Public Health

Health in India: Public apathy, Private enterprise

Shubh Kumar-Range

October 2006

As with everything in India, this is a land of stark contrasts. And so it is in the health arena. On the one hand we have such a high quality of medical facilities available here, that more and more patients from other countries, including the West are traveling here to avail of state of the art medical services at a fraction of the cost back home. New Delhi, in particular has the highest number of new private hospitals that are catering to the well heeled national and international clientele.

But what about the average Indian, what is the situation for her? In cities, medical services are quite widely available and reasonably priced. Well qualified medical practitioners are mostly concentrated in urban centers. In Delhi, one has the luxury of home visits by specialists, such as a geriatric specialist for my father for Rs 700 (equivalent to approx. US$ 16.00). So much so that medical insurance is virtually unheard of (estimated at less than 10% of the population), unless one is traveling overseas. Government officials have medical insurance of sorts that enables them to avail of free or subsidized services at public dispensaries or hospitals – which no one but the most desperate would venture to go to. In the past few years, access of public officials has been expanded to include private facilities as part of this insurance scheme. Private companies providing health insurance are few, and mainly derived from MNC collaboration with Indian private sector health providers. Regulation of the sector is virtually non existent given the newness of it all, and as a result benefits from the insurance are spotty. Growth of private sector health insurance is also being fuelled by the expansion of international companies operating in India – that are required by laws back home to provide health insurance coverage to their employees.

Even when I was growing up in India, decades ago, the middle class still preferred to go to private nursing homes and tried to avoid government hospitals as much as possible. However, the conditions then were far better than they are now in these same government hospitals. One may safely generalize, keeping in mind that all generalizations have exceptions, that the availability of public health facilities provided by the government have failed to keep up with the population needs, and the quality may have actually become worse.


Private and Public Sector

Consider the contrast between private enterprise and public apathy. Private hospitals in India say that the inflow of foreign patients is doubling each year. They come for organ transplants, hip replacements, cosmetic surgery, lens implants for vision, and a variety of rare and delicate surgical procedures that are performed here. Patients pay a fraction of the cost they would in Europe, UK or USA, and they are treated royally, and most important, there are no waiting periods due to scarcity of these high end facilities.

At the same time, government hospitals in the nation’s capital are in shambles. Lok Nayak hospital -- used to be Irwin Hospital when I was growing up, and considered one of the better government hospitals, is pathetic now. In this 1500 bed hospital, there are only 12 ventilators, out of which half do not work at any time. There is only one operation theatre for departments of neurosurgery, general surgery, plastic surgery, orthopaedic surgery and paediatric surgery. There is no drinking water, and patients have to pay for procedures that are supposed to be free of charge in government hospitals. To make matters worse, since there is such an acute shortage of medical staff, patients actually have to bribe hospital staff to get an appointment to see a doctor. Even the premier government-run facility in New Delhi – All India Institute of Medical Sciences (AIIMS) which formerly used to attract overseas patients from the region, is now so run down that even middle class Indian dread going there. According to a World Bank study in 2004, 69% of injections given in government hospitals were unsafe either due to improper sterilization or poor skills of those who administered the injection.

Health conditions in the countryside, where the majority of the people live are much worse. Public facilities are meager, and hence most prefer private clinics and are prepared to shell out the exorbitant costs even though their incomes are low -- the cost of hospitalization is on average nearly 60% of annual total expenditure. Over 40% of Indians borrow or sell assets to cover health expenses.

An ambitious new health initiative was launched in 2005 – the National Rural Health Mission. It was inaugurated with great fanfare, and as usual the targets are highly ambitious -- such as halving infant mortality rate from 63 to 30 per 1000 live births in six years. Its annual budget (2005-2006) is about US$ 1.34 billion. Contributions towards this budget are being provided by the World Bank and UN agencies such as UNICEF. It is yet to be seen if this scheme will show results that previous government allocations to the sector have failed to deliver.


Public Health Conditions: Past and Present

Even though the economy of India is steaming forward, and rates of abject poverty are lower now than recorded at anytime in India’s history, hundreds of millions of women and children have no access to health care. Just before the launch of India’s National Rural Health Mission in 2005, WHO released its annual report in New Delhi to highlight the failure of the country’s public health record. This report puts India in the list of 51 “slow progressing” countries as far as infant, child and maternal mortality is concerned. One in every three malnourished children in the world is from India, and about 50% of all child deaths are linked to this scourge. This is clearly not rocket science, but a doable proposition for a country with so much brain power and talent. And to prove that there are regions of the country, such as Kerala, where health conditions match those in developed countries.

Kerala is often noted as a region in India that has since the 1950’s (at the start of India’s independence from Britain) been far ahead in all health indicators. Kerala comprises the former states of Travancore and Cochin in the south and Malabar in the north. The southern part was relatively free from British governance and continued to have more equitable land and income distribution compared with the rest of the country. During the time of British rule in India, farmers were rapidly become tenants due to the tax policies and land inequity was rising rapidly. In Travancore on the other hand, land reforms had begun in 1865, conferring ownership to all tenants. A similar proclamation in Cochin in 1914 also conferred land security to its farmers. Parallel to these land reforms was expansion of education and health services.

As a result of these early developments in Travancore-Cochin, by 1903-4 the residents here were ahead of India-wide levels in health and education by six decades. In the post independence (from Britain) period, Kerala has also been quick to avail of national policies promoting health and nutrition and their early implementation in the state. Other parts of the country where high political support is being given to health and nutrition, such as in Tamil Nadu, rapid improvements in public health have also occurred in the past few decades.

Health problems that need to be tackled in India are growing. The traditional diseases of poverty are still around, such as tuberculosis, malaria, leprosy, undernutrition and others such as cholera and typhoid, to name a few. At the same time diseases of affluence such as heart disease, diabetes and cancers are on the rise, as is HIV/AIDS. Growing scarcity of water and pollution with organic and chemical toxins is rampant, with no solution in sight. The public health system is weak and over stretched. The private health system is much more vibrant, and 1growth in the economy and personal wealth are helping to nurture its rapid expansion. Numerous new ‘state of the art’ health facilities have mushroomed. Unfortunately, these can only be afforded by a small minority of India’s population, and now a growing breed of ‘medical tourists’ who are visiting this country.

India’s growing health problems should be of great concern globally. They affect not only the poor and marginalized people. Public health conditions have a way of hitting back at everyone. Take for example the current epidemics of dengue and chikungunya in India (summer-fall of 2006). Both these are highly virulent mosquito borne diseases that are spreading rapidly, and the health system is already strained. The prestigious AIIMS in New Delhi, has recently stopped accepting other patients so that it can cope with dengue infections, and many of the deaths are reported due to the inability of the system to provide the necessary treatment. In this age of economic globalization and interdependency, India’s weak medical care system is a threat to countries that invest and trade here. According to WHO, both dengue and chikungunya, as well as other bugs can easily be transported by visitors to and from India and spread to countries where they are not currently prevalent.

Dr. Shubh Kumar-Range received a PhD from Cornell University; she directed projects for IFPRI and the EU; at present she is doing research work for a book in India