Healthcare in India

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India's constitution guarantees free healthcare for all its citizens and all government hospitals are required to provide free of cost healthcare facilities to the patients.[1] Each district headquarters in most states have one or more Government hospitals where everything from diagnosis to medicine is given for free. Most experts agree that building on these Government and public healthcare units across the nation is crucial to India's future while private insurance is probably not conducive to India's conditions. [2] 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.[3] In fact, recent world health statistics have indicated that India has the highest out of pocket private healthcare costs for families, among many other comparable developing nations including Pakistan, Sri Lanka, and Mexico.[3] Penetration of health insurance in India is low by international standards. Private health insurance schemes, which constitute the bulk of insurance schemes availed by the population, do not cover costs of consultation or medication. Only hospitalisation and associated expenses are covered. India has typically addressed concerns pertaining to pricing of medication through indirect but more pragmatic means such as tax sops[clarification needed] for medical expenses and patent law. Indian patent law only protects formulation and not the composition of a drug. This means that generic drugs that typically become available after the patent protections afforded to a drug's original developer expire, are available in India much earlier. Indian pharmaceutical companies routinely re-engineer processes for manufacturing generic drugs to make medication available at much lower costs.[4][5] Accordingly, most of the research budget in Indian pharmaceutical companies is oriented at developing processes for synthesizing drugs, rather than drug development. In India, the development assistance for health for a population of 1.3 billion is a total of $650 million out of which the majority is provided for child and newborn care ($230 million) and maternal health ($110 million).[6]

Health care system[edit]

Public Healthcare[edit]

Public healthcare is free for those below the poverty line.[7] The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status.[8] However, reliance on public and private health care sector varies significantly between states.[8] In addition, 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.[9] Most of the public healthcare caters to the rural areas; and the poor quality arises from the reluctance of experienced health care providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation.[9]

Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved.[8] Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.[8]

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.[10] In 2015, implementation of a universal health care system was delayed due to budgetary concerns.[11]

Private Healthcare[edit]

With the help of numerous government subsidies in the 1980s, private health providers entered the market. In the 1990s, the expansion of the market gave further impetus to the development of the private health sector in India.[12] After 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector.

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.[9] 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.[13] In terms of healthcare quality in the private sector, a study originally published in Health Policy and Planning by the Oxford University Press, indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare.[14]

However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure (CHE), which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living.[15] One study found that over 35% of poor Indian households incur CHE and this reflects the detrimental state in which Indian health care system is at the moment.[15] With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services.[15] 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.[16] A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured.[17] Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices. On 27 May 2012, the popular actor Aamir Khans program Satyamev Jayate did an episode on "Does Healthcare Need Healing?" which highlighted the high costs and other malpractices adopted by private clinics and hospitals. In response to this, Narayana Health plans to conduct heart operations at a cost of $800 per patient.[18]

Rural Health[edit]

A community health centre in Kerala.

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.[19] It has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff.[20] In addition, only 2% of doctors are in rural areas - where 68% of the population live.[1] Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities.[21] Full immunization coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India.[21] Inequalities in healthcare can result from factors such as socioeconomic status and caste, with caste serving as a social determinant of healthcare in India.[21]

Access to Healthcare in Rural South India[edit]

A study published in the Indian Journal of Ophthalmology analyzed different barriers that prevent people from seeking eye care in rural Andhra Pradesh, India.[22] The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).[22]

Recent research studies have also examined the willingness of people in rural South India to pay for health care services, and how this affects the potential access to healthcare.[23] A study published in the International Journal of Health (2017) specifically compared the willingness of people to pay for various health care services in rural versus urban districts of Tamil Nadu.[23] The findings indicated that willingness to pay for healthcare services of all types were greater in the urban areas of Tamil Nadu compared to the rural areas, attributing this statistic to the greater awareness of healthcare importance in urban areas.[23] In addition, as educational level increased in the rural districts of Tamil Nadu, the willingness to pay for healthcare services also increased, indicating the link between education and access to healthcare.[23]

Urban Health[edit]

The National Urban Health Mission as a sub-mission of National Health Mission was approved by the Cabinet on 1 May 2013. It aims to meet health care needs of the urban population with the focus on urban poor, by making essential primary health care services available to them and reducing their out of pocket expenses for treatment.[24]

Rapid urbanisation and disparities in Urban India[edit]

India's urban population has increased from 285 million in 2001 to 377 million (31%) in 2011. It is expected to increase to 535 million (38%) by 2026 (4). The United Nations estimates that 875 million people will live in Indian cities and towns by 2050. If urban India were a separate country, it would be the world's fourth largest country after China, India and the United States of America. According to data from Census 2011, close to 50% of urban dwellers in India live in towns and cities with a population of less than 0.5 million. The four largest urban agglomerations Greater Mumbai, Kolkata, Delhi and Chennai are home to 15% of India's urban population.[25]

Child Health, Survival Disparities in Urban India[edit]

Analysis of National Family Health Survey Data for 2005-06 (the most recent available dataset for analysis) shows that within India's urban population – the under-five mortality rate for the poorest quartile eight states, the highest under-five mortality rate in the poorest quartile occurred in UttarPradesh (110 per 1,000 live births), India's most populous state, which had 44.4 million urban dwellers in the 2011 census[26] followed by Rajasthan (102), Madhya Pradesh (98), Jharkhand (90) and Bihar (85), Delhi (74), and Maharashtra (50). The sample for West Bengal was too small for analysis of under-five mortality rate. In Uttar Pradesh was four times that of the rest of the urban populations in Maharashtra and Madhya Pradesh. In Madhya Pradesh, the under-five mortality rate among its poorest quartile was more than three times that of the rest of its urban population.[27]

Maternal Health care Disparities in Urban India[edit]

Among India's urban population there is a much lower proportion of mothers receiving maternity care among the poorest quartile; only 54 per cent of pregnant women had at least three ante-natal care visits compared to 83 per cent for the rest of the urban population. Less than a quarter of mothers within the poorest quartile received adequate maternity care in Bihar (12 percent), and Uttar Pradesh (20 percent),and less than half in Madhya Pradesh (38 percent), Delhi (41 percent), Rajasthan (42 percent), and Jharkhand (48 percent). Availing three or more ante-natal check-ups during pregnancy among the poorest quartile was better in West Bengal (71 percent), Maharashtra (73 percent).[27]

High levels of undernutrition among the urban poor[edit]

For India's urban population in 2005–06, 54 percent of children were stunted, and 47 percent underweight in the poorest urban quartile, compared to 33 percent and 26 percent, respectively, for the rest of the urban population. Stunted growth in children under five years of age was particularly high among the poorest quartile of the urban populations in Uttar Pradesh (64 percent), Maharashtra (63 percent), Bihar (58 percent), Delhi(58 percent), Madhya Pradesh (55 percent), Rajasthan (53 percent), and slightly better in Jharkhand (49 percent). Even in the better-performing states close to half of the children under-five were stunted among the poorest quartile, being 48 percent in West Bengal respectively.[27]

High levels of stunted growth and underweight issues among the urban poor in India points to repeated infections,depleting the child's nutritional reserves, owing to sub-optimal physical environment. It is also indicative of high levels of food insecurity among this segment of the population. A study carried out in the slums of Delhi showed that 51% of slum families were food insecure.[28]

Quality of healthcare[edit]

Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges.[29] The sad state of rural health care in India is detailed in this article. [30]

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.[31] But there are incidents where doctors were attacked and even killed in rural India [32] 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.[33]

According to a study conducted by Martin Patrick, CPPR chief economist released in 2017 has projected people depend more on private sector for healthcare and the amount spent by a household to avail of private services is almost 24 times more than what is spent for public healthcare services.[34]

South India[edit]

In many rural communities throughout India, healthcare is provided by what is known as informal providers, who may or may not have proper medical accreditation to diagnose and treat patients, generally offering consults for common ailments.[35] Specifically, in Guntur, Andhra Pradesh, India, these informal healthcare providers generally practice in the form of services in the homes of patients and prescribing allopathic drugs.[35] A 2014 study in the journal Health Policy and Planning, published by the Oxford University Press, found that in Guntur, about 71% of patients received injections from informal healthcare providers as a part of illness management strategies.[35] The study also examined the educational background of the informal healthcare providers and found that of those surveyed, 43% had completed 11 or more years of schooling, while 10% had graduated from college.[35]

See also[edit]

References[edit]

  1. ^ a b Britnell, Mark (2015). In Search of the Perfect Health System. London: Palgrave. p. 59. ISBN 978-1-137-49661-4. 
  2. ^ Rajendran, Arvind (June 22, 2017). "Private Health Insurance – A Bad Idea". primetimes.in. PrimeTimes.in – India News. Retrieved September 18, 2017. 
  3. ^ a b Berman, Peter (2010). "The Impoverishing Effect of Healthcare Payments in India: New Methodology and Findings". Economic and Political Weekly. 
  4. ^ George T. Haley; Usha C.V. Haley (2012). "The effects of patent-law changes on innovation: The case of India's pharmaceutical industry". Technological Forecasting and Social Change. 79 (4): 607–619. doi:10.1016/j.techfore.2011.05.012. 
  5. ^ Atkin, Michael; Keep, Joel (20 August 2015). "Hepatitis C sufferer imports life-saving drugs from India, takes on global pharmaceutical company". ABC News Australia. Retrieved 18 September 2017. 
  6. ^ "Of India’s healthcare spend, 2/3 out of patients’ pockets: Study". The Indian Express. 2017-04-21. Retrieved 2017-04-21. 
  7. ^ Rajawat, K. Yatish (January 12, 2015). "Modi's ambitious health policy may dwarf Obamacare". qz.com. Quartz – India. Retrieved September 18, 2017. 
  8. ^ a b c d Chokshi, M; Patil, B; Khanna, R; Neogi, S B; Sharma, J; Paul, V K; Zodpey, S (2016). "Health systems in India". Journal of Perinatology. 36 (Suppl 3): S9–S12. ISSN 0743-8346. PMC 5144115Freely accessible. PMID 27924110. doi:10.1038/jp.2016.184. 
  9. ^ a b c International Institute for Population Sciences and Macro International (September 2007). "National Family Health Survey (NFHS-3), 2005–06" (PDF). Ministry of Health and Family Welfare, Government of India. pp. 436–440. Retrieved 5 October 2012. 
  10. ^ "India's universal healthcare rollout to cost $26 billion". 
  11. ^ Aditya Kalra (27 March 2015). "Exclusive: Modi govt puts brakes on India's universal health plan". Reuters India. 
  12. ^ Baru,Rama V(2010): "Public Sector Doctors in an Era of Commercialisation" in Sheikh and A George(ed)Health Providers in India, on the Frontlines of Change(New Delhi: Routledge)81-96.
  13. ^ Ramya Kannan (30 July 2013). "More people opting for private healthcare". Chennai, India: The Hindu. Retrieved 31 July 2013. 
  14. ^ Basu, Sanjay; Andrews, Jason; Kishore, Sandeep; Panjabi, Rajesh; Stuckler, David (2012-06-19). "Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review". PLOS Medicine. 9 (6): e1001244. ISSN 1549-1676. doi:10.1371/journal.pmed.1001244. 
  15. ^ a b c Sekher, T.V. "Catastrophic Health Expenditure and Poor in India: Health Insurance is the Answer?" (PDF). iussp.org. Retrieved September 18, 2017. 
  16. ^ "Government-Sponsored Health Insurance in India: Are You Covered?". worldbank.org. The World Bank Group. October 11, 2012. Retrieved September 18, 2017. 
  17. ^ Mehra, Puja (April 9, 2016). "Only 17% have health insurance cover". The Hindu. Retrieved September 18, 2017. 
  18. ^ Britnell, Mark (2015). In Search of the Perfect Health System. London: Palgrave. p. 58. ISBN 978-1-137-49661-4. 
  19. ^ Umesh Kapil and Panna Choudhury National Rural Health Mission (NRHM): Will it Make a Difference? Indian Pediatrics Vol. 42 (2005): 783
  20. ^ Britnell, Mark (2015). In Search of the Perfect Health System. London: Palgrave. p. 60. ISBN 978-1-137-49661-4. 
  21. ^ a b c BARU, RAMA; ACHARYA, ARNAB; ACHARYA, SANGHMITRA; KUMAR, A K SHIVA; NAGARAJ, K (2010). "Inequities in Access to Health Services in India: Caste, Class and Region". Economic and Political Weekly. 45 (38): 49–58. doi:10.2307/25742094. 
  22. ^ a b Kovai, Vilas; Krishnaiah, Sannapaneni; Shamanna, Bindiganavale Ramaswamy; Thomas, Ravi; Rao, Gullapalli N (2007). "Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India". Indian Journal of Ophthalmology. 55 (5): 365–371. ISSN 0301-4738. PMC 2636013Freely accessible. PMID 17699946. 
  23. ^ a b c d Ramu, K. (2016-12-15). "An estimation of willingness to pay for secondary health care services in Tamil Nadu, India". International Journal of Health. 5 (1): 12–19. ISSN 2309-1630. doi:10.14419/ijh.v5i1.6542. 
  24. ^ "NUHM". Retrieved 6 May 2015. 
  25. ^ Agarwal, Siddharth (2014-10-31). "Making the Invisible Visible". Rochester, NY: Social Science Research Network. SSRN 2769027Freely accessible. 
  26. ^ Office of the Registrar General and Census Commissioner (2011). Population Census of India 2011 Accessed 9-10-016http://www.census2011.co.in/census/state/uttar+pradesh.html
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  28. ^ Agarwal, Siddharth; Sethi, Vani; Gupta, Palak; Jha, Meenakshi; Agnihotri, Ayushi; Nord, Mark (2009-08-04). "Experiential household food insecurity in an urban underserved slum of North India". Food Security. 1 (3): 239–250. ISSN 1876-4517. doi:10.1007/s12571-009-0034-y. 
  29. ^ "India". 
  30. ^ Why good home care is needed in rural areas
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  32. ^ "Assaults on public hospital staff by patients and their relatives: an inquiry". Indian journal of medical ethics. Retrieved 2016-10-20. 
  33. ^ Fox, Hannah (8 April 2015). "I've seen first-hand how palliative care in India is compromised by privatisation". The Guardian. Retrieved 19 April 2015. 
  34. ^ "Researchers in Kochi call for revival of public healthcare system". The New Indian Express. Retrieved 2017-10-01. 
  35. ^ a b c d Gautham, Meenakshi; Shyamprasad, K. M.; Singh, Rajesh; Zachariah, Anshi; Singh, Rajkumari; Bloom, Gerald (2014-07-01). "Informal rural healthcare providers in North and South India". Health Policy and Planning. 29 (suppl_1): i20–i29. ISSN 0268-1080. doi:10.1093/heapol/czt050.