It is a known fact that the Indian healthcare system is outdated, under funded and over burdened. Adding to this, with increasing population every year, there is increasing incidence of chronic diseases and infectious diseases and deaths due to these diseases. Therefore the role of the government in healthcare becomes more pivotal. There is a 'faith gap' and a 'need gap' when it comes to availing the services from the government facilities. There are countries that spend over USD 7000 per capita (like the USA) for healthcare. Still the healthcare issues remain unaddressed. So there is a lesson to be learned - just spending more on healthcare does not solve the problem.
Indian government started the Jawaharlal Nehru Rural health mission (JNRHM) with a budget outlay of approximately Rs 11000.00 crore. Still it remains to be seen if this amount can bring about a positive change in the healthcare delivery. There are a host of issues like lack of political will, bureaucratic inefficiency, non-transparent allocation / tendering processes and the channels of delivery that eat up any money that is pumped in the Indian healthcare system without bringing about a change in the system.
India has a healthcare system where the doctors available is 0.60 per 1000 population, beds at 0.70 per 1000 population and nurses 0.80 per 1000 population, dentist 0.06 per 1000 population and pharmacist at 0.56 per 1000 population. If we check on some of the specialties like psychiatry, and take the rural and urban divide into account, doctor to population ratio is 1:1 million. We have just about 700000 doctors and we churn out about 22000 doctors per year. Current healthcare system is accessible to just 30-35 per cent of the population.
There was a shortage of 4,833 primary health centres (PHCs) across India and over 800 rural hospitals were functioning without a single doctor. "A total of 807 PHCs are working without a single doctor," Ramadoss said in a written reply to the Lok Sabha.
There are a total of 22,370 primary health centres functioning across the country, and the shortfall is of 4,833 PHC. There are only 15,546 female health assistants against the requirement of 22,370.
The PHCs function as the first contact point between villagers and medical officers. They render curative, preventive, promotive and family welfare services to rural Indians.
Giving details about the status of community health centres, the minister said there is a shortage of 2,525 community healthcare centres (CHCs) across the country. Of the total 4045 CHCs, 26 are running in rented buildings, while 306 in panchayat buildings.
He said 449 buildings are under construction and 199 buildings need to be constructed, and that there are only 5,117 specialised doctors working in these CHCs, though the requirement is a whopping 16,180. Against a demand for 4,045 radiographers, only 1,740 were working in such centres.
In both PHCs and CHCs there is a requirement of 50,685 nurses and midwifes but only 29,776 are in position.
The CHCs are established and maintained by the state governments. A CHC has at least 30 indoor beds and provides facilities for emergency obstraetrics care and specialist consultations.
Adding to this deficiency, absenteeism in PHC is around 40 per cent. There is an average of one urban primary health facility for about 150000 urban population, with only 2-4 health workers.
India according to World Health Organisation (WHO) is short by 2.4 million physicians, nurses and midwives. According to a recent planning commission document India was short of 6 lakh doctors, 10 lakh nurses and two lakh dental surgeons.
Investment issue
Major private groups are shying away from foraying into healthcare in a big way due to high real estate costs, lack of trained manpower and high gestation periods. A few years ago, two of the biggest business houses announced investments into healthcare aiming to capture 20 per cent of the healthcare. But they gave up quickly seeing the cash burnout without quick financial returns. Most of the privately run healthcare entities are run for charity. Adding to the woes is penetration of health insurance that is 1.08 per cent of the total population.
Knowing well that currently 2/3rd of the Indian population is under 35 years of age, India will become older before it becomes rich. The healthcare issue is like a ticking time bomb.
India already has the infamous distinction of being the diabetic capital and no doubt, will soon be crowned as the cardiovascular disease (CVD) capital as well. But these are all merely reduced as 'academic statistics' and no concrete action has been taken to address chronic care management which accounts for approximately 60 per cent of all the deaths. In the last three decades, there has been a shift from infectious diseases to chronic diseases. It is estimated that by 2015, India will lose approximately USD 54 billion due to NCDs.
To reach to the average level of one bed per 1,000 people, India needs about 3 lakh beds as additional installed capacity. At an average cost per bed of 25 lakh for a secondary care hospital, the total investment required amounts to INR 75,000 crore.
It is high time that India paid serious political and bureaucratic attention to this huge and unavoidable issue. India cannot bear the burden of healthcare financially, and the current healthcare system cannot bear the burden of diseases due to lack of resources.
The government has to address the healthcare issues of India both in rural and urban areas separately but with a holistic approach. Also, the public-private-partnership (PPP) has to be 'sweetened' and made 'profitable' in the short or mid term. No corporate is interested in long term relationships with the governments that even does not last its whole term. There has to be a certainty and continuity of the relationship and it has to be guaranteed irrespective of the government that takes the decision. It calls for a separate 'high powered autonomous PPP regulatory body' that has a public-private representation along with unambiguous guidelines to ensure financial viability without compromising on the quality of care. The PPP model cannot be without profits.
Rural areas have different issues and urban areas have different issues. There are a few things that the government needs to consider as options. They are:
● Define delivery standards for healthcare entities from rural primary care centres to high end urban facilities like AIIMS. Those who fail to deliver on the set bench marks need to be private players for achieving the set standards
● The private players must have an incentive to earn as long as they keep the pricing standards and quality of care
● The government must play the role of a regulator and an underwriter for any shortfall or losses
● The government must partner in risk as well as profits
● Waive the taxes and duties for PPP model to keep the healthcare delivery costs low
● Make the healthcare screenings mandatory for the entire population:
● There should be a tax benefit for people undergoing healthcare screenings and not just for health insurance
● Government must insist on making generic medicines available at all places in the country to cut down heavily on the cost of medicines
● Government must set the target for creating disease free zones by 2025
● Immunisation and preventive care model must be adopted as the first ladder in healthcare even for PPP model
● All the government employers and private sector employers must be mandated to get the preventive screening for hypertension and diabetes every year. For some specific towns and industries with a potential health hazards, asthma, opthal and spinal screenings be made compulsory
● Indian government must promote healthy lifestyle and not just awareness about diseases
● Indian government must encourage quality traditional medicines and preparations that promote wellness
● The government must come up with specific healthcare guidelines for all age groups and specific for each industry
● Channels of delivery of preventive and primary care must not be limited to just PHCs and hospitals but must be routed through every potential
channel, may be even beyond the chemist shops
● Government regulated media must dedicate at least 60 minutes a day on wellness and healthcare
● Telemedicine must be adopted as the POC tool for the entire nation. The applications of telemedicine has been proven to deliver the similar healthcare outcomes at reduced costs
● A complete epidemiological survey must be undertaken. India, unfortunately, does not have any such data to analyse and predict healthcare disease patterns and outcomes
● India needs to move towards a paperless healthcare system. It does not necessarily mean an electronic health record. It can be done via various storage media that is available cheaply
India needs more innovative care in healthcare that is low cost, scalable and effective. That would bring healthcare closer to the population and take sickness away.
(The author is president,Disease Management Association of India)