In the dazzle and frenzy of the electoral battle, which seems to become more strident by the day, one of the most neglected aspects has been the priority given to the health sector. Health, and primary health to be specific, does not figure prominently in the manifestos of both the national parties and that of the others as well. Their well crafted documents have taken pains to cover every area of national importance and it seems a bit of a surprise that they have neglected this one aspect that should have been the most vital.
Since the theme of this year’s World Health Day is to highlight the importance of Universal Health Coverage (UHC) with the catchy mantra of ‘UHC for everyone everywhere’, which also gets reflected in the United Nations Sustainable Development Goals (SDGs) that all countries must achieve by 2030, where does India stand in meeting that target deadline?
With just a decade to measure the success in achieving the SDG target of UHC, elected governments need to redeem the pledge they have made to the electorate by 2024. That should be the immediate need but is there any evidence of proceeding in that direction, or urgency? There does not seem to be any indication of that as of now.
The UHC has also been envisaged to be cashless at the point of care and health benefits under the programme and to be available for access anywhere in the country. The health workforce has also, likewise, to be expanded to make available multi-layered, multi-skilled teams which can deliver the needed services. Basic and specialist doctors, nurses, nurse practitioners, physician assistants, pharmacists and an array of allied health professionals need to be developed in large numbers and deployed across the country, it was envisaged.
All of this calls for expediting reforms in professional health education, cadre, planning and incentives for rural postings. Strengthening of primary care infrastructure and district hospitals has also to be a government priority. Free provision of essential drugs and diagnostics at public healthcare facilities will have an immediate impact. These are lofty ideals and meticulously worked out, and also with imagination. But it is at the implementation stage that there seems to some mismatch. Since healthcare induced financial distress is one of the reasons for the alarming number of farmer suicides this is also one area that needs to be addressed seriously.
According to one US think tank, there is an acute shortage of doctors and nurses in India and there is also a shortage of trained staff to administer antibiotics and this is what makes patients unable to reach life-saving drugs. And when these are available, they found that the patients are unable to afford these drugs. The Centre for Disease Dynamics, Economics and Policy (CCDP) of the US says such medical costs and the limited government funding for health is at the root of the problem that is plaguing India.
The details are even more disturbing; in all 65 per cent of health care in India is out of pocket and such staggering sums push nearly 57 million people into poverty every year. With a shortage of 600,000 doctors and 2 million nurses this economic burden is something that the country is unable to bear. To quote some more figures, most of the country’s antibiotic-treatable deaths, amounting to 5.7 million, happen in low-income as well as middle income countries. The mortality burden from treatable cases far exceeds the annual 700,000 deaths from antibiotic-resistant infections.
According to the Indian Journal of Public Health, even to achieve a modest one-to-one thousand doctor population ratio, the country needs 2.07 million doctors by 2030 and the World Health Organisation says that the country has seven doctors per 10,000 people in 2014 and of these there were only 4.8 practicing doctors per thousand available. Things have not improved much since then and the prospects look even bleaker. The availability of doctors, based on the data collected since the last 100 years, has not been taken into account the attrition due to retirement, emigration and similar factors. According to an expert India would be achieve the ratio of 6.9 practicing doctors per ten thousand people only by 2030.
Even the governments that are serious about implementing the UHC will run into hurdles of limited budgets and they have to set their priorities right with the meagre funds at their disposal. Primary health care has to be recognized and made the foundational basis for an efficient and equitable health care system. It has to cater to the widest range of beneficiaries as well as provide a wide range of services so that this can check the number of patients going to hospitals through effective prevention at the source itself.
The UHC, meanwhile, has come to be interpreted in various ways depending on the services that are available. Should it give priority to the vulnerable and poorer sections to ensure availability as well as access for the rest of the population to be covered at a later stage or provide a basic package to everyone with full financial protection? These are some of the possibilities that need to explored, chalked out and framed.
Qualified healthcare providers are in short supply across the country and even these are distributed not quite evenly with marked disparities between the rural and urban areas and across regions and there are vast regions of the landscape that have a not been reached by the man in the white coat and stethoscope.
For all this to happen, primary health care has to be recognized as a fundamental right of all citizens as well as access to the health facilities. So also emergency health services need to given high priority as well as life giving care on site and during transport, considering the number casualties that happen in road accidents.
Finally, there is need for some quiet introspection and the health sector can be one starting point. Is it the failure of the political class that had not set its priorities, or some case of blindness? As one expert asked, ‘Why is it the system that is able to produce the atomic bomb, send an unmanned spacecraft to the Mars at such low cost, execute the Delhi Metro in record time, and develop the IT industry and many other similar success stories, unable to run a primary hospital or primary school efficiently?’
It is not surprising that in the heated debates and election speeches across the country that flood the media and television screens through the day, a lot of contentious issues have been debated, and thrashed out but primary health does hardly figure at all. Considering that even the countries around that started their journey to independence later and had looked up to India as the role model have made such strides on the health front, this need serious introspection. Bangladesh, Sri Lanka, even Myanmar have much better health care indices than India, and that is something that needs to be thought about too.
Indian doctors and nurses have been the backbone of many countries, from West Indies to the Britain’s NHS to even the United States, and are much praised for their providing the human touch, but the country suffers from acute deficiency. That also needs to be examined. There is no dearth of medical private colleges and their mushrooming started in the late seventies but the results have not been evident. There are super specialty hospitals and medical tourism is one of the thriving sectors on the fringes of our mega cities. But the rural landscape is bereft of any of these privileges.
It seems that the development of the health system was right from the beginning based on a vision that was slightly flawed. The focus at that time was on controlling infectious diseases and family planning to the exclusion of everything else. The neglect of medical treatment and hospital care led to the mushrooming diagnostic clinics and nursing homes catering to the urban and semi-urban sections and the concept of the family doctor and neighbourhood clinic was totally lost. We had adopted the US model totally, along with everything else, including fast food and travelling on the fast lane. Now that the much vaunted Obamacare and Britain’s National health Scheme have reached a dead end, it is necessary that we look inwards for a more humane and benign treatment of our own needy.