Even as the ruling right-wing Bharatiya Janata Party celebrates the triumphant return of Prime Minister Narendra Modi for a second term with a historic mandate in the just-concluded 17th Lok Sabha elections, one of the greatest challenges confronting the new government will be the nation’s health.
Lack of hospitals, missing doctors, ill-equipped health professionals, and paucity of funds have dogged the Indian health sector for decades. But as the country stakes a claim at the geopolitical high table under a nationalist government, its human development indices — including citizens’ wellness — are increasingly coming under scrutiny.
And the picture isn’t looking good. According to a recent study published in the British Medical Journal, the Indian medical industry fares poorly on many critical parameters, including quality of health care as well as qualification of doctors, traditionally regarded as a prized human resource in the West.
The report states that 54 percent of health professionals in India — including doctors, nurses, paramedics, and midwives — do not have proper qualifications while 20 percent of adequately qualified doctors are not part of the current workforce. Of the currently working health professionals, around 25 percent do not possess the necessary qualifications as laid down by professional councils, the study states.
Over 58 percent of doctors are males, reinforcing underrepresentation from women even though they constitute 50 percent of the country’s population. In addition, the survey finds that over 80 percent of Indian doctors and 70 percent of nurses and midwives opt to join the private sector, which offers a more conducive work environment.
“Distribution and qualification of health professionals are serious problems in India when compared with the overall size of the health workers,” the study concluded. “Policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce.”
India’s own National Sample Survey of 2016 also highlighted glaring lacunae in the country’s health system. According to the pan-India survey, at least a quarter of Indian allopathic physicians do not have the requisite qualifications. Besides, their geographical distribution too is a problem with two-thirds of doctors, nurses, and midwives working in urban areas where only 29 percent of Indians live. In many villages, the density of healthcare professionals lags behind many African countries, the survey added.
India’s low spending on healthcare has been a sore point with experts for years. Despite being the world’s sixth largest economy, public health spending has languished at under 1.5 percent of GDP, one of the lowest rates in the world. For comparison, the United Kingdom shelled out 9.6 percent of its GDP in 2017 on health. The United States’ health expenditure is 18 percent of GDP.
India’s paltry figure for health spending is in stark contrast to the 10.6 percent of GDP (almost five times more) that the government allocated to defense in the interim budget.
Critics suggest this asymmetry needs to be corrected forthwith. “An increasingly aspirational Indian electorate is more invested in acquiring better education, jobs, housing, and quality of life. Matters like military spending are tertiary to their existence. And now that the new government has come back with a thumping majority, expectations will be greater in terms of deliverables,” says Sheila Chamanna, a senior consultant with Ram Manohar Lohia Hospital, New Delhi.
Though public per capita expenditure on health increased from about $10 in 2009-10 to $15 in 2015-16 according to the National Health Profile of 2018, it is still quite dismal. Worse, in India, a government doctor, on an average, attends to a population of 11,082 people, which is 10 times more than the WHO-recommended doctor-population ratio of 1:1,000.
What’s even more disconcerting is that the issue is not on top of the national agenda. “Healthcare has featured in public discussions in the run-up to the elections and in some manifestos, but it wasn’t really prominent in the campaigns,” says Seetha Lakshmi, health coordinator with a Delhi-based health nonprofit. “In 2014, the BJP manifesto promised substantial progress across social sectors like health and education but we’re still waiting for dramatic change.”
In 2017, the BJP government promised to amp up the health budget to 2.5 percent of GDP by 2025. In 2018, it also launched the “world’s largest healthcare program,” the Ayushman Bharat scheme, which promised insurance coverage of $7,081 paid for by the government to 100 million families or 500 million people whom the government identified as “marginalized.” While the insurance was for secondary and tertiary care, the scheme also promised to develop primary health facilities.
However, Ayushman Bharat was not really a universal “healthcare program,” but a “health coverage” one, aimed at less than half the population and excluding 700 million people.
More than anything, it is the high cost of medicines in India that is most disconcerting for the common man. An overwhelming 70 percent of healthcare expenses in India are paid by Indian patients out of their own pockets, one of the highest rates in the world.
Lack of preventive treatments is another sore point. The National Health Profile 2018, an annual report released by the Central Bureau of Health Intelligence, elaborates that due to a lack of focus on preventive oncology in India, over 70 percent of cancers are diagnosed only after reaching stage III or IV, when treatment is more difficult and less likely to succeed. Small wonder, then, that India’s number of cancer-related deaths ranks among the world’s highest. Last year, 784,821 people succumbed to cancer in the country, according to the National Institute of Cancer Prevention and Research.
For Indian cancer patients in particular, poor preventative care coupled with high prices makes for a near insurmountable barrier. “The standard health insurance policies cover cancer but only part of the treatment cost. As a consequence, either out-of-pocket expenditure goes up or patients drop out of treatment,” explains Chamanna.
To be fair, the central and state governments have tried to introduce several innovations in the healthcare sector in recent times, albeit with mixed results. That includes efforts to improve access for poor and middle-class families by reducing the prices of essential medicines, cardiac stents, and knee implants, and making medicines available at affordable prices through the Pradhan Mantri Jan Aushadhi Kendras scheme.
Also in the pipeline is the setting up of 150,000 health and wellness centers under Ayushman Bharat, which will focus on preventive health, screening, and community-based management of basic health problems.
But as critics have pointed out, the real urgency lies in increasing the funding for Ayushman Bharat. While the scheme is a watershed innovation in universal healthcare, the government should increase its funding by 20-25 percent every year for the next five years or more to reach its target.
The effects of poor health on workforce productivity are well documented. Indians work for just six-and-a-half years at peak productivity (compared to 20 years in China, 16 in Brazil, and 13 in Sri Lanka), ranking 158th out of 195 countries in an International Ranking of Human Capital.
Malnutrition – though not as rampant as before – also needs to be conquered. A 1 percent loss in adult height due to childhood stunting is associated with a 1.4 percent loss in economic productivity, according to World Bank estimates. Stunted children earn 20 percent less as adults compared to nonstunted individuals.
A relatively high prevalence of diseases among the population coupled with the underwhelming healthcare extended by the state means India is risking its future economic growth by underinvesting in its citizens’ health. Human capital, defined as the number of expected years lived between the age of 20 and 64, is considered an important determinant of economic growth.
Life expectancy and good health greatly impact the quality of labor generated within a country. Given the new government’s massive mandate, and relatively better access to funds, taking care of its citizens’ health should be priority number one on its agenda.
Neeta Lal is a New Delhi-based editor and journalist.