Health in India
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The Constitution of India makes health in India the responsibility of state governments, rather than the central federal government. It makes every state responsible for "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. The National Health Policy is being worked upon further in 2017 and a draft for public consultation has been released.
The private sector is the dominant healthcare provider in both urban and rural Indian households, according to surveys.
- 1 Twelfth Five Year Plan
- 2 Quality of healthcare
- 3 Private Health Care
- 4 Health issues
- 5 Health care system
- 6 See also
- 7 References
- 8 External links
Twelfth Five Year Plan
Based on the recommendation of a High Level Experts Group (HLEG) and other stakeholder consultations, the key elements of the Twelfth Five Year plan strategy is outlined. The long term objective of this strategy is to establish a system of Universal Health Coverage (UHC) in the country. Following are the 12th plan period strategy:
- Substantial expansion and strengthening of public sector health care system, freeing the vulnerable population from dependence on high cost and often unreachable private sector health care system.
- Health sector expenditure by central government and state government, both plan and non-plan, will have to be substantially increased by the twelfth five-year plan. It was increased from 0.94 per cent of GDP in tenth plan to 1.04 per cent in eleventh plan. The provision of clean drinking water and sanitation as one of the principal factors in control of diseases is well established from the history of industrialized countries and it should have high priority in health related resource allocation. The expenditure on health should increased to 2.5 per cent of GDP by the end of Twelfth Five Year Plan.
- Financial and managerial system will be redesigned to ensure efficient utilization of available resources and achieve better health outcome. Coordinated delivery of services within and across sectors, delegation matched with accountability, fostering a spirit of innovation are some of the measures proposed.
- Increasing the cooperation between private and public sector health care providers to achieve health goals. This will include contracting in of services for gap filling, and various forms of effectively regulated and managed Public-Private Partnership, while also ensuring that there is no compromise in terms of standards of delivery and that the incentive structure does not undermine health care objectives.
- The present Rashtriya Swasthya Bhima Yojana (RSBY) which provides cash less in-patient treatment through an insurance based system should be reformed to enable access to a continuum of comprehensive primary, secondary and tertiary care. In twelfth plan period entire Below Poverty Line(BPL) population will be covered through RSBY scheme. In planning health care structure for the future, it is desirable to move from a 'fee-for-service' mechanism, to address the issue of fragmentation of services that works to the detriment of preventive and primary care and also to reduce the scope of fraud and induced demand.
- In order to increase the availability of skilled human resources, a large expansion of medical schools, nursing colleges, and so on, is therefore is necessary and public sector medical schools must play a major role in the process. Special effort will be made to expand medical education in states which are under-served. In addition, a massive effort will be made to recruit and train paramedical and community level health workers.
- The multiplicity of Central sector or Centrally Sponsored Schemes has constrained the flexibility of states to make need based plans or deploy their resources in the most efficient manner. The way forward is to focus on strengthening the pillars of the health system, so that it can prevent, detect and manage each of the unique challenges that different parts of the country face.
- A series of prescription drugs reforms, promotion of essential, generic medicine and making these universally available free of cost to all patients in public facilities as a part of the Essential Health Package will be a priority.
- Effective regulation in medical practice, public health, food and drugs is essential to safeguard people against risks and unethical practices. This is especially so given the information gaps in the health sector which make it difficult for individual to make reasoned choices.
- The health system in the Twelfth Plan will continue to have a mix of public and private service providers. The public sector health services need to be strengthened to deliver both public health related and clinical services. The public and private sectors also need to coordinate for the delivery of a continuum of care. A strong regulatory system would supervise the quality of services delivered. Standard treatment guidelines should form the basis of clinical care across public and private sectors, with the adequate monitoring by the regulatory bodies to improve the quality and control the cost of care,
The High Level Expert Group report recommends an increase in public expenditure on health from 1.58 per cent of GDP currently to 2.1 per cent of GDP by the end of the 12th five-year plan. However, even this is far lower than the global median of 5 per cent. The lack of extensive and adequately funded public health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the private sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. Though, the 12th plan document express concern over high out-of-pocket (OOP) expenditure, it does not give any target or time frame for reducing this expense . OOP can be reduced only by increasing public expenditure on health and by setting up widespread public health service providers. But the planning commission is planning to do this by regulating private health care providers. It takes solace from the HLEG report which admits that, "the transformation of India’s health system to become an effective platform for UHC is an evolutionary process that will span several years".
Instead of developing a better public health system with enhanced health budget, 12th five-year plan document plans to hand over health care system to private institutions. The 12th plan document causes concern over Rashtriya Swasthya Bhima Yojana being used as a medium to hand over public funds to the private sector through an insurance route. This has also incentivized unnecessary treatment which in due course will increase costs and premiums. There have been complaints about high transaction cost for this scheme due to insurance intermediaries. RSBY does not take into consideration state specific variation in disease profiles and health needs. Even though these things are acknowledged in the report, no alternative remedy is given. There is no reference to nutrition as key component of health and for universal Public Distribution System (PDS) in the plan document or HLEG recommendation. In the section of National Rural Health Mission (NRHM) in the document, the commitment to provide 30- to 50-bed Community Health Centres (CHC) per lakh population is missing from the main text. It was easy for the government to recruit poor women as ASHA (Accredited Social Health Activist) workers but it has failed to bring doctors, nurses and specialist in this area. The ASHA workers who are coming from a poor background are given incentive based on performance. These people lose many days job undertaking their task as ASHA worker which is not incentivised properly. Even the 12th plan doesn't give any solace. To summarize, successive administrative and political reforms have conveniently bypassed training citizens and local bodies to actively participate in healthcare. In a situation where people are not enabled to identify poor quality, speak up and debate. There is dire need for the health system to fill that role on behalf of the people and can be easily done by decentralization of healthcare governance.
Quality of healthcare
In major urban areas, the quality of medical care is close to and sometimes meets first-world standards. High-quality medical care is limited or completely unavailable in most rural areas, although rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.
In 2015 the British Medical Journal published a report by Dr Gadre, from Kolkata, exposed the extent of malpractice in the Indian healthcare system. He interviewed 78 doctors and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions were commonplace.
Private Health Care
With the help of numerous government subsidies in the 1980s the private health providers entered the market to cater to the middle class which was disillusioned with the public health sector and sort to exit it wherever possible. Also opening up of the market in the 90s further gave impetus to the development of the private health sector in India.
According to a 2005 report, 60% of India’s children below the age of three were malnourished, which was greater than the statistics of sub-Saharan African region of 28%. It is considered that one in every three malnourished children in the world lives in India. The estimates varies within the country. It is estimated that Madhya Pradesh is having the highest rate of 50% and Kerala the lowest with 27%. Although India’s economy grew 55% from 2001–2006, its child-malnutrition rate only dropped 1%, lagging behind countries of similar growth rate.
Malnutrition can be described as the unhealthy condition that results from not eating enough healthy food.
Infants and Preschool children
|Low birth weight||22|
|# Bitot’s spots||0.8-1.0|
|Iron deficiency anaemia (6 -59 months)||70.0|
|# Underweight (weight for age)* (<5 years)||42.6|
|# Stunting (height for age)* (<5 years)||48.0|
|# Wasting (weight for height)*||20.0|
|Childhood Overweight/ Obesity||6-30|
|Chronic Energy Deficiency (BMI <18.5)||%||33.2||40||36.0||49|
|Anaemia in Women||%||75|
|Iodine deficiency- Goitre||millions||54|
|Iodine deficiency - Cretinism||millions||2.2|
|Iodine deficiency - Still births (includes neo natal deaths)||90,000|
|Obesity related chronic diseases||(%)||36.0||40.0||7.8||10.9||*2.4||3.2|
|Diabetes Mellitus (year 2006)||%||16.0||5.0||16||5.0|
|Coronary Heart Disease||(%)||7-9||3-5||7-9||3-5|
|Cancer incidence Rate||Per Million||11.3||12.3|
- Median -2SD of WHO Child Growth Standards
- NNMB Rural Survey - 2005-06 ; NNMB Tribal Survey - 2008-09
A well nourished child is one whose weight and height measurements compare very well within the standard normal distribution of heights and weights of healthy children of same age and sex. Malnutrition impedes the social and cognitive development of a child. These irreversible damages result in lower productivity. Just as with serious malnutrition, growth delays also hinder a child’s intellectual development. Sick children with chronic malnutrition, especially when accompanied by anaemia, often suffer from a lower learning capacity during the crucial first years of attending school. Also it reduces the immune defence mechanism,which heightens the risk of infections. Due to their lower social status, girls are far more at risk of malnutrition than boys their age. Partly as a result of this cultural bias, up to one third of all adult women in India are underweight. Inadequate care of these women already underdeveloped, especially during pregnancy, leads them in turn to deliver underweight babies who are vulnerable to further malnutrition and disease.
Different forms of malnutrition
Protein-energy malnutrition (PEM), also known as protein-calorie malnutrition
Iron deficiency : nutritional anaemia which can lead to lessened productivity, sometimes becoming terminal
Vitamin A deficiency, which can lead to blindness or a weakened immune system.
Iodine deficiency, which can lead to serious mental or physical complaints
Foliate deficiency itself can lead to insufficient birth weight or congenital anomalies such as spina bifida. 
High infant mortality rate
Despite health improvements over the last thirty years, lives continue to be lost to early childhood diseases, inadequate newborn care and childbirth-related causes. More than two million children die every year from preventable infections.
Approximately 1.72 million children die each year before turning one. The under five mortality and infant mortality rates have been declining, from 202 and 190 deaths per thousand live births respectively in 1970 to 64 and 50 deaths per thousand live births in 2009. However, this decline is slowing. Reduced funding for immunization leaves only 43.5% of the young fully immunized. A study conducted by the Future Health Systems Consortium in Murshidabad, West Bengal indicates that barriers to immunization coverage are adverse geographic location, absent or inadequately trained health workers and low perceived need for immunization. Infrastructure like hospitals, roads, water and sanitation are lacking in rural areas. Shortages of healthcare providers, poor intra-partum and newborn care, diarrheal diseases and acute respiratory infections also contribute to the high infant mortality rate.
Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis. HIV/AIDS in India is ranked 3rd highest among countries with the amount of HIV-infected patients.National AIDS Control Organisation, a Government of India 'Apex Body' is making efforts for managing the HIV/AIDS epidemic in India. Diarrheal diseases are the primary causes of early childhood mortality. These diseases can be attributed to poor sanitation and inadequate safe drinking water in India. India also has the world's highest incidence of Rabies.
Indians are also at particularly high risk for atherosclerosis and coronary artery disease. This may be attributed to a genetic predisposition to metabolic syndrome and adverse changes in coronary artery vasodilation. NGOs such as the Indian Heart Association and the Medwin Foundation have been created to raise awareness of this public health issue.
As more than 122 million households have no toilets, and 33% lack access to latrines, over 50% of the population (638 million) defecate in the open.(2008 estimate) This is relatively higher than Bangladesh and Brazil (7%) and China (4%). Although 211 million people gained access to improved sanitation from 1990–2008, only 31% use the facilities provided. Only 11% of Indian rural families dispose of stools safely whereas 80% of the population leave their stools in the open or throw them in the garbage. Open air defecation leads to the spread of disease and malnutrition through parasitic and bacterial infections.
Safe drinking water
Several million more suffer from multiple episodes of diarrhoea and still others fall ill on account of Hepatitis A, enteric fever, intestinal worms and eye and skin infections caused by poor hygiene and unsafe drinking water.
Access to protected sources of drinking water has improved from 68% of the population in 1990 to 88% in 2008. However, only 26% of the slum population has access to safe drinking water, and 25% of the total population has drinking water on their premises. This problem is exacerbated by falling levels of groundwater caused mainly by increasing extraction for irrigation. Insufficient maintenance of the environment around water sources, groundwater pollution, excessive arsenic and fluoride in drinking water pose a major threat to India's health.
Female health issues
Maternal deaths are similarly high. The reasons for this high mortality are that few women have access to skilled birth attendants and fewer still to quality emergency obstetric care. In addition, only 15 per cent of mothers receive complete antenatal care and only 58 per cent receive iron or folate tablets or syrup.
Women's health in India involves numerous issues. Some of them include the following:
- Malnutrition : The main cause of female malnutrition in India is the tradition requiring women to eat last, even during pregnancy and when they are lactating.
- Breast Cancer : One of the most severe and increasing problems among women in India, resulting in higher mortality rates.
- Maternal Mortality : Indian maternal mortality rates in rural areas are one of the highest in the world.
Rural India contains over 68% of India's total population, and half of all residents of rural areas live below the poverty line, struggling for better and easy access to health care and services. Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a serious problem in resource-poor settings and contributes to maternal mortality, particularly in rural India. A study conducted in 2009 found that 43.9% of mothers reported they experienced postpartum illnesses six weeks after delivery. Furthermore, because of limited government resources, much of the health care provided comes from non profits such as The MINDS Foundation.
Health care system
The private healthcare sector is responsible for the majority of healthcare in India. Most healthcare expenses are paid out of pocket by patients and their families, rather than through insurance. Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the World Bank, about 25% of India's population had some form of health insurance in 2010. A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured. Public healthcare is free for those below the poverty line.
Plans are currently being formulated for the development of a universal health care system in India, which would provide universal health coverage throughout India.
Public and private healthcare
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. Reliance on public and private health care sector varies significantly between states. Several reasons are cited for relying on private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas.
Following the 2014 election which brought Prime Minister Narendra Modi to office, Modi's government unveiled plans for a nationwide universal health care system known as the National Health Assurance Mission, which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments. In 2015, implementation of a universal health care system was delayed due to budgetary concerns.
National Health Mission (Former National Rural Health Mission)
The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on 18 states which have poor public health indicators and/or weak infrastructure. Lack of political, economic and administrative decentralization of health care is being chronically ignored by NHM.
National Urban Health Mission
The National Urban Health Mission (NUHM) as a sub-mission of National Health Mission (NHM) has been approved by the Cabinet on 1 May 2013. The goal of NUHM is to meet health care needs of the urban population with the focus on urban poor, by making available to them essential primary health care services and reducing their out of pocket expenses for treatment.
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- HIV/AIDS in India
- Indian states ranking by institutional delivery
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