Universal health care is possible in India


Dinesh C. Sharma

lives and works as a journalist, columnist and book author in New Delhi. His latest book on the Indian health system is coming soon.

Translation: Stefan Mentschel

India's health system

If you get sick in India, you have two options: Either you put yourself in the hands of the state health system, which is characterized by a shortage of personnel, poor infrastructure and poor service. Or you can be treated privately, but often have to dig deep into your own pocket. The government wants to reform the system and make it fairer, but the hurdles are high.

Patients await treatment in a hospital in Mumbai. (& copy picture alliance / Frank May)

The Indian health system is full of contradictions. On the one hand, the country has made significant progress in the area of ​​health. The government was able to announce the eradication of polio at the beginning of 2014. In addition, life expectancy increased in the last 15 years for men from 62.3 to 67.3 years and for women from 63.9 to 69.9 years. On the other hand, India is still plagued by significant problems such as widespread malnutrition and high child and maternal mortality rates. In addition, there is a double burden with illness. On the one hand, infectious diseases such as malaria and tuberculosis are still a major public health problem. On the other hand, lifestyle diseases such as diabetes are claiming more and more victims, with cardiovascular diseases now the number one killer in the country.

India has the most privatized health system in the world. The cost of private treatment is so high that it is estimated that two to three percent of Indians slide below the poverty line every year as a result of this expenditure. Government funded health care is in poor shape. In rural areas in particular, there is a lack of doctors, nurses and health stations. In large cities, on the other hand, there are five-star clinics that also attract medical tourists from western countries.

Child and Maternal Health as an Indicator of Progress

The health of children and mothers is a key indicator of the development progress of a nation. India is lagging behind in this area as improvements are progressing more slowly than necessary. The under-five mortality rate has risen from 125 per 1000 births in 1990 to 52 per 1000 births in 2012. The target for 2015 is 49, but this is also above the target of 42 set in the United Nation's Millennium Development Goals (MDGs).

Infant mortality is currently 42 per 1000 births. By 2015 it should drop to 40, which is well above the MDG target of 27. Maternal mortality, i.e. the number of women who die in childbirth, fell gradually in India between 1990 and 2011 from 437 to 178 out of 100,000 births. Regardless of this, India also clearly misses the target of 109 in the MDGs. There are also significant differences between the individual states. For example, maternal mortality in economically backward Uttar Pradesh is still 300 out of 100,000 births.

This is a worrying situation because most child and maternal deaths would be preventable. This in turn reflects the inadequacies of the public health system, which is supposed to guarantee people on low incomes free or at least inexpensive care, including childbirth and all necessary vaccinations. The money for this comes from the central government and flows into specially developed programs. However, the states are responsible for implementation.

Lack of staff and poor facilities

The main problem facing the public health system is the shortage of doctors, nurses, and other medical and technical personnel. In addition, there is the inadequate infrastructure. It is true that the central government recently increased spending in the health sector - from the equivalent of 5.6 billion euros from 2002 to 2007 to 14.2 billion euros from 2007 to 2012. The spending of the federal states also rose in this period from 12.7 billion euros to 27 , 4 billion euros.

But the problems with the primary health centers (PHC), which are supposed to serve as the first point of contact for the population, as well as with the community health centers (CHC) are glaring. Safe abortion options are not available in all CHCs, which contributes to higher maternal mortality rates. There is also an acute shortage of personnel: at the end of 2012, 52 percent of nurses and midwives, 76 percent of doctors, 88 percent of specialists and 58 percent of pharmacists were missing from state health facilities.

(Click HERE for official numbers of doctors and nurses in India)

In rural areas, women health workers (Accredited Social Health Activists, ASHA) act as a link between the population and the state health system. One of her tasks is to convince expectant mothers to give birth to their children in the hospital (and not at home). They also advise on nutrition and help with vaccinations for newborns. There are currently around 900,000 such workers in India, but they are hopelessly underpaid.

Every year around 50,000 trained doctors (Medical Graduates) leave the almost 380 medical schools in India. In addition, there are a large number of doctors who are trained in classic Indian healing methods such as Ayurveda and Unani. However, colleges and universities for medical training are unevenly distributed, with a strong concentration in the south and west of the country and only a few institutions in the north and east, where there is a particular lack of medical staff.

Young doctors and nurses trained in the cities shy away from going to the countryside, where facilities are poor and financial incentives are few. Numerous Indian doctors also go to western countries. In the United States, it is estimated that 4.9 percent of all practicing physicians come from India, in Great Britain it is 10.9 percent, in Australia 4 percent, in Canada still 2.1 percent. In order to close the personnel gap in rural areas, the Indian government is planning the use of so-called barefoot doctors, who only have to be able to meet the minimum requirements for a medical professional. Medical associations oppose this plan because they fear government funding for quackery.

The most privatized healthcare system in the world

The vacuum that the Indian state health system has left in rural and urban regions is being filled by private providers. The system of private health care is extensive and covers the entire spectrum of services - from private medical practices to nursing homes and maternity clinics, outpatient clinics and diagnostic centers to specialist hospitals and hospital chains in metropolitan areas. Following the opening of the health sector to foreign investors, numerous special clinics - for example in the field of artificial insemination - that are operated by international companies have been added in recent years.

India now has the strongest privatized health system in the world. Of the estimated 4.1 percent of gross domestic product that is spent on health care, just 29 percent go to government spending. In other words, the rest - 71 percent - is paid for by the Indian citizens themselves. Experts call this Out of Pocket Health Expenditures, i.e. out-of-pocket medical care expenses. The poor state of the state system is forcing even members from poor sections of the population to make use of services from the private sector, which often results in massive financial burdens, because pricing in the private health sector has not yet been subject to any state control.

Even those who remain in the state system have to pay some of the costs out of their own pocket, especially for drugs that state hospitals do not keep in stock for patients. The majority of out-of-pocket expenses go into practice fees, the purchase of medication and diagnostics or medical tests - all costs that health insurance companies would not cover, which in any case only affects a minority of the population. According to the World Bank, only about 25 percent of Indians have access to health insurance, including the insurance funded and provided by the Indian government. This means that in addition to access to public or private health care, the most important question for most Indians is whether they can afford this care at all.

Medical Tourism - A Profitable Business

The goal of the entrepreneurially run private hospitals is to provide international standards in health care, so profit, not the affordability of services, is the focus of interest. In order to further increase their income, these hospitals have discovered a new, lucrative business area for themselves - medical or health tourism. To attract medical tourists from Western countries, the clinics employ Indian doctors who have been trained in the West. In addition, they acquire international approvals in order to be able to offer their services to patients from all over the world. Some of these hospitals are set up like five-star hotels, others cooperate with providers from the tourism sector.

Medical tourists come to India because the costs are lower here and because they can avoid the often long waiting lists for certain operations in their home countries. The price differences are enormous. A hip transplant in India costs US $ 7,000 (5075 euros), while in the United States it costs US $ 50,000 (36,240 euros). Patients in India can get bypass surgery for $ 5,000 versus $ 100,000.

Recently, more and more Europeans have found their way to India to have their desire for children fulfilled here. In addition to artificial insemination, the services also include surrogacy, which is banned in many Western countries. In addition, the cost of artificial insemination is only a quarter of the price that is charged for it in the West. Cosmetic surgery also attracts patients from abroad.

All in all, it turned out to be good business. According to information from the industry, around 250,000 medical tourists come to India every year, with a turnover of around one billion US dollars (726 million euros). While the financial motives of the healthcare companies are perfectly understandable, the ethical question arises when it comes to the diverse government support for this branch of industry.

Numerous private clinics have been built on land that the government has made available to companies on favorable terms. The clinic operators also benefit from indirect subsidies. Many of the doctors who care for medical tourists were trained in state universities. The Ministry of Tourism is investing public money in elaborate advertising campaigns to attract foreign patients to the country. The Ministry of Foreign Affairs issues special visas to medical tourists. So is it ethically and morally justifiable for the state to promote medical tourism when, at the same time, many citizens are denied access to appropriate medical care?

Universal Health Coverage: Access to health care for all

In 2011, the government appointed a commission of experts to prepare for a reform of the health system. Among other things, this proposed the introduction of a system of universal health coverage (UHC). In it, the state should provide a minimum of medical care and thus enable all citizens to have access to health care, regardless of income.

The government included UHC in the 12th five-year plan (2012 to 2017). In doing so, she affirmed that the public health system should play an important role in ensuring basic health care for the population. At the same time, it promised its "substantial expansion and strengthening". So India needs good and affordable public health care while the private sector should continue to provide services to those who can afford it. Government departments believe that improving the public health sector can also end the dependence of the poor on expensive private treatment.

The expert group also recommended increasing government spending on health from currently 1.2 percent of gross domestic product to 2.5 percent by 2017 and to 3 percent by 2022. Tax revenues should be used to finance the health system instead of burdening the industry with a separate tax. In some states, pilot projects are now running to test UHC in practice.

Regardless of this, there are fears that, in view of the deficit state health system, the government will be forced in the medium term to integrate the private sector into the UHC system in order to be able to guarantee guaranteed basic care at all. In any case, the private sector should be involved in the plans to reform the Indian health system. The challenge will be not to undermine the principles of fair access and equal treatment.

"The challenges in health care are gigantic"

Due to its staffing and infrastructure problems, the public health system is also not prepared to master the challenges posed by non-contagious diseases such as diabetes, high blood pressure, cardiovascular diseases and cancer - not only in cities, but also increasing in rural areas . The nature of diseases in India is changing. According to the 2013 Global Burden of Disease study, more Indians die from non-contagious diseases than from infectious diseases.

Since drug costs make up a large part of health expenditure, it would also be important to ensure access through various measures, such as subsidizing essential drugs, using generic drugs, or buying and keeping drugs available by government agencies. State pharmaceutical manufacturers could be revived and promoted for this. In addition, the regulatory system for pharmaceutical products as well as patient rights must be strengthened in order to meet the requirements of the World Health Organization. The quality of medical education needs to be improved, as does training for rural health workers. Common standards for public and private care should also be developed.

To ensure the success of UHC, the government must work on multiple construction sites at the same time. In addition, any effort to improve the health system would be pointless if factors such as the provision of safe drinking water, hygiene, nutrition and education were ignored. The challenges facing the Indian healthcare system are indeed gigantic.