It has been said that healthcare and education form the two most important and fundamental pillars of a welfare state. Unfortunately, both of these have been ignored in India for a long period. The condition of healthcare in India has never been satisfactory. India was ranked 145th among 195 countries as per the Healthcare Access and Quality Index 2016. It’s disappointing.
At a time when the pandemic has challenged the capacity of well developed and advanced healthcare of western countries, Indian healthcare system seems to struggle with the ongoing crisis with its challenges and shortcomings.
These include insufficient hospital beds (0.7 per 1000 individuals), shortage of doctors (0.8 per 1000 individuals), shortage of paramedical and nursing staff, lack of medical equipment and devices, operational machinery and ventilators to be specific, low-quality care due to misdiagnosis by under-trained staff, unnecessary and expensive diagnosis, corruption and poor cooperation between public and private spheres, etc.
Moreover, there exists a rural-urban divide when it comes to healthcare service delivery. Affordability and accessibility of quality healthcare in rural areas have always been a concern. Nearly 31.5% of hospitals and 16% of beds are located in rural areas where 75% of the total population resides.
If there is one reason behind most of the challenges of Indian healthcare in general, and public healthcare in particular, it is the inadequate government spending. India’s total healthcare spending (out of pocket and public), at 3.6% of GDP, as per OECD, is way lower than other countries. The government spending on healthcare has to be increased, without a doubt.
However, it is of equal importance for the Government to know where and how to spend. As long as the aim of Government is the translation of its healthcare expenditure into tangible economic outputs, issues on the ground will remain unsolved. Much of its expenditure has been done to strengthen the private healthcare sector which provides the majority of secondary, tertiary and quaternary care.
Quality and affordable healthcare can be provided to a large population in roughly two ways. One is to make an investment in private healthcare and make it affordable to citizens by various means, including viability gap funding. The other one is to improve public healthcare and make it large, competitive and advanced.
Unfortunately, India has followed the first option, which is not sustainable. The underlying idea behind this approach is the assumption, or perhaps misconception, of the Government that private healthcare is the epitome of quality healthcare, which is not true. Even private healthcare is not immune to corruption, the inefficiency of staff and infrastructural bottlenecks. It requires only a single visit to a large private hospital to observe prevalent unethical practices in the name of professionalism and service.
India needs a quality healthcare system which is affordable and accessible to most of the population. This can only be ensured if public healthcare is strengthened. The first and foremost step to be taken in this direction is upgradation of sub-centres and primary health centres. Overcrowding in district hospitals happens because we have shifted our focus from Primary and Secondary Healthcare to Tertiary and Quaternary Healthcare.
On the other hand, urban healthcare is dominated by single, unqualified practitioners since government healthcare is grossly inadequate to cater to a large population. Divide between the public and private sector in terms of service delivery, capacity and cost is a unique feature to the Indian healthcare system.
The Government needs to adopt the PPP model in narrowing this divide. Few such successful models are Yashasvini Health Scheme of Karnataka, Arogya Raksha Scheme in Andhra Pradesh, Telemedicine initiative by Narayana Hrudayalaya in Karnataka, GVK EMRI, Chiranjeevi Yojana of Gujarat, etc.
Since there is a shortage of hospitals, doctors and medical staff, technology and innovative solutions can play a huge role in reducing the overcrowding of clinics. eHealth (which includes ePrescribing, Clinical decision support system, Telemedicine, Telesurgery, Consumer Health Informatics), mHealth and Telerobotic surgeries are of huge significance, provided that the government pay heed to promote it. Telemedicine, particularly, is a solution to various challenges of the Indian healthcare system.
Moreover, biomedical research remains on the back seat in India, citing a lack of government expenditure. The Indian Council of Medical Research, a premier biomedical research agency in India, itself reported one of the lowest budgetary expenditures on research and development among major central government scientific agencies. Government spending has to be increased and incentives are to be provided to researchers to bridge the ever widening gap between academics and research.
Changing disease profiles and the emergence of new zoonotic diseases has questioned our existing health approach. In this situation, one health approach, which aims to integrate efforts in medicine, veterinary medicine, public health, agriculture and environmental health, assumes a much important role.
As I said earlier, a mere quantitative jump in spending without analysing where and how to spend takes our healthcare system nowhere. Steps such as strengthening infrastructure through sustainable financing and investment instruments, capacity building of the workforce including Auxiliary Nurse Midwives, adoption of new technologies viz. nanotechnology, biotechnology, machine learning, blockchain, addressing supply-side issues and regulation of medical practices is required.
Since health is under the State list of the constitution, corrective measures have to be taken by the centre to ensure effective cooperation for the betterment of health services. It is to be noted that in any healthcare system, there reaches a point beyond where the capacity of the healthcare system will fall short of resources. It is highly unrealistic to imagine, considering the population of our country, that supply will always outweigh demand. Can doubling the number of beds in hospitals guarantee that it is going to fulfil demand?
Ensuring effective and efficient curative healthcare has become a challenge because enough attention has not been given to preventive healthcare. The outbreak of the Coronavirus is proof of that. Had the population been careful about sanitation and hygiene (WASH), outcomes would have been less disastrous.
The deplorable condition of sanitation and hygiene in government hospitals has never made policymakers and administrators concerned and attentive about the issue. After all, WASH has a direct relation with nosocomial infections and antimicrobial resistance.
Simple economics suggests to us that if we have supply-side constraints, we need to make sure the demand remain less. This can be ensured by looking for alternatives like AYUSH, strengthening preventive healthcare, using traditional knowledge and most importantly, by creating awareness which is one of the fundamental pillars of healthcare.