By Dr. Amar Patnaik & Anshuman Sharma
India’s public health system has struggled to cope with the COVID-19 crisis. Even before the pandemic, India’s public health infrastructure was inadequate with only 0.55 beds per 1,000 population, while out-of-pocket expenditure was pushing almost 63 million people back into poverty, as a large number of healthcare positions lie vacant across the country. Faced with a growing disease burden, India’s public health system is in dire need of investment and the COVID-19 crisis is the perfect opportunity to back this policy decision with political will.
Early in the lockdown, India had relative control over curbing the potential spread of COVID-19, and may have prevented as many as five times more cases in April in a scenario without a lockdown (Dwivedi et al 2020). However, some states have succeeded more than others. Among larger states, Kerala and Odisha have performed relatively better for varying reasons like an efficient public health system and timely response, respectively. However, as experts are suggesting, the peak of the spread may likely still be in the future, with our public health systems being strained to full capacity.
Health System’s Response
The ongoing crisis has brought into focus three important arguments.
First, robust health systems like Kerala’s are better placed in containing the spread and providing care to citizens. Even before COVID-19, Kerala had fared well in containing the Nipah outbreak. Had Nipah not been contained within the state, it could have become a national epidemic. Globally, too, countries with robust health systems have already flattened the curve and have started coming out of lockdowns.
Second, the COVID-19 crisis has provided a glimpse of what a full-scale public health response looks like. For instance, Odisha, which is experienced at tackling super cyclones like Amphan, has adopted a disaster management approach and mobilised resources more effectively than most states and has been more successful in containing the spread and keeping the case fatality rate low. Odisha established quarantine facilities, created more hospital beds, and allocated more resources towards combating the crisis. The main governance strategy in the state has been that of decentralisation and trusting panchayats to manage the pandemic response at the village level, and converting schools and colleges into isolation centres. This strategy has prevented pressures on the health systems and the healthcare workforce. In the state and even nationally, public health communication has been a continuous feature of the crisis response, with messages about personal hygiene, social distancing, and public safety emerging as key topics of dissemination.
Third, India’s public health system is in dire need of investment, and since we are witnessing that public health emergencies can bring down not just national but global economies, long lockdowns and emergency responses cannot be the only way to deal with them.
Studies have shown that even due to climate change (McMichael 2015) and increased mobility of people, infectious diseases are more likely to occur in the future (Hoberg and Brooks 2015). Moreover, India is going through an epidemiological transition, implying that the disease profile of the country is diverse, which puts additional pressure on the health system. Combine a pandemic with an inadequate health system and we have a situation where Indians will be predisposed to larger lockdowns in any crisis, with the poor being disproportionately affected, as has been evident in the COVID-19 crisis.
In most states, the public health infrastructure is inadequate and has struggled to cater to the health needs of the citizens, even in times of relative normalcy, before the COVID-19 pandemic.
Public Health Infrastructure
Health infrastructure is the foundation to deliver an effective health system response to the delivery of health services. To prevent, manage, or cure a health condition, adequate healthcare infrastructure is essential, which includes beds, doctors, paramedics, etc. The National Health Profile 2019 (CBHI 2019) highlighted that there were 7,13,986 total government hospital beds available in India or about 0.55 beds per 1,000 population. For comparison, Sri Lanka, which is a neighbouring country with a better health system and similar gross domestic product (GDP) per capita, has 3.7 beds per 1,000 population, and China, which is comparable in population size, has 4.2 beds per 1,000 population, respectively, while the World Health Organization (WHO) recommends five beds per 1,000 population (Figure 1).
Moreover, there are 12 states with 70% of India’s population that have less than 0.55 beds per 1,000 population, namely Bihar, Jharkhand, Gujarat, Uttar Pradesh (UP), Andhra Pradesh, Chhattisgarh, Madhya Pradesh (MP), Haryana, Maharashtra, Odisha, Assam, and Manipur. States like Sikkim (2.34) fare better on this indicator, while Kerala (1.05), Delhi (1.05), and Tamil Nadu (1.1) fare moderately.
Similarly, WHO recommends one physician per 1,000 population and India fares at 0.8, while Sri Lanka fares at one, and China at 1.8 physicians per 1,000 population. Even in trained surgical workforce, India lags way behind with seven surgeons per 1,00,000 population compared to China’s 40 surgeons per 1,00,000 population. To train this highly skilled workforce, India will need to substantially improve on its 529 medical colleges, which take in about 58,756 students each year.
It is important to understand the impact the low availability of healthcare infrastructure and human resources has on the citizens. Since public facilities are inadequate, citizens frequently turn to private healthcare providers, bearing the cost of healthcare on their own. While it may be a normal practice for those who can afford it, for our poorest citizens, it may be the biggest reason that is keeping them poor.
Pushing Millions into Poverty
In India, spending on private healthcare is much higher than that on public health compared to many other countries at a similar stage of development (Figure 2). More importantly, even in private spending, the share of out-of-pocket (OoP) expenditure is much higher. The lack of adequate public health and high OoP expenditure imposes a high financial burden on Indian households.
OoP spending on health is pushing millions of Indians into poverty. A study estimated, using the National Sample Survey Office (NSSO) survey, that around 63.22 million individuals or 11.88 million households were pushed below the poverty line due to healthcare expenditure (Bhandari et al 2010). The paper also found that 6.2% of total households (6.6% in rural areas and 5% in urban areas) fell into the below poverty line (BPL) category as a result of total healthcare expenditure. Around 1.3% of total households (1.3% in rural areas and 1.2% in urban areas) fell into the BPL category as a result of expenditure on inpatient care, while 4.9% of households (5.3% in rural areas and 3.8% in urban areas) fell into the BPL category as a result of outpatient care.
Moreover, much of this impoverishment (79.3%) is due to outpatient care, which involves relatively small but more frequent payments, and only 20.7% of impoverishment is due to inpatient care. The paper also found that a higher share of this burden is borne by those living in rural areas, possibly due to transportation costs to private facilities situated in the nearest urban centres.
It is important to understand how the poor finance this OoP burden. A paper by Flores et al (2008) provides some important insights into this. The paper highlights that in rural areas, borrowing is the main financial coping mechanism, financing almost 34% of OoP expenditures, whereas in urban areas, savings are the main source of funding but borrowing still accounts for 22% of health expenditure. The situation is so dire, the paper finds, that increased expenditure or borrowing to finance OoP payments does not lead to contraction of other spending, but rather an inflation in overall household expenditure, indicating a permanent debt trap.
It has also been documented globally that more than hospitalisation costs, recurring payments for medical supplies and pharmacy cause a bigger dent in household finances (Wagstaff and Doorslaer 2003).
One of the key goals of a health system is to protect populations from large financial risks associated with healthcare expenditures. It is imperative that India invests in its public health infrastructure. Even during times of relative normalcy, our health systems are stretched, and the poor bear the burden of poor public health by shelling out money from their pockets to seek healthcare.
India’s High Disease Burden
India has what is called the “triple burden of disease,” which implies that the Indian population, with around 85 lakh deaths per year, is susceptible to preventable infectious diseases, non-communicable diseases, as well as injury-related ailments.
While the total share of deaths due to infectious diseases has gone down over the last couple of decades, these diseases still cause the most number of premature deaths in the country, with five of the top seven causes of premature deaths in India in this group (Figure 3; ICMR et al 2017). When combined causes of death and disability are studied, malnutrition and dietary risks, like anaemia, still feature as the top two causes.
In the last decade, India has also witnessed a rise in non-communicable diseases (NCDs), which in the past were considered diseases of affluence or lifestyle diseases. The top three causes of death in India currently are cardiovascular conditions (heart disease), chronic obstructive pulmonary disease (COPD) (lung diseases) and stroke, and these diseases also feature in the top six causes of premature deaths. In the last decade, the prevalence of asthma, diabetes, and kidney disease has also risen (ICMR et al 2017). India also faces a high number of injury-related deaths and disabilities like self-harm and road accidents. India has the world’s highest number of road accidents at about five lakh annual accident cases or about 1,370 accidents per day (NCRB 2017).
Burden of disease is measured by a metric called disability-adjusted life years (DALYs), measuring the loss of years in good health because of either premature death, disease, or disability. One DALY represents one lost year of healthy life. DALYs vary for different disease groups. For infectious diseases, DALYs are as high as ninefold for diarrhoeal disease, sevenfold for lower respiratory infections, and nine-fold for tuberculosis in 2016, because of higher mortality compared to years lived with disability, and given that a lot of these deaths occur at younger ages (Figure 4).
From an economic and policy point of view, DALYs are critical for an economy and imply life lived under the “burden” of morbidity, often accompanied with decreased productivity, financial burden on family members, rising health costs, and debt.
In India, while accidents and injuries are spread out across the country, the other two disease groups are not as omnipresent. Communicable or infectious diseases are mostly concentrated in the poorer and less economically developed states, often categorised as the Empowered Action Group (EAG), which includes Bihar, Jharkhand, UP, Uttarakhand, MP, Chhattisgarh, Odisha, Rajasthan, and Assam. Southern states transitioned epidemiologically before northern states. For example, the infant mortality rate in Kerala had fallen as early as the 1980s, and in the last 30 years, the burden of NCDs has risen gradually in the south. However, in the last decade, NCDs have risen across the country.
What is more important is that even neighbouring states can have vastly different disease profiles. The India State-Level Disease Burden report highlights that MP and UP, both with relatively lower levels of development indicators and a similar epidemiological transition stage, differ in disease profiles (ICMR et al 2017). UP had 50% higher disease burden from chronic obstructive pulmonary disease, 54% higher burden from tuberculosis, and 30% higher burden from diarrhoeal diseases, whereas MP had 76% higher disease burden per person from stroke. Disease outcomes cannot be seen in isolation from geographic, cultural, and economic factors. Punjab, for example, has a higher than average consumption of alcohol with 28.5% people consuming alcohol, which is one of the factors directly correlated with heart disease, and road injuries due to drunk-driving. Alcohol consumption in Himachal Pradesh for comparison is 8.9% (NDDTC 2019).
India’s past experience has shown that the country as a whole has been successful whenever it has worked in a mission mode: eradication of polio, keeping HIV prevalence low, and in the case of COVID-19 responding with a disaster management approach. Moreover, India’s public health system is omnipresent, albeit one that underperforms.
What India needs to build on is for times of crisis as well as relative normalcy. For that, improving on service delivery, training workforce, and financing public health are extremely critical. Studies have suggested that despite its omnipresence, India’s public health system is underutilised, mainly due to trust issues and perceived higher quality in private clinics, suggesting that there are issues in the quality of care provided at the public health facilities.
Public Health Services
Reforming a health system is a mid- to long-term task and has been challenging for governments around the world. Different countries have adopted varying strategies to reform their health systems as per local contexts and needs. However, there are a couple of widely-used frameworks that can be referred to while planning for a health system reform. One of the most popular frameworks is the WHO Building Blocks framework, which lists six building blocks for an effective health system: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance (WHO 2007).
Another popular framework is the “Control Knobs model” of health system reform, which prioritises financing, payments, organisation, regulation, and persuasion as “knobs” that the government can manipulate to achieve a desired health system (Roberts et al 2004).
In both models, there are key common intermediate variables that explain the pathway to achieving desired system goals. These are access to facilities, equity through financial risk protection, quality of health services, and affordability of health costs.
Access to facilities: Access to healthcare must include access to both infrastructure as well as human resources for health. To achieve an effective primary- and tertiary-care infrastructure, a workable strategy could be to build on what India currently has. India has a large network of primary health centres; however, they are often underfunded, ill-equipped and the staff is undertrained or even absent. Moreover, there is a large number of healthcare positions that lie vacant. Tertiary care in India is also often considered inadequate by WHO recommended standards and is in dire need of an upgrade. Overall, we need to upgrade the capacity of both the infrastructure and human resources to a minimum standard, which could be WHO prescribed standards or comparative standards of a similar better-performing country.
Various reports have put the available human resources for health at 8 to 11 human resources per 10,000 population as against the WHO prescribed figure of 25 to 26 per 10,000. According to one estimate, the number of allopathic doctors, nurses, and midwives combined (11.9 per 10,000 people) was about half the WHO benchmark of 25.4 workers per 10,000 population (Rao et al 2011).
Moreover, these resources are unequally distributed across the country. In northern and central states, which happen to be the poorest regions of the country, the number of health workers is even lower. There is a wide geographical and urban–rural variation too, as almost 69% of India’s population in villages have access to only about 26% of the country’s doctors. Among these, the share of doctors in the private sector is considerably higher than those in the public health sector.
To redistribute a high number of doctors to the rural areas is a gargantuan task. However, it is something that has been achieved before, most notably in Turkey, which successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, and addressed inequities in health service access and health outcomes (Atun et al 2013). For India, Odisha’s success in swiftly signing memorandum of understanding and getting into public–private partnership agreements with private sector healthcare can be replicated, especially in states where the public health system is far from providing adequate healthcare immediately. The vast network of private hospitals, clinics and other doctors and paramedics need to be effectively collaborated with while addressing adequacy to provide access to healthcare.
Moreover, investing in centres of healthcare and healthcare training will be a prudent investment for India. Not only will more health training cater to the deficiency of medical human resources across the country, it will also provide critical care at places where those centres are established. Centres like All India Institute of Medical Sciences (AIIMS), which India prides itself on, are indeed a need at a much lower level. India could look at district-level plans for high-quality healthcare and healthcare training centres. Investing in a high-quality healthcare and training centre in a cluster of three to four districts could be a strategic long-term investment and should be prioritised. Moreover, certain district-level hospitals could also be remodelled to work as district-level health and wellness centres to provide more holistic healthcare at the district level.
Equity through financial risk protection: Equity in the health system should ensure that healthcare costs do not become a financial burden on the poor and the economically disadvantaged, as it is so currently. For the last 15 years or so, there has been a lot of focus on state-sponsored public health insurance. With this view, the Rashtriya Swasthya Bima Yojana (RSBY), now Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was launched. The scheme was also seen as a move towards universal health insurance coverage. More recently, the PMJAY scheme aims to cover the bottom 40% of the population, based on the socio-economic caste census, with an insurance coverage of up to `5 lakh for hospitalisation.
However, studies have shown ineffective utilisation of national- and state-sponsored insurance schemes. In the most recent and comprehensive study, it was found that only a maximum of 38% of those enrolled under state health insurance utilised the public health facilities (Table 1; Prinja et al 2019). The study also found that the mean OoP expenditures for outpatient care among the insured and uninsured were `961 ($16) and `840 ($14), and `32,573 ($543) and `24,788 ($413) for an episode of hospitalisation, respectively.
The most alarming finding of the study was that catastrophic health expenditure among the insured and the uninsured was almost similar at 28% and 26%, respectively, with that among the insured marginally higher. Indian poor are not protected against financial strains in times of healthcare needs and the OoP expenditure remains high.
However, it is not to say that utilisation of the public health system always yields undesired results. In terms of maternal health indicators and improving institutional deliveries, the public sector has led the way and provided inexpensive and accessible health services (Prinja et al 2012).
The public sector has the ability to provide cost-effective services that are utilised by the citizens. Even if the public sector cannot provide all services in a cost-effective manner, it can definitely cater to the poor, with basic services and reduce catastrophic expenditure on health. Universal insurance or universal public healthcare is much desired by most policymakers. However, till the time we reach that stage in terms of state finances and the health system’s capacity, the public sector can compete with the private sector to provide quality services.
An example of moving towards universal health coverage is the Biju Swasthya Kalyan Yojana (BSKY) in Odisha, which provides coverage for both above poverty line (APL) and BPL populations in the state, unlike the Ayushman Bharat Scheme, which only covers BPL households. Under the scheme, besides free healthcare services at government healthcare institutions up to district headquarters hospital level, additional facility of free healthcare beyond district headquarters hospital level, through annual health coverage of `5 lakh per annum per family and `7 lakh per annum for women members of the family is also provided. This scheme also serves all currently enrolled Biju Krushak Kalyan Yojana cardholders, RSBY cardholders, BPL cardholders and Antyodaya Anna Yojana (AAY) cardholders and families with annual income below `50,000 in rural areas and below `60,000 in urban areas. The BSKY covers the target population even at the primary-care level by providing free health services in state government healthcare facilities starting from sub-centre level up to the district headquarters hospital level through a network of Swasthya Mitras (health buddies)working as point of care query response executives. Besides public hospitals, 208 private hospitals are also empanelled under the scheme and the claim settlement is provided by insurance companies.
Quality of health services: Quality in healthcare is achieved through public satisfaction of services provided at the public health facilities. Quality of service delivery is an essential component of building trust with the citizens and improving utilisation of public health facilities. The Mohalla clinics in Delhi are a good example of improving service quality and building trust and reliance with citizens. A study highlighted that a key reason for higher utilisation of Mohalla clinics was less waiting time at clinics, increased interaction time with the doctor, perceived performance of doctor, and effectiveness of treatment (Agrawal et al 2020). The study also pointed out that similar reasons motivated the users to return to the facility to seek healthcare. Other state governments could adopt these lessons and improve the service quality at public health centres.
Of course, there is no substitute for high-quality tertiary care that can save lives and a network of multi-specialty tertiary care centres are a need across the country, which, barring some elite medical institutions, is restricted to big private hospitals around the country.
Affordability of health costs: Affordability ensures that not just primary but tertiary care is not placing a catastrophic burden on citizens. However, affordability is not only about an inexpensive public health sector. In the presence of a large private health sector, the public health sector needs to provide good-quality care to compete and provide similar satisfaction as private facilities. This would ensure competition and reduce prices even in the private sector.
Additionally, there is a need to regulate prices of healthcare costs and drugs. Prices of private healthcare can be as high as six to eight times that of public facilities (NSSO 2019). These costs include only inpatient costs; however, the costs for pharmacy and drugs are also much higher compared to medicines at public facilities and pharmacies.
Affordability is not a stand-alone argument and needs to be seen with the whole function of a public health system. To reduce high costs of tertiary care, it is imperative that a strong primary-care network exists across the country that can diagnose and refer disease early. An effective primary-care system can also prevent a lot of conditions becoming adverse. Most effective health systems, like Japan, prioritise prevention of disease as a public health strategy. Since most health conditions, infectious or non-communicable, are preventable, this strategy keeps the burden on the health system low and minimises DALYs.
In Conclusion
State-specific prevention strategies require customising health infrastructure as well as tailoring the technical capacity of human resources. In UP, for instance, front-line health workers need training support on infectious disease control and modules of how to navigate sociocultural gatekeepers to enable behaviour change at the community level. Similarly, in Punjab, an effective outreach would require motivating families and individuals to moderate the consumption of alcohol and adopt healthier diets. This level of outreach requires a dynamic primary healthcare system that is adept at responding to local needs with local contexts, and utilises technology to deliver quality of care at primary, secondary and tertiary care centres.
To achieve an accessible, equitable, quality, and affordable health system, government financing is indispensable. However, India does not spend as much as most public health literature would recommend. The WHO recommends spending 6% of the GDP on health. In 2020, India budgeted to spend about 1% of its GDP on healthcare (Figure 5).
To invest in upgrading the number and capacity of human resources and modernising infrastructure, public health will require a higher priority in terms of financing. Currently, health does not feature as a priority expenditure in our national budget. The type of reform our health system needs will require massive investments from our national budgets and a strong political will at the national as well as state levels.
Advocating for an increased health expenditure as a percentage of national budgets, is the first step towards realising an effective public health system. The government health expenditure (GHE) per person per year in India is only `1,108, which comes to `3 per day. States have started prioritising increased health spending within their annual budgets, with Delhi as a notable example. Other states like Mizoram and Sikkim have better functioning public health systems, which is directly correlated with their high per capita expenditure on public health, at `5,862 and `5,126, respectively (MoHFW 2017).
Larger states like Odisha have started investing in public health with a multi-pronged approach to investment. Already, plans for an AIIMS-like centre are underway and cancer treatment facilities along with medical colleges in each district have been planned for the state. There is much to learn from experiences of different states as well, as India is vast and diverse and so are the health needs and strategies of its states.
The article was originally published in Economic & Political Weekly Vol. 55, Issue No. 47, 28 Nov, 2020
Dr. Amar Patnaik is a member of Parliament, Rajya Sabha from Odisha, an academic, author of the book Institutional Change and Power Asymmetries in the Context of Rural India, and former Principal Accountant General of Sikkim, Odisha, West Bengal, and Kerala.