Sixty children died in Gorakhpur between August 7th and 11th, at the BRD Hospital, a shocking trend that is blamed on a multitude of causes – news reports cite the hospital facing an average of 200-250 encephalitis patients daily, with a 7-8% mortality rate (Nath, Damini, The Hindu, August 16, 2017) while the hospital and the oxygen supplier blame each other. Meanwhile, funeral pyres, a metre in length each, burn on the banks of the Rapti river.
On the State of Healthcare
The irony is that Gorakhpur’s health and development statistics are almost above average for Uttar Pradesh – 65.4% of children aged 12-23 months old are fully immunized, compared to an average of 51.1% for Uttar Pradesh (National Family Health Survey, 2016). Uttar Pradesh ranks amongst the lowest amongst Indian states in spending on healthcare (with just 0.8% of its gross state domestic product, spending Rs 452 per capita on medical and public health needs compared to Rs 1042 for Uttarakhand and Rs 647 for all India in 2014; CMIE States of India, 2014). Half of all sanctioned posts for doctors in rural primary health centre stand vacant (Jain, D., Live Mint, August 2017) (CAG Report No. 25 of 2017).
Such events and statistics sound depressingly familiar. India faces a cocktail of maternal, child health, infectious and non-communicable diseases – we have 63 million people with diabetes, while there are 253 deaths per 100,000 due to communicable diseases annually (compared to a global average of 178) (World Bank, 2010). Doctors remain few and far between (India has 650,000 doctors, with another 400,000 needed by 2020; Unnikrishnan, CN, 2015).
Despite decades of spending on healthcare (annually reaching ~6 trillion rupees), India’s healthcare system consistently fails to provide minimal healthcare services. Let alone oxygen cylinders, even hospital bed density continues to be low (~0.9 beds per 1000 people, vs a WHO recommendation of 3.5; WHO, 2017). The 12th five year plan estimated a healthcare expenditure requirement of Rs 10.7 lakh crore, of which only Rs 3.8 lakh crore was allocated and just Rs 30,000 Cr spent by the fourth year (Unnikrishnan, CN, 2015).
On Improving Delivery
Given the size of our population, it might seem difficult to ensure primary healthcare coverage, let alone improve delivery – however, such issues are not insurmountable. Consider the case of China – in 2008, China’s rural healthcare sector faced four key challenges – there were significant health inequalities (maternal mortality rate was 73 per 100,000 live births in the poorest 20% towns and villages, while the richest fifth had 17 per 100,000), and healthcare was increasingly unaffordable (World Bank, April 2015).
In 2009, the Chinese government launched a new round of healthcare reforms, (WHO, “Rural Health Reform and Development in China, 2012). The reforms focused on improving and expanding its existing three-tier rural health delivery system (divided between county level hospitals, township healthcare facilities and village clinics, a network covering 2,856 counties in 31 provinces). Between 2009 and 2012, 52 billion RMB yuan was allocated from the central government budget to improve over 2000 county hospitals and 25,000 village clinics. Within 2 years, there were 6,400 county hospitals, over 1500 county maternal and children’s hospitals, 1500 county health inspection institutions, 38000 township hospitals (ensuring that every township had one or more hospitals and 648000 village clinics, covering 92.3% of all villages). This was not a short term plan – between 2004 and 2011, over 2.26 billion RMB had been allocated to train rural health professionals; by 2010, over 1.6 million health workers were working in county hospitals, 1.2 million in township hospitals, giving 1.3 health workers per 1000 in townships. The New Rural Cooperative Medical Scheme (NRCMS), a rural health insurance plan, was expanded, covering 832 million people by 2011 (97.5% of the rural population). This was reflected in percentage of out-of-pocket expenditure for rural residents dropping from 73.4% in 2008 to 49.5% in 2011.
On Healthcare Financing
Our approach to healthcare financing needs to change. Total healthcare expenditure in India is expected to rise to $280bn by 2020. Our existing system is built on a tax-based funding approach, with health insurance barely covering ~5% of total health expenditure (In 2015, there were only 5 standalone healthcare insurance firms and 17 general insurers offering healthcare insurance products; in comparison, the UK has 911; Sharma, S., Financial Times, Mar 2015) .
While reforms in public services often seek to unleash the hand of the free market, such conditions do not prevail when providing healthcare services – most developed and developing countries have sought to build high capacity healthcare systems, seeking to pool risk, while pursuing prepayment, concentrating purchasers with insurance providers and utilizing the government’s hand to shape and manage the entire healthcare system. Funding this appropriately remains key – higher taxation (as used in the UK for the National Health Service) or mandatory health insurance (as pursued in the United States, Japan and Germany) are the typical mechanisms used to fund the creation of treatment pools. Such pools are typically managed either by large public trusts, insurance players (consider Obamacare) or a single national health security office (like in Thailand). Such systems can improve healthcare outcomes – Thailand, emerging from a turbulent 1960s, has managed to eliminate healthcare related impoverishment by establishing a universal healthcare system, despite starting at healthcare statistics similar to India.
Towards Universal Healthcare
India’s first healthcare policy white paper in 1946 sought to establish an ambitious healthcare system that would see the Central Government delivering public health programs, while state governments provided secondary care. Seven decades later, India’s public health programs remain limited in scope and uncoordinated, while primary and secondary healthcare is provided at a poor quality and increasingly unaffordable rates (Bali, A., Ramesh, M., Public Administration Committee, Vol 30, Issue 3-4, 2015).
India’s healthcare system needs to evolve towards this universal ideal, seeking to provide additional government funding through a health cess, if needed, while additional taxes on tobacco and alcohol, and extractive industries, could help fund the provision of free drugs, diagnosis and emergency care. All national and state health insurance schemes should be consolidated into a single scheme, with a single fund pool, that could offer diagnostic services and healthcare insurance for serious ailments. In this uncertain age, the provision of affordable and timely healthcare services should be a fundamental right of every Indian citizen.