Andhra Pradesh (AP). In 2018, the AP state government partnered with Apollo and launched a programme called the e-Eye Kendram, under which ophthalmology screening, diagnosis and consultation was provided at Community Health Centres. Apollo has also partnered for similar projects with Himachal Pradesh, Uttar Pradesh and Jharkhand, there is more community-based participation that private healthcare firms should be taking up.

Conclusion

Of the many steps that the current government has taken back over its tenure when it comes to healthcare, it did take one step ahead in the form of Ayushman Bharat programme. To make healthcare affordable, the scheme provides health insurance of upto Rs 5 lakh to low-income groups. By December 2020, a total of 1.5 crore hospital admissions had been made under the scheme, involving an expenditure of Rs 17,000 crore (albeit with a few cases of corruption). However, the insurance scheme can only work well with better infrastructure and health talent.

Healthcare has been too longer ignored as a political issue to be mention in political parties’ manifestos or sloganeering during election; health infrastructure is a long-term impact, while parties are interested in focusing more on tempting short-term promises. Now that healthcare has entered the mass consciousness as an issue, the governments must be pressured to think in the direction of national healthcare coverage that is primary health-centred.

Featured image credit: Getty Images
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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.

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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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