SMCH/HCDS/28: Health care challenges in India

Quadrant-I

Personal Details

Role Name Affiliation

Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras
Hindu University, Varanasi
Paper Coordinator Prof. Najam Khalique Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Writer Dr. Anees Ahmad Department of Community Medicine,
Associate Professor J N Medical College, AMU, Aligarh
Content Reviewer Dr. Urfi Department of Community Medicine,
Assistant Professor J N Medical College, AMU, Aligarh

Description of Module

Items Description of Module

Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module name/Title Health care challenges in India
Module Id SMCH/HCDS/28
Pre-requisites Understanding of magnitude and pattern of diseases in India.
Objectives To know the various challenges in provision of health care in India.
Non-communicable diseases, Tribal burden of diseases, Health care
Keywords challenges

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Introduction
Historically, the Indian commitment to health development has been guided by two principles-with
three consequences. The first principle was State responsibility for health care and the second (after
independence) was free medical care for all (and not merely to those unable to pay), The first set of
consequences was inadequate priority to public health, poor investment in safe water and sanitation
and to the neglect of the key role of personal hygiene in good health, culminating in the persistence of
diseases like Cholera. The second set of consequences pertains to substantially unrealized goals of
NHP 1983 due to funding difficulties from compression of public expenditures and from
organizational inadequacies. The ambitious and far reaching NPP - 2000 goals and strategies have
however been formulated on that edifice in the hope that the gaps and the inadequate would be
removed by purposeful action. Without being too defensive or critical about its past failures, the rural
health structure should be strengthened and funded and managed efficiently in all States by 2005. This
can trigger many dramatically changes over the next twenty years in neglected aspects or rural health
and of vulnerable segments. The third set of consequences appears to be the inability to develop and
integrate plural systems of medicine and the failure to assign practical roles to the private sector and
to assign public duties for private professionals. In spite of overall achievement it is a mixed record of
social development specially failing in involving people in imaginative ways. Even the averaged out
good performance ides wide variations by social class or gender or region or State. The classes in may
States have had to suffer the most due to lack of access or denial of access or social exclusion or all of
them. This is clear from the fact that compared to the riches quintile, the poorest had 2.5 times more
IMR and child mortality, TFR at double the rates and nearly 75% malnutrition - particularly during
the nineties. Not only are the gaps between the better performing and other States wide but in some
cases have been increasing. Large differences also exist between districts within the same better
performing State urban areas appear to have better health outcomes than rural areas although the
figures may not fully reflect the situation in urban and peri-urban slums with large in migration with
conditions comparable to rural pockets. It is estimated that urban slum population will grow at double
the rate of urban population growth in the next few decades. India is a vast, complex country, and
despite recent economic development, its health-care system is inadequate to deal with the country's
main health challenges: infectious diseases, chronic diseases, and poor maternal and child health.
India is passing through demographic and environmental transition which is adding to burden of
diseases. The first half of the 20th century witnessed a large number of communicable disease
epidemics. There have been major improvements in public health since 1950s. Affordable medicines
and tools are now available which are highly effective, when used appropriately. Examples are: Anti-
tubercular medicines, Anti-malarials, Insecticide-treated bednets, and condoms (to prevent HIV
infection). However, there have also been health consequences of urbanization and industrialization.
There is persisting inequality in health status due to varying economic, social and political causes.

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Learning outcomes:
Upon completion of this module, the reader should be able to:

 Enlist the burden of disease in India

 Enumerate the challenges for health care in India
 Describe the health care structure of India
 List the lessons for future development

Main Text

1. Burden of disease
Developing countries like India currently face a TRIPLE BURDEN of diseases from:
 Unfinished agenda of Communicable Diseases.
 Emerging Non-communicable disease related to life styles, and
 Emerging Infectious Diseases.
This high burden of disease, disability and death can only be addressed through an effective public
health system. Ever increasing population with increasing geriatric population and changing lifestyle
with more urbanization is putting pressure on environmental as well as on nutritional requirement
resulting in nutritional deficiency, poor sanitation increasing communicable and non-communicable
diseases etc.
India has the highest number of TB cases in the world. Out of 9.2 million cases of TB that occur in the
world every year, nearly 1.9 million occur in India which accounts for one-fifth of the global TB
cases. Experts estimate that about 2.5 million persons have HIV infection in India. This is nearly 7.6%
of the global burden of 33 million cases. More than 1.5 million persons are affected with malaria
every year. Almost half of them suffer from falciparum malaria. One third of global cases infected
with filarial disease live in India. Nearly half of leprosy cases detected in the world in 2007 were
contributed by India. More than 300 million episodes of acute diarrhoea occur every year in India in
children below 5 years of age. Emerging infectious diseases are a major public health problem in
developing countries like India. Because of the existing environmental, socio-economic and
demographic factors, developing countries like India are vulnerable to rapidly evolving micro-
organisms. Infectious diseases, especially the new emerging and re emerging diseases, result in high
morbidity and mortality and affect the public health and economy adversely.
Burden of non-communicable diseases is not less. Overall non-communicable diseases are the leading
causes of death in the country, constituting 42% of all deaths. Communicable, maternal, perinatal and
nutritional conditions constitute another 38% of deaths. Injuries and ill-defined caused constitute 10%
of deaths each.

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Life expectancy has increased from 36.5 years in 1951 to more than 63.1 years. While Crude birth
rate declined from 40.8 in 1951 to 22.8 in 2008, crude death rate declined from 25.1 in 1951 to 7.4 in
2008. Infant
Mortality Rate (IMR) declined from 146 per 1000 live births in 1951 to 53 per 1000 live births in
2008. Maternal Mortality Ratio (MMR) declined from 398 per 100,000 live births in 1997-98 to 254
per 100,000 live births in 2006. However, India has a long way to go in further reducing mortality
among infants, mothers and the people in the most productive age-groups (15-45 years). Estimates
suggests that in India the total health expenditure is around 6% of GDP, and is dominated by out of
pocket spending i.e. around 5%. The government/public expenditure on health care is around 1% of
GDP. Due to this low public expenditure the reach and quality of public health services are below the
desired level.

2. Health care challenges:

2.1.Health Care Indicators continue to Lag:
Outcome indicators such as Infant Mortality Rate and Life expectancy continue to fall behind LMIC
averages. It is likely that India will fall short of the 2015 targets for IMR and MMR set in the
Millennium Development Goals. Non- Communicable Diseases have surpassed communicable
diseases as the most common causes of morbidity and premature mortality in the country.
2.2. Health Care Spending is not growing at the same pace as GDP:
As per National Health Accounts, India’s Health care spending as a percentage of GDP has reduced
from 4.4% in 2000 to 4.0% in 2010.
2.3. Out of pocket spending continues to be high:
This is despite that the public Health spending has increased and implying that thus public spending
has struggled to keep pace with rise in health care demand.
2.4. Infrastructure Gaps remain substantial and are exacerbated by undernutrition of existing
resources. Total Bed density has increased to 1.3/1000 by 2010, but remain significantly lower than
the WHO guidelines of 3.5 beds per 1000. Underutilization of existing resources further compounds
the problem of meagre infrastructure. Private Sector hospitals routinely face utilization issue.
Utilization of Public Sector facilities remain low (10).
2.5.Health workforce remains inadequate and underutilized:
The total number of Allopathic Doctors and nurses in the country lags the WHO benchmark of 2.5
doctors per 1000 population at 2.2/1000 people. With a high proportion of AYUSH doctors and rural
medical practitioners not actively involved in the formal sector, the density of practicing workforce
falls to 1.9 per 1000.
While regulatory systems have been partially defined, a holistic regulatory framework is required.

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A well functioning and effective system is required to manage the large and diverse set of services
providers in India. New legislations (e.g the clinical establishments registration acts) have been passed
but lagged in Implementation.
2.6. Public Private collaboration has not yet achieved scale:
Several pilots of public private partnerships have been successful. However, none of them have been
scaled to meet India’s health challenges. While government sponsored social programmes have grown
rapidly, nearly 75% of the population remained uncovered.

In India healthcare has been a neglected area by the government. That is evident from the fact that in
2002 investment in healthcare was only 0.9% of the total GDP. India is a country was people are
treated for the most basic diseases. In 2003 the patients treated for malaria were 1.65 million, for
leprosy there were 2.4 million people and there were 214 cases of polio. The cases for each disease
have reduced significantly over a number of years but still even after so much technological
development the diseases continue to exists. Also the number of cases for AIDS and cancer has
emerged as a major concern for health authorities.
To cope up with both the old and the new challenges the need is to get a sound infrastructure and
making sure that it has been implemented to perfection. Infrastructure has been described as the
economic arteries and veins. Roads, ports, railways, airports, power lines, pipes and wires that enable
people, goods, commodities, water, energy and information to move about efficiently. Increasing,
infrastructure is regarded as a crucial source of economic competitiveness. One cans easily
differentiate the infrastructure used at urban level and rural level.
Fig (1) gives a detailed diagrammatic display of the health structure defined in India.

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3. Health care structure of India

National Level
Ministry of Health & Family Welfare
Institutes of Health
State & Union Territories
Department of Health & Family Welfare
Apex Hospital
Districts
District Hospitals
Rural Area Urban Area
Community Health Centres Hospitals
Primary Health Centres Urban Primary Health Centres
Sub-Centres Urban Health Posts
Village Health Guides, ASHAs, Trained Dai

As it is visible from the figure the infrastructure developed in India is very complex and very well
made but the problem has been the implementation of the same
The government has achieved success in implementation of the infrastructure in the urban areas but it
failed in the rural areas where the 65% of India's population live. The major reason for success of the
model in urban areas has been its simplicity and industrial development. On the other hand the rural
area faces with a complex 4 level health model which includes tained dias to community health
centres and the major drawback for the implementation has been the diversity of rural sector. To cope
up with the difficulty the government started the system of the Village Health Guides that were
responsible to train one person for safer health care of the village but with a small salary and
corruption in the Indian administrative system it wasn't a very attractive job. The other health care
system has worked but still all of them have their drawbacks.
Public spending on health in India has itself declined after liberalization from 1.3% of GDP in 1990 to
0.9% in 1999. Consider the contrast with the Bhore Committee recommendation of 15% committed to
health from the revenue expenditure budget, against the WHO, which recommended 5% of GDP for
health. The current annual per capita public health expenditure is no more than Rs. 160 and a recent
World Bank review showed that over all primary health services account for 58% of public
expenditure mostly but on salaries, and the secondary/tertiary sector for about 38%, perhaps the
greater part going to tertiary sector, including government funded medical education. Public health
spending accounts for 25% of aggregate expenditure, the balance being out of pocket expenditure
incurred by patients to

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But the current situation has somewhat changed 17 per cent of all health expenditure in India is borne
by the government, the rest being borne privately by the people, making it one of the most highly
privatized healthcare system of the world.
The above data calls for greater participation of the government in the health infrastructure. One
cannot hope to depend on the private expenditure by the people to contribute 75% of the healthcare
system. The need is to call for greater participation by the central government and the third-party
insurance to close the balance.
To summaries, the Health care Challenges of India is manifolds, the prominent being:

India Lags in key healthcare indicator

There is a growing burden of Diseases

Inadequate and poor health care planning

Inequitable distribution of resources between states as well as urban rural setting

Shortfall in Physical Infrastructure

Shortfall in trained manpower

Miniscule health budget by government

High cost of advance treatments

Low insurance provisions

Unregulated Private sector

4. Lessons for future health development

The unresolved challenges of India’s healthcare sector during past decade hold at-least five lessons
for its future development. First, an all encompassing vision of future demand for health services
should guide the vision and roadmap for Indian Health system.
Second, prevention and early stage management should be a core focus area. This is particularly
relevant given the rising burden of Non –Communicable Diseases., Such investments can
significantly mitigate disease and cost burden. Third, a constructive and transparent dialogue will be
needed between private and public sectors at its early stage of journey. Fourth, the focus needs to be
on efficiency, especially through better utilization. Finally, large scale implementation needs
strengthening.
In considering how to transforming India’s health system, there is much to learn from similar
journeys by other countries like Brazil, Thailand, South Korea whose health Statistics similar to or
worse than those of India. In their attempt to reform healthcare, countries tend to undergo the
transformation in two phases: first; when political leadership makes a strong commitment to providing

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access to all citizens: Second, when having achieved access to a level greater than 80%, governments
attempts to strike a balance between the cost effectiveness and quality of health care.
Delivery of Quality health services is considered a basic need irrespective of age, gender and culture.
Indian healthcare system faces substantial challenges in providing quality health care.

Summary

The health care challenges in India are mainly lags in key healthcare indicator, growing burden of
diseases, inadequate and poor health care planning, inequitable distribution of resources between
states as well as urban rural setting, shortfall in physical infrastructure, shortfall in trained manpower,
miniscule health budget by government, high cost of advance treatments, low insurance provisions,
unregulated private sector that can be tackled through proper vision, focus on early diagnosis &
treatment, strengthening of public & regulation of private health system, ensuring effective utilization
etc.

References

 Park K. Park’s Text Book of Preventive and Social Medicine, 23rd edition, Jabalprur; M/s
Banarsi Das Bhanot Publicantions: 2015

 Tirunavalli BR, Chadalawada UR. Text book of Community Medicine, 3rd edition.
Hyderabad;Paras Medical Publisher:2015