HEALTHCARE SECTOR OF INDIA. India's rapid growth has brought about many changes in demographics and lifestyle. Rising incomes, hectic pace of life and stress have resulted in a change in disease patterns, even as there is greater awareness about health and a demand for quality healthcare.Healthcare, which is a US$ 35 billion industry in India, is expected to reach over US$ 75 billion by 2012 and US$ 150 billion by 2017 according to Technopak Advisors in their report - 'India Healthcare Trends 2008'. The healthcare industry is interestingly poised as it strives to emerge as a global hub due to the distinct advantages it enjoys in clinical excellence and low costs. The industry, which was once the exclusive domain of the government, has seen a steady participation of major corporate houses which have helped set up premium hospitals and medical facilities across the country. The sector offers immense potential to healthcare players as the country witnesses a rise in the incidence of lifestyle-related and other diseases. A growing elderly population and rise in income levels are also pushing for better facilities in the country.Driving the sector's growth will be the health-conscious middle class which can afford and wants quality healthcare. Over 150 million Indians have annual incomes of more than US$ 1,000, and many who work in the business services sector earn as much as US$ 20,000 a year. If the economy continues to grow at the current rate and the literacy rate keeps rising, much of western and southern India will be middle class by 2020. To meet this growing demand, the country needs US$ 50 billion annually for the next 20 years, says a Confederation of Indian Industry (CII) study. India needs to add 2 million beds by 2027 to the existing 1.1 million, and requires immediate investments of US$ 82 billion as per the Technopak Advisors report. Today India offers World Class Medical Facilities, comparable with any of the western countries. India has state of the art Hospitals and the best qualified doctors. With the best infrastructure, the best possible Medical facilities, accompanied with the most competitive prices, you can get the treatment done in India at the lowest charges.Patients from around the globe are beginning to realize the enormous potential of modern and traditional Indian medicine. Indian hospitals, medical establishments and the government of India have also realized the potential of this niche segment and have begun to tailor their services for foreign visitors. International marketing divisions have been set up by most of the top India Hospitals like Apollo, Max, Fortis, Wockhardt, etc.At a regional level, this nascent healthcare industry came to limelight with the arrival of 'Naby Noor' from Pakistan, who came for her Heart Surgery treatment to a hospital in Bangalore. Quite a few Indian state governments have with time, realized the potential of this 'Healthcare industry' and have been actively promoting it. Visitors, especially from the United States of America, United Kingdom and the middle-east find Indian hospitals a very affordable and viable option to coping with insurance and National medical systems in their respective countries. Travellers prefer to combine their medical treatments with a visit to the 'exotic east' with their families, visiting places like the Taj Mahal in Agra, the palaces in Rajasthan, the serene beaches in Goa and the mountains of Kashmir and the backwaters of Kerela among others. The total price of an overseas treatment with airfare, hotel accommodation and even a few days of vacation is often far less than just the procedure cost back in the US or UK.

The year 2003 and 2004 saw a trickle of tourists from the healthcare systems of western countries seeking medical treatment in India. By the year 2005 and 2006 this became a deluge, much of it propelled by a blast of free publicity from programmes like 60 Minutes. Judging by the buzz in the hospital circuit, it won't be very long before every cosmopolitan private hospital offers yoga, ayurvedic massages, aromatherapy, mudbaths, pranic healing, reiki and meditation classes. With time more and more visitors will flock to this part of the globe for their treatment and relaxation needs. HEALTHCARE STATUS DEFICIENT IN STATE Tribune News Service Jammu, February 12 Though the state government has initiated various efforts to upgrade two of its premier health institutes on the lines of the All-India Institute of Medical Sciences (AIIMS), the healthcare structure in the state cannot provide standard healthcare facility to majority of its people. As per official documents, there are only 3,698 health centres in the state where one health institution caters to a population of 3,127 persons. Further disturbing figures are that in Jammu and Kashmir, there is only one doctor against a population of 2,266 persons. Pointing a finger on the poor healthcare infrastructure in the state, the report shows that against a population of 1 lakh, there were only 108 beds available in the hospitals. Commenting on the healthcare infrastructure, the report states that though there had been a steady increase in healthcare infrastructure since independence, yet the state faced shortage of infrastructure both qualitatively and quantitatively. To augment the healthcare infrastructure and to provide better health care to the people, the state government has projected the additional requirement of 1,288 healthcare institutions of various categories from the Centre. The state is also contemplating to establish a super-speciality hospital under the public private partnership mode, in this context the state government has already approached the Apollo and the Fortis group. Another major aspect which the report points out is the low awareness level of HIV/AIDS among the people. “The HIV/ AIDS awareness level among people is quite low as compared to other states,” the report reads out. The state also has a lower couple protection rate, only 15.9 percent as against the 46.6 percent at the national-level. The state health department also suffers with a deficiency of 2,922 MBBS doctors, and little is being done to fill in the vacancies. A proposal worth Rs 1051.57 crore to upgrade the healthcare scenario of the state has been forwarded to the Government of India for its approval. “As a major step to provide better healthcare in the tertiary health sector, the Government Medical College, Jammu and Srinagar, have been approved to upgrade to the level of AIIMS at an estimated cost of Rs 120 crore each with a share of Rs 20 crore under the Prime Minister’s reconstruction plan,” the report reads. HEALTH SECTOR REFORM IN INDIA. The decade of the 1990s is seen as a marker for the beginning of health sector reform in South Asia. These reforms are premised on four cardinal market principles that shifted the discourse from the centrality of public provisioning to greater role for markets. The four cardinal principles were: 1. Individual, charities and private organizations should be made responsible for health care 2. Public funding must be restricted to health promotion and prevention of disease 3. Central government’s role should be restricted to policy formulation and

technical guidance, with delivery of services left to the private sector and local authorities 4. Private and non governmental sector should be supported to become the key providers of health and social services. It is these principles that guided the design of health sector reforms across South Asia with the active support of multilateral and bilateral agencies. Most of these countries initiated reforms in the 1990s and has been guided by a similar design for these reforms. This paper presents some of the similarities and variations with these reforms across South Asia and explains it terms of the complex interaction between a variety of factors like the role of global actors; the character of the state; domestic capital and the growth of middle classes. 1. Global actors that include bilateral and multilateral agencies, pharmaceutical, medical equipment industries, insurance company and research institutions. These actors have played a critical role in shaping health policies across the world. 2. The role of the state in each of the countries, especially in terms of socio-political contexts; investments in social sectors especially public health services. 3. The role of domestic capital in the provisioning of health services, pharmaceutical, medical equipment and insurance sectors within each of these countries 4. The growth and role of the middle classes, their influence on both the supply and demand for public and private health services (Baru, 2003). History of Health Service Development in South Asia All the countries in this region have a shared history of being former colonies of the British and have varied socio-political contexts and welfare provisioning. Although all these four countries belong to the same region, they present variability in terms of size, population, political regimes and state investment in welfare schemes. Amongst all the South Asian countries, historically, Sri Lanka has the strongest tradition of welfarism followed by India while Pakistan and Bangladesh have weaker welfare provisioning. These factors reflect the variations in access to basic needs and subsequently health outcomes. While the indicators of Sri Lanka are on par with developed countries, Bangladesh, Pakistan and India fare poorly when compared to Sri Lanka (HDR, 1999) Table 1: Health Status Indicators of Countries in South Asia Countries Life Expectancy at Birth Infant Mortality Rate (per 1000 live births) Maternal Mortality Rate (per 100,000 live births) Child Mortality Rate Bangladesh 58 years 81 850 112 Pakistan 60 years 38 340 136 Sri Lanka 73 years 16 140 19 India 62 years 70 570 73 Source: Human Development Report, Delhi, Oxford University Press, 1999. The health sector reform has privatization at its core and the restructuring of public sector through the introduction of market principles. This trend is clearly discernable across South Asia the outcome varies depending on the interaction of factors discussed above. Role of the State in Public Provisioning of Services There is variation in the extent and nature of state involvement in ensuring access to basic needs including health services across countries in this region. In Sri Lanka the role of the state was central wherein ‘public action and state responses had politically and socially constructed health care as a public good, a basic right for all citizens.” (Mills, 2002: 217). This was a result of a strong

socialist government that focused on ensuring food security and public health services to all its citizens. This resulted in high investment in the social sectors with an emphasis on food security, maternal and child health services and an expansion of health services at the primary, secondary and tertiary levels of care. It is this combination of inputs coupled with reduction in socio-economic inequalities that is reflected in better health outcomes. Public investments in Sri Lanka were made in both service provisioning and training of human resources. The expenditure on health as a percent of total government expenditure was 5.5 percent in 1977, it declined to 3.2 in 1981 and rose to 5.5 percent and peaked to 6.5 percent in 1989. During the nineties it declined from 5 percent to 4.1 (Fernando, 2001). Health services were quite evenly distributed and physical access in terms of roads and transportation was good. However a few studies have shown that indirect costs in terms of transportation, drugs and other incidental expenses were issues of concern for the poor in both urban and rural areas (Pieris, 1999). During the late 1970’s, Sri Lanka opted for loans under the Structural Adjustment Programme (SAP) of the World Bank for restructuring the economy that affected all the universal welfare programmes. Most of them shifted from a universal to a targeted programme, with food subsidies being largely withdrawn. Until the seventies, Pakistan and Bangladesh shared a common history for economic and social development where the state played an important role in the provisioning, financing and administration of services. There was variation in the development of health services between West and East Pakistan in terms of growth of beds and institutions. The growth rate of hospitals was 7 percent from 1959-66 for East Pakistan while it was 16.27 percent for West Pakistan. The growth rate of public beds was 15.61 percent in East Pakistan while it was 56.17 percent in West Pakistan (Rahman, 1999). Thus after the liberation of Bangladesh during the early 1970’s, health services were underdeveloped both public and private with declining outlays for health. The percentage of outlay for health to total outlay was 4.48 percent in 1973-78, it declined to 3.72 percent in 1980-85, further declining to 3.05 percent in 1990-95 and to 3.17 in 1997-2002 (Rahman, 1999). The government spending on health care constitutes only 34 percent of total expenditure on health, private expenditure accounts for 64 percent and the remaining 1.0 percent is from NGOs (MOHFW, 1998). In Pakistan the investments in the public sector were minimal and largely urban based. The government expenditure has never been more than 1.3% of GNP and subsequently has registered a steady decline (Zaidi, 1988). In India the trends in public investments have been similar to Pakistan and Bangladesh with outlays not higher than three percent. Over the years it has registered a decline and is clearly inadequate for the expansion of facilities. This gets reflected in the stagnation of public services from the mid eighties through the nineties. In the Indian case the highest investment was 3 % that declined to around 1% during the 1990s. Except for Sri Lanka, the under-investment of the public sector led to the stagnation in the growth of public services that created spaces for greater dependence on private services across all the other countries. The weak public provisioning gave legitimacy for the neo-liberal ideas of restructuring and the acceptance of conditionalities of the Structural Adjustment Programme of the World Bank. The health sector reform agenda takes root during the mid 1990s with a fairly vibrant private sector across all these countries. Nature of Health Sector Reform The worldwide economic recession of the late seventies had a negative impact on public spending across developing and developed countries. During the eighties and nineties the World Bank and the IMF put in place a policy agenda that promoted privatisation both in the industrial and services sectors, including the social sectors, referred to as the structural adjustment programme. All the countries in this region have opted for World Bank loans that included cutback on public spending, encouraging the growth of private services and restructuring public

institutions on principles of the market. During latter half of the 1990s, the governments of these countries took the initiative to reform the health sector informed by the ideas and design of the World Development Report 1993- Investing in Health. The health policy of these countries sought a more prominent role for the private sector and NGOs in the provisioning of services. It clearly stated the inability of the state to provide services and also allowed and encouraged private practice by government doctors (World Bank,1997) The reform of the health sector was part of the larger project of economic restructuring and among the four countries Sri Lanka was the first to go in for World Bank loans (Perera,2002). The indicators of health sector reform initiatives are discernable when the Sri Lankan government offered direct concessions to the private sector and these included: 1. Permission to foreign providers of medical cares to operate in Sri Lanka. 2. Encourage private health insurance industry. 3. To lease spare capacity in public facilities to private practitioners. 4. Offer concessional loans to private practitioners to establish practice in rural areas. Instituting a regulatory framework for the private sector. (Perera,2002). When Pakistan went in for a Structural Adjustment Programme in 1988, a number of moves were initiated for economic restructuring and there was a squeeze on public expenditure on health, which further paved the way for privatisation. This resulted in cuts in the recurring expenditure for health care, which meant that there was little expansion of facilities and manpower. Across the South Asian region HSR has accelerated the privatization process as is reflected in the percentage share of private and public beds. What is significant across these countries is that the percentage share of private beds has been increasing during the decade of 1990s. Among all the South Asian countries, India has the largest private sector and is an exporter of tertiary corporate health care to others in the region. The growth of institutions in the private sector presents a varied picture across countries. While Bangladesh, Pakistan and Sri Lanka have a very small presence of institutions at the secondary and tertiary levels, India has a fairly large private sector at these levels, marked by regional variations (Jesani, 1993; Baru,1998) Table 1: Percentage Share of Private and Public Beds in Bangladesh Hospitals Years Private Public 1973 15.0 85.0 1978 14.0 86.0 1983 19.0 81.0 1988 19.0 81.0 1993 22.0 78.0 1996 22.0 78.0 Table 2: Percentage Share of Private and Public Beds in Indian Hospitals Private Public 1973 28.8 71.2 1983 40.7 59.3 1993 57.7 42.3 1996 61.0 39.0

Consequences of Health Sector Reforms Impact of Reforms on Users According to an estimate, more than 45 percent of the population in Pakistan does not have access to basic health facilities. The urban-rural divide in service provisioning is indeed dramatic. Of the total public health services available in Pakistan, only 18 percent are located in rural areas (Taylor Associates: 1997).

In Sri Lanka National surveys show that there is plurality in provisioning and utilisation at different levels of care. For minor illnesses, treatment consists of simple herbal preparations or analgesics. For chronic ailments, there is greater resort to traditional healers and ayurvedic practitioners. The data clearly indicates that the utilisation of the private sector is related to income levels. There is higher utilisation of the private sector among the urban middle classes compared to others (Pieris,1999). Pieris observes that there is marked preference for allopathic medicine but the choice of medical facilities shows variations across classes. The study showed that the urban middle classes used the private facilities more than government facilities while the urban poor utilise the facilities of government hospital, especially if it was accessible. In rural areas the use of private hospitals was slightly less than private doctors. In India, states where there is a sizeable presence of the private sector, the middle and upper income groups have largely moved out of public services and it is the poor who rely on private services much more. The 42nd and 52nd Rounds of the National Sample Survey shows that even the poor use the private sector for hospitalisation but a larger proportion of them use the public sector (Baru,1998 and Sen & Iyer,2002). An additional aspect is the rising cost of medical care in both public and private sectors especially from the 1990s. Impact on Health Institutions and Workers As far as health services were concerned there was a shift in government policy in 1977 in Sri Lanka, which allowed medical officers and other technical officers within the state health sector to practice privately, outside their working hours. (Pieris,1999: 44). In the remaining countries government doctors were allowed to practice privately and there was no effort to regulate or ban it. Even the nascent private sector was unregulated and therefore grew in a haphazard and uncontrolled manner. The consequences of rapid privatization during the 1980s and 1990s is much more significant in India, Pakistan and Bangladesh as compared to Sri Lanka. The private interests within and outside public services eroded the motivation and commitment of public providers while in Sri Lanka the quality and reach of public services was definitely better than the other countries in the region. In Bangladesh, there was a steady growth of institutions and manpower until the late seventies, after which the data shows stagnation in the growth of facilities. While there was an expansion of facilities until the eighties, the decline in investment resulted in a shortage in availability of facilities, personnel and supplies. A study conducted in the late nineties showed that 63 percent had inadequate facilities, 60 percent had inadequate personnel, 80 percent faced a shortage of vaccines or drugs (Ahmed,1997 cited in Rahman,1999). In Pakistan there was a shift towards increased privatization during the 1990s that resulted in the burgeoning of outpatient and in patient care. According to an estimate there were 20,000 small ambulatory clinics operated by general practitioners, 300 maternity homes, usually with two or three rooms; 340 dispensaries and 450 small to medium diagnostic facilities. In 1993 there were more than 500 private hospitals (including maternity and nursing homes) with a total of 13,000 beds. Most of these hospitals are located in urban areas with an average capacity of 30 beds (Taylor Associates,1997). As far as training of doctors and paramedical personnel was concerned, the state started encouraging the establishment of private medical colleges. This meant that those trained in private colleges were interested in finding jobs in the private sector. This kind of a trend is seen in India as well. Some recent trends show a shift in terms of the appointment and also training of personnel. Several states within India have been appointing doctors on contract basis in order to overcome the shortage of personnel in rural areas. There is a

shortage of paramedical workers as well due to a freeze on training and recruitment of various categories of these workers. The solution to this impasse has been to introduce multi-skilling of existing workers or to encourage community health workers on a voluntary basis with a small honorarium. Conclusion The experience of health sector reform in South Asia presents certain common trends but also variations in terms of the political economy and health services development in the four countries. Soon after independence the governments of all the four countries had committed themselves to investing and building a welfare state governed by principles of equity and social justice. Except Sri Lanka, which managed to build a universal and free welfare service, the others did not make the required investments in the welfare sector, especially health. The global recession during the late seventies had an adverse impact on public spending and this resulted in either a cutback or stagnation in investments in health across all these countries. This had serious consequences for public services and in fact created spaces for the growth of the private sector. During this period there was a shift in policy in favour of privatisation by offering concessions and subsidies to encourage the private sector, across all the countries in the region. The role of multilateral agencies like the World Bank furthered the privatisation agenda by influencing national health policies under the Structural Adjustment Programmes (SAPs). The SAPs not only advocated policies for a greater role for private health services but also introduced structural changes in the public sector by introducing market principles like user charges, contracting out, importing high technology equipment etc. Privatisation in highly inequitous societies like South Asia is bound to marginalise access to the lower middle and poorer sections, which constitutes around 30-60 percent of the population. Available studies on the utilisation of services in India and Sri Lanka show that the middle class has largely moved away from public provisioning in favour of for-profit care and it is the poor who use public services. The indirect costs for even publicly provided services are increasing and there is evidence that there maybe section of the population who may not be able to afford even these services. Equity concerns are very important at this juncture for health policy. Since the middle classes have moved out of public provisioning the principles of universality have also been gradually undermined. Therefore the concern for public health derives not only from the excessive growth of for profit market-based health care, but also from the differential state of public services across the region.

7 PS IN HOSPITAL PRODUCT: Medicines, different types of equipment like ECG, ultrasound, MRI, injections, X-rays… PRICE: prices of medicines, doctor fee, prices of various tests PLACE : location should be easily accessible PROMOTION : through various MRs, chemists, dealers and doctors themselves

PEOPLE : doctor, patients, compounders, nurses, machine operators, suppliers of medicine equipments, PROCESS : method of diagnosis, treatment, technology used, operating machines PHYSICAL EVIDENCE : infrastructure, appointment, bills, machines, medicines, prescriptions, injections, medicines, reports, uniforms, beds etc…

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