CHALLENGES OF PUBLIC HEALTH SYSTEM IN INDIA

WHY IN NEWS:

• The COVID pandemic has exposed the deep vulnerabilities of India’s healthcare system. Much of this is blamed on India’s low expenditure on public health -1.29% of the GDP

BACKGROUND:

• The WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
• SDG Goal 3: Ensure healthy lives and promote well-being for all at all ages.

CONSTITUTIONAL PROVISIONS

• Directive Principles of State Policies:
  • Article 39(e): Securing health of workers, men and women.
  • Article 41: Public assistance basically for those who are sick and disable.
  • Article 42: To protect the health of infant and mother by maternity benefit.
  • Article 47: Raising of the level of nutrition and standard of living of its people and improvement of public health 
• Fundamental Rights:
  • Article 21: Supreme Court of India in many cases interpreted the right to health under Article 21. Examples: Bandhua Mukti Morcha v/s Union of India, State of Punjab v/s Mohinder Singh Chawla etc.

CHALLENGES:

• Low level of public expenditure on health:
  • India’s public expenditure on healthcare was 1.3% of its GDP in 2019-20 which was substantially lower that other BRICS countries (Brazil: 3.8%, China: 3.1%, Russia: 3.7%, South Africa: 4.2%)
• High out of pocket expenditure on health:
  • Over 70% of ailing population in rural areas and almost 80% in urban areas utilize private facilities.
• Lack of health infrastructure:
  • India faces an acute shortage of hospital beds with a ratio 0.5 per 1000 population for India as compared to 2.3 for China, 2.6 for Brazil and 3.2 for the US.
• Human capital crunch:
  • Healthcare sector requires highly skilled human resources from doctors to other medical support staff like nurses, lab technicians, pharmacists, etc.
• Presence of quacks exacerbates the issue:
  • WHO says that 57 per cent of the people who claim to hold an MBBS degree in India actually have no medical qualification and 31 per cent have only been educated up to Class X
• Shortage of staffs:
  • India’s public system has a shortage of health workers
  • For example we have 0.6 nurses per doctor while the World Health Organization specification is three nurses per doctor.
• Regional disparities:
  • Evident in differences between rural-urban gaps and inter-state gaps.
  • According to a KPMG report, 74% of India’s doctors cater to a third of urban population.
  • As a consequence, India is 81% short of specialists at rural community health centers.
• Rising cost of treatment:
  • Per capita public expenditure on health in nominal terms has gone up from Rs 621 in 2009-10 to Rs 1112 in 2015-16.
• Quality of health care services:
  • The regulatory standards for public and private are not adequately defined and ineffectively enforced.
  • Low quality of training and skill building for medical staffs
• Poor track record in social determinants of health
  • Unhealthy lifestyle, sedentary life, consumption of junk foods etc.
  • Malnutrition still remains the most important risk factor (14.6 per cent) that results in disease burden in the country, though dropping substantially since 1990.
  • Anemia among women – 45% of Indian women are anemic
  • Social divisions (casteism, patriarchy etc.) >> Low coverage of marginalised sections
• Health insurance:
  • Despite the increase in annual growth, more than 80% of the population still does not have any significant health insurance coverage.
• Insufficient and inefficient role of public sector:
  • About 70% of all outpatient care and 60% of inpatient treatments are provided by private sector
• Legislative hurdles:
  • Health is under the state list, hence coordination issues and lack of uniformity across the countries
  • State governments also struggles with fiscal deficits >> low budget spending on health
• Overlapping Jurisdiction:
  • There is no single authority responsible for public health that is legally empowered to issue guidelines and enforce compliance of the health standards.
• Fragmented Health Information System:
  • Data is incomplete and often it is duplicated.

SOLUTIONS:

• Adopt one health approach:
  • One Health is "the collaborative efforts of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals and our environment"
• Health financing and financial protection (ensuring affordability):
  • Government should increase public expenditure on health from the current 1.2% of GDP to at least 3% of GDP by 2022.
  • Expenditures on primary healthcare should account for at least 70 per cent of all healthcare expenditure. 
• Access to medicines, vaccines and technology:
  • Price controls and price regulation, especially on essential drugs, should be enforced.
  • The Essential Drugs List should be revised and expanded, and rational use of drugs ensured.
• Human Resources:
  • More health professionals need to be deployed for primary care in rural areas.
  • Regional Faculty Development Centers should be selectively developed to enhance the availability of adequately trained faculty and faculty-sharing across institutions
• Governance and Institutional Reforms:
  • All India and State Level Public Health Service Cadres and a specialized State level Health Systems Management Cadre should be introduced in order to give greater attention to Public Health. 
• Community Participation and Citizen Engagement:
  • Existing Village Health Committees should be transformed into participatory Health Councils.
  • There is a need to build up institutions of citizens’ participation, in order to strengthen accountability and complement what the regulatory architecture seeks to do. 
• Focus on primary health care:
  • Primary health care should receive three times more allocation in the budget and doctor and paramedic strength should be doubled merely on the basis of population increase.
• Gender and Health:
  • Improve access to health services for women, girls and other vulnerable genders which goes beyond the maternal and child health.
• Access to services that are determinants of health:
  • Ensure access to services that are determinants of health, such as safe drinking water and sanitation, wholesome nutrition, basic education, safe housing and hygienic environment are of utmost importance. 
• Strengthening institutions:
  • In order to promote preventive care, the Union government has announced the conversion of primary health care centres into Health and Wellness Centers (HWCs)
  • These HWCs will act as the pillar of preventive care and ‘gateway’ for access to secondary and tertiary health services.
  • HWCs should be well-staffed and well-provisioned through a reasonable fee which will cover at least part of the cost
• Use of ICT:
  • Leverage the power of India’s innovation, technology and ICT capability- tele-consultation
  • National Digital Health Mission (NDHM) aims to bridge the existing gap amongst different stakeholders of Healthcare ecosystem through digital highways.
• Ensure robust Public- Private Partnership:
  • Use PPPs judiciously and fit them to local circumstances, so they will drastically change the healthcare landscape in India.  
• Fiscal measures:
  • Tax on fat:
    • A fat tax is a tax or surcharge that is placed upon fattening food, beverages or on overweight individuals.
    • It aims to discourage unhealthy diets and offset the economic costs of obesity.
  • Tax reduction/exemption for low cost medical devices
  • Tax holidays for domestic enterprises in drug/API manufacturing.
• Decentralisation:
  • There is a need to make nutrition, water, sanitation and hygiene (WASH) part of the core functions of Panchayati raj institutions and municipalities.

BEST/APPLICABLE MODELS

• The National Health Service of the United Kingdom
  • Government-funded universal health care
• Arogyakeralam project of Kerala:
  • Providing medical care and support to every citizen in need of palliative care through community-based approach
  • It is a holistic approach to medical care, focussing not only on health concerns but also on the social, economic and psychological condition of a patient.
• Comprehensive Annual and Total Health Check-up for Healthy Sikkim (CATCH):
  • It is a flagship programme launched by Sikkim to provide basic healthcare services at the doorstep of the state’s rural population

PRACTICE QUESTION:

Q. Health-care spending by the government must be appropriate, based on evidence, and transparent and accountable