Equitable access to public healthcare may be defined where individuals receive equal public healthcare facilities irrespective of his/her social, economic and geographic background. Serving a population of over 1.3 billion, India’s healthcare sector is a far cry from such an egalitarian access. It is common knowledge that despite a vast network, India exhibits a number of crippling disparities across various parameters in healthcare. Variations are even sharper when private and public healthcare infrastructure
Access to Healthcare in India | Where do we stand?
According to the report, ‘Global Burden of Diseases: 2016’, India ranks 154th in 195 countries on the healthcare index. Interestingly, even Bhutan, Nepal, Sri Lanka and Bangladesh have secured a better ranking than India. According to the National Health Profile 2017, India has a mere 1 million qualified doctors for a population of 1.3 billion people. Out of this, roughly 10 per cent of doctors are employed in the public sector—which translates into one allopathic doctor for approximately 10,200 people. as shown in Figure 1, Bihar for example has only 3,576 government doctors available for a population of almost 100 million, taking the ratio of patients per doctor to about 1:27,000. Other states with a low doctor to patient ratio include Andhra Pradesh, Chhattisgarh, Gujarat, Madhya Pradesh and Maharashtra (CBHI, 2017). In terms of medical staff, the public healthcare sector requires over 177 per cent additional nurses, over 70 per cent additional pharmacists and over 49 per cent additional doctors to reach the desired density of personnel required (Patel et al., 2015).
Similar to acute shortage of doctors, hospital infrastructure too falls short. As of January 1, 2017, the total number of government hospitals (including community health centres) in India is 14,379 with 634,879 beds. On an average, bed to patient ratio is 1:2,406 people for the country. States such as Assam, Goa, Kerala, Sikkim and Meghalaya have a greater availability with a ratio of 1 bed to 1000 patients. On the other end of the spectrum, Bihar has one bed for over 8,000 people, while Uttar Pradesh holds a ratio of 1:3,500 people and Andhra has one bed for 3,819 people (CBHI, 2017). This uneven distribution reflects the lop-sidedness of access to healthcare in the public sector.
The gaps in India’s public healthcare system are well documented. One study points out that over 70 per cent of community health care centres do not have emergency obstetric care services, while only 50 per cent of the centres offered protected abortion services. Obstetrics and gynaecology are considered a primary need of any community and the patient load is usually highest in this category. Also, by March 2015, only 21 per cent of the primary health centres and 26 per cent of the community health centres functioned as per the Indian Public Health Standards. Such factor drive the general public to private healthcare, which provides better quality infrastructure and care (Patel et al., 2015).
The Indian public healthcare system is based on a referral system. Starting from the basic sub-centers, it moves upward to the primary health centers (PHC), community health centers (CHC), district/ general hospitals, government medical colleges and the All India Institutes of Medical Sciences (AIIMS). Currently, India has seven functioning AIIMS, which are located at New Delhi, Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh. Citing the low number of the institutions and a less than adequate human resources, the current government has announced as many as 12 new AIIMS which are to be constructed in Assam, Himachal Pradesh, Punjab, and Bihar among other states (Express Web Desk, 2017). Experts, however, argue that it is not the lack of doctors per se, but their paucity in public service that is the main issue.
As such, although capacity building will augment the manpower, a deeper insight will have to be sought about whether they will opt to work in governmental hospitals.
Rural and urban divide
Healthcare disparities over rural and urban spaces are common knowledge. According to a report on Healthcare Access Initiatives by Organisation of Pharmaceutical Producers of India (OPPI) and Klynveld Peat Marwick Goerdeler (KPMG), approximately 75 per cent of dispensaries, 80 per cent of doctors and 60 per cent of hospitals are situated in urban areas, which hold 28 per cent of India’s population. In addition, only 37 per cent of people in rural India can access in-patient department (IPD) facilities within a 5 km radius, whereas 68 per cent people have access to out-patient department (OPD) (OPPI, 2016). This leads to an increasing ‘out-of-pocket’ expenditure in healthcare for rural communities.
Expenditure on healthcare
Direct payments made to health care providers while availing a health service, usually unplanned, is known as ‘out-of-pocket’ expenditure. Kerala records the highest out-of-pocket expenditure with 84 per cent being private spending. Ironically, the State also marks a high per capita governmental expenditure on health at INR 1070, as compared to the other Indian states. Himachal Pradesh ranks at the top with a maximum per capita expenditure on healthcare at INR 1,830, while at a dismal INR 348 per capita, Bihar spends the least on healthcare among all states (Brookings India, 2016).
The average medical expenditure per hospitalisation in rural and urban areas has increased from INR 5,965 and INR 8,851, respectively in 2004 to INR 16,956 and INR 26,455 respectively in 2014 (PIB, 2017). This can be unswervingly attributed to the shift from public to private healthcare in the past few years. The private healthcare has become a booming market for investors and is expected to continue yielding profits as they offer complex differentiated and specialised services.
So vibrant is the private medical industry in India that it serves as a viable destination country for medical tourism. According to the Federation of Indian Chambers of Commerce and Industry (FICCI), over 500,000 foreign patients seek treatment each year in India (FICCI, 2017). Comparing the prices of various health procedures in multiple countries, India emerges as one of the most affordable destinations. For instance, a heart valve replacement surgery costs approximately USD 170,000 in the United States, USD 30,000 in Costa Rica, USD 13,500 in Malaysia and merely USD 9,500 in India. To put things into perspective, surgery costs just about 18 times more in the United States when compared to India. Similar price disparities can be witnessed in many other health procedures, which has turned India into a medical tourism hub (Medical Tourism, 2016)
Corruption in health and the clinical
establishments act (CEA)
The healthcare sector, which primarily should have been a social service sector, is today an industry—ushering in malpractices and corruption. According to a Berlin-based non-profit, Transparency International, India ranks 81 out of 180 countries in the Corruption Perceptions Index 2017, which measures corruption in the public sector. Using a inverse scale of 0-100, where lower the number higher the corruption, India received just 40 points and shared the rank with Ghana, Morocco and Turkey (Transparency International, 2018).
Corruption in granting approvals to open medical colleges, medical admissions, escalated cost of medical care and other malpractices have turned India into one of the most corrupt countries in the health domain. Countless cases have been unearthed which have put doctors in poor light as they continue to refer patients for avoidable diagnostic tests to their hospitals or partner labs which provide a defined target or a hefty cut for the referrals. Similar unprofessional misconduct exists in medicines as well where doctors prescribe expensive and low-quality medicines with drug companies offering doctors kickbacks.
To ensure the delivery of a minimum standard of services by clinical establishments across the nation, the government enacted the Clinical Establishments Act (CEA) in 2010. The Act encompassed all types of clinical establishments except the ones run by armed forces and was passed by the Parliament in 2012. It was hailed as a model Act aimed to streamline healthcare services and simultaneously ensure private institutions curb immoral practices. However, six years down, the ground reality is that most states are yet to implement the Act. Only a few states and union territories (interestingly NCT of Delhi is in the has-not list) have followed the Act. The states that have complied include Arunachal Pradesh, Rajasthan, Assam and Jharkhand.
According to Mohit Khatana, founder of the non-profit outfit ‘People Against Medical Corruption’, “CEA 2010 is a weak Act as it has not been implemented in all the states of India. In such states where no law has been established under this Act, all private medical institutions are engaged in negligent practices, charging higher prices and more. Poor or lower middle class families are suffering the most. The Indian government must amend the CEA to make it strict, and it should be mandatorily implemented in all states to control unfair practices in private institutions.”
There are multiple incidents of malpractices in healthcare. One such episode that caught the media attention was from Fortis Hospital, Gurugram in August 2017; where the grief stricken parents of a seven-year-old girl admitted with dengue shock syndrome, who subsequently lost her life, was billed over INR 16 lakh for the treatment. The girl’s family alleged negligent treatment (Raghavan, 2017). The government probed the allegations and found numerous irregularities in the functioning of the institution following which the retail sale drugs license and the license of its blood bank were suspended (Dayal, 2017). Such an incident could perhaps have been avoided if the CEA was applied correctly and compellingly.
In a bid to provide a public health cover to the people of the country, the BJP-led government announced the Ayushman Bharat Programme, which contains two initiatives. The first includes the National Health Policy’s vision to promote health and wellness centres as the principle point of contact in India’s Public Health System. To implement this vision, the government allocated INR 1200 crore in the 2018 budget to establish 1.5 lakh centres to connect the health system effectively.
The second initiative is the National Health Protection Mission. The scheme aims to provide a benefit cover of INR 5 lakh every year to every family that comes under the Scheme. Targeting 10 crore families falling under poor and vulnerable category, the cover will encompass almost all secondary care and most of tertiary health procedures (PIB, 2018).
Sheetal Ranganathan, vice-president of life sciences and healthcare operations at a research and consulting firm, while talking to G’nY observes, “National Health Protection Scheme (NHPS) is a welcome announcement—a departure from previous years as it has pulled health of the nation from the sidelines to the very centre. But the scheme alone will not take us any closer to the ‘health for all’ or Ayushman Bharat claim. It offers no provision whatsoever to alleviate financial hardship for primary healthcare, which is the mainstay for any nation to achieve universal healthcare. One has to look at the health-spending profile of 72 per cent families in rural areas and 80 per cent families in urban areas falling under the socio economic caste (SEC) status, who qualify to be intended beneficiaries of the NHPS. And
yes, 80 per cent of their out-of-pocket expenditure is for OPD services, not falling under the
Even though the government has approved the launch of the Scheme, it is still unclear as to how the government aims to allocate funds for such a high density scheme. On an average, a fund of INR 50 lakh crore is required every year to cover the target populace of 10 crore families with the desired insurance cover of 5 lakh per family per year.
“No doubt, insurance of 5 lakhs per annum would be a comforting thought in an event that one may need hospitalisation and surgical intervention, but such events are few and far between. The topmost ailments prevalent in India, especially in the NHPS-targeted SEC include ischaemic heart diseases, lower respiratory tract infections such as bronchitis and asthma, chronic obstructive pulmonary disorder, tuberculosis and diarrhoeal diseases. Most of these are chronic conditions that require regular outpatient consultations. Hospitalisation is a one-off event. NHPS will also not help the biggest problem of India’s health system—severe shortage of healthcare personnel (doctors, nurses, lab technicians) and outdated infrastructure”, adds Sheetal Ranganathan.
Despite the initiation of the process of implementing the CEA, a robust healthcare system can only be created if and when the Act is in force across the nation. We are at a critical point of time where the topic of equal and accessible health is gaining momentum. Whether the answer to equitable access to healthcare lies in privatisation of healthcare or augmenting the role of government through intercession to reduce the equity concerns, the need to attain a robust and basic healthcare system is essential to attain the desired results.
Brookings India, 2016. Health and Morbidity In India (2004-2014): Brookings India. Available at: https://brook.gs/2mib4JL
Central Bureau of Health Intelligence (CBHI). 2017. National Health Profile 2017. Available at:https://bit.ly/2HcL6oq
Dayal S., 2017. Licences for Gurgaon Fortis pharmacy, blood bank suspended after inspections, The Indian Express, December 31.
Express Web Desk, 2017. Status check of 12 new AIIMS announced by PM Modi’s government, The Indian Express, October 3.
FICCI, 2017. Advantage Healthcare India 2017 global summit on medical value travel to begin in Bengaluru on Oct 12, Available at: https://bit.ly/2vzG9Rq. Accessed on April 15, 2018.
Medical Tourism. Compare Prices. Available at: medicaltourism.com/Forms/price-comparison.aspx. Accessed on: April, 07, 2018.
Organisation of Pharmaceutical Producers of India (OPPI), 2016. Report on Healthcare Access Initiatives: Klynveld Peat Marwick Goerdeler (KPMG). Available at: https://bit.ly/2HOToAe
Patel V., Rachna P., Sunil N., Priya B. And Kavita N., … Srinath R., 2015. Assuring health coverage for all in India, The Lancet 386 (10011): 2422-2435.
Press Information Bureau (PIB) , 2017. Increase in Costs of Healthcare Services , July 25.
Press Information Bureau (PIB) , 2018. Ayushman Bharat for a new India -2022, announced, February01.
Raghavan P., 2017. Haryana government to file FIR against Fortis for negligence in dengue case, The Economic Times, December 7.
Transparency International, 2018. Corruption Perceptions Index 2017: Transparency International. Available at: https://bit.ly/2BJaDBF.