‘’The mismatch between the objectives and resources is at the heart of the inadequacies and inequities of the health system.”- Dr. N. J. Kurian
According to the Global Burden of Disease Study (GBD) published in the medical journal ‘The Lancet’, India ranks 154 among 195 countries on the healthcare index. Although, India’s Healthcare Access and Quality (HAQ) index has increased by 14.1 escalating from 30.7 in 1990 to 44.8 in 2015. The nation lags behind its peers like China (74), Sri Lanka (72.8), Bangladesh (51.7), Bhutan (52.7), and Nepal (50.8). It only ranks above Pakistan and Afghanistan, their HAQ being 43.1 and 32.5 respectively.
As per the study, India has performed incompetently in tackling diseases like tuberculosis, diabetes, maternal disorders, chronic diseases and rheumatic heart diseases. The journal lists India among the biggest “underachievers” in Asia in healthcare access. A pertinent question is why India performs so poorly in comparison to its neighbouring countries in spite of its GDP or per capita index being far better than all these countries except China.
If we probe deep into this issue, we shall find that the major cause behind such “underperformance” on India’s part in terms of healthcare has been its policies pertaining to the management of its healthcare issues as well as the insufficient expenditure made by the Indian government on healthcare. Healthcare has not been provided with due importance in India whereas its neighbouring countries have prioritised it.
In comparison to India’s 5%, China spends around 10.4% of its budget on health. Vietnam spends around 14.2% and Nicaragua around 24%. In fact, a recent report published by a leading daily based on a study analysed by health economists Sakthivel Selvaraj and Habib Hassan Farooqui (experts from the Public Health Foundation of India) reads, “Health spending pushed 55 million Indians into poverty in a year.” The article talks about how around 55 million Indians were pushed into poverty in a single year because of having to fund their own healthcare. According to the study, 38 million out of these 55 million people fell below the poverty line only due to their spending on medicines.
After independence, India opted to follow the National Health Service (NHS) pattern of healthcare financing that was widely popular in the U.K. which was a vivid example of a state-run and publicly-funded health system. Parallel to the NHS, which was based on the William Beveridge Committee Report (1994), India had the Joseph Bhore Committee report which came up with somewhat similar recommendations. The Government of India’s acceptance of its major recommendations led to a nationwide healthcare machinery with reasonable norms in terms of coverage, availability of personnel and institutional linkages. This continued till India embraced neo-liberalism. Since the start of the economic reforms in the early 1990s, as Dr. N. J. Kurian puts it, “systematic efforts have been there to weaken India’s public healthcare system”. The share of health expenditure in total public expenditure peaked in the Indian states in 1987, but it has been more or less declining thereafter. According to the constitutional division of expenditure responsibilities, the principle load of healthcare expenditure has to be borne by the states. However, in recent years, the centre had stepped up healthcare expenditure through various schemes, the most prolific and widely accepted of which was the Public-Private-Partnership (PPP) scheme which was part of the eleventh Five Year Plan.
The PPP model entails collaboration between the public and the private sector that enables the fulfilment of certain common goals by overcoming the visible limitations. But in spite of such collaborative efforts, a visible demand-supply mismatch has been marked over these years in the health sector. In spite of its many advantages, the system faces serious problems relating to equity, quality and costs. The most significant feature of the PPP scheme, in India, has been its insurance policies. The government insures and pays health insurance premium for families below the poverty line. These families, in turn, are insured against expenses on health and hospitalisation, up to a certain amount. Apart from these, various other facilities such as subsidies, contracting (both in and out) policies, voucher system, mobile health vans among others are also said to have been provided by the government but none of these policies or schemes have been adequately implemented.
The government alone cannot meet the required infrastructure capacity and delivery shortages existing in the current healthcare system. There has to be an increased participation of private sector under the umbrella of PPP schemes for infrastructure building, capacity development and delivery. Moreover, the disparities that exist between the rich and the poor in terms of access to healthcare and purchasing power parity are also to be taken into consideration. The private sector’s profit maximisation motive should not impede the economically marginalised from availing premium health services.
The basic problem of the Indian healthcare system is its severe shortage of doctors. Even today, 70% of primary healthcare is provided by unqualified practitioners owing to paucity and misallocation of funds. While the developed countries bear around 80% of the healthcare expenditure, around 80% of the healthcare expenditure in India is in the private sector. Insurance companies provide less than 3% coverage. Moreover, they provide healthcare only to the young, the employed and the rich, while the elderly, unemployed and poor are not even taken into consideration.
As far as the government’s promise to provide cheap medicines through Jan Aushadhi Stores is concerned, it has remained only in paper as most of these 3000 plus stores face serious stock shortages and quality issues. According to a report published in a leading daily, “Most Jan Aushadhi Stores have barely 100-150 formulations instead of the promised 600 plus medicines and their numbers are too small compared to the 5.5 lakh plus pharmacies in India.” Even after 60 years of planned development, there is a serious disparity in India between the declared objectives of universal healthcare through the public health system and the actual level of public health expenditure, which accounts for its “under performance.”