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Private sector key to solving India’s healthcare woes

As India takes up its ambitious targets for reducing maternal and child mortality, a senior USAID official says participation of the corporate sector is a must to fulfil the government’s aims. United States Agency for International Development (USAID) Deputy Administrator for Asia Nisha Biswal stressed that success in the field of healthcare in India depended on interventions which could show quick results, and the changes in India will have a global impact. ‘I can say India’s private sector is going to be the biggest factor in scaling change,’ Biswal told IANS in an interview.

‘First, it makes sense for their own business. When the people are healthy, the economy prospers. Also, when the corporates provide benefits like healthcare and social security to their employees, the employee is loyal to the company,’ she said. ‘Secondly, there is a deep desire to connect the needs of the base level and the aspirations of the top level. You cannot keep the two disconnected very long without creating disturbance in society… As it is said, India needs to work for Bharat,’ Biswal added. ‘The government of India has a methodological and data oriented working style, which is showing results. The government has identified target districts, and if they succeed in bringing change in these places, the effect will be seen. Focussed interventions are the need of the hour, identifying areas, as well as threats,’ Biswal said.

 

For instance, India accounts for the largest number of under-5 deaths – nearly 1.5 million, of which close to 0.8 million die within 28 days of birth. Nevertheless, steady progress in curbing child deaths has been demonstrated. The rate of decline in the under-5 five mortality has much faster than the global average; from 115 in 1990 to 59 in 2010 as against the global average of 87 and 57 respectively. USAID has also announced a new effort to support diarrhea management, one of the leading causes of child deaths in India. Out of the total funding of $4.7 million, the partnership is leveraging $2.4 million from the private sector.

India is now looking beyond the UN Millennium Development Goal (MDG) of reducing child mortality rate (CMR) to 38 per thousand. The target in the 12th Five Year Plan is to reduce it to 33 per thousand by 2017. USAID provides funding and other assistance for several programmes in the fields of health, education and food security. Health programmes, especially on maternal and child healthcare, are in the agency’s focus. The agency recently extended two flagship projects on child survival – the Maternal and Child Health Integrated Project (MCHIP) and the Health of Urban Poor Project (HUPP).

Healthcare woesThe right to good health is of paramount importance. It’s sad that we, the world’s most populous democracy, can’t guarantee that to our citizens. India has the most inequitable healthcare scenario feasible. On one hand, our country is fast becoming the hub for medical tourism where people from other countries flock to get good quality, affordable medical treatment.  On the other most of these facilities are simply not available to the natives.

India may be the big boy in the sub-continent but a recent report card shows that we as a nation are worse of when it comes to health of its citizens. Be it life expectancy or infant mortality, India ranks below Brazil, China, Sri Lanka, Nepal and Bangladesh and only have always-in-strife Pakistan as our peer when it comes to the poor standard of health parameters.
The Global Burden of Diseases, Injuries and Risk Factors 2010 study details the causes of deaths and disability across various age groups for 187 countries. Sri Lanka and China are the neighbours that are heading the list in most parameters followed by Bangladesh, Bhutan and Nepal and it’s usually India and Pakistan that occupy the last spot.The nature of the beast has changed though and while in 1990 the top killers in India were diarrhoeal diseases, in 2010 it’s ischemic heart disease. The second leading cause of death is Chronic Obstructive Pulmonary Disease (COPD) which has been a killer for the last two decades. Stroke comes third and diarrhoeal diseases and tuberculosis round up the top five. Ischemic heart disease is actually the number one killer all over the developed world while in poorer countries the common killers were respiratory disorders, malaria and HIV.Suicide and road accidents
In the 15-49 age group, suicide and TB were the biggest threats for South Asia while in China it was road accidents instead of suicide. The situation is very different in Africa though where HIV/AIDS is the biggest killer for the 15-49 age group. In India, road injury is the leading cause of death in the 15-49 demographic for men while for women it’s suicide.
Under-five mortality
Among children under five the biggest killer is preterm birth complications which have replaced diarrhoeal diseases from 1990.
Developed world problems?
Interestingly, the biggest risk factors for Indians were dietary risks, high blood pressure, indoor air pollution and tobacco smoking. A poor diet consisting of high fat foods is causing immense damage. The unhealthy commodities industries – packaged food, alcohol, non-alcoholic soft drinks, fast foods and others – have permeated all urban areas. More and more people are falling ill in what is supposed to be the healthiest period of their life and it’s because of the choices they are making. Junk food, soft drink consumption, alcohol, tobacco and a sedentary lifestyle are all coming together to create a dangerous cocktail where more and more people are vulnerable to lifestyle disorders like diabetes and heart disease.

So how did the situation get so bad?

Healthcare was never a top priority after independence. The initial onus was on agriculture, infrastructure and military. This led to social sectors like health and education being neglected. In fact, it wasn’t until 1982-83 that the National Health Policy was endorsed by parliament.  Most of the services provided thereon were preventive (vaccinations against various ailments) and very few curative healthcare services were provided. Preventive services were mostly provided by the private sector. Medical education too was neglected, a case in point being that there are no superlative medical institution brands like the IITs or the IIMs.

Here are some of the major issues we need to tackle if we hope to one day become the nation that our freedom fighters and forefathers thought we’d become:

1. Woeful rural healthcare

Mahatma Gandhi had a dream that India would be a land of self-sustaining villages.  “The true India is to be found not in its few cities, but in its seven hundred thousand villages. If the villages perish, India will perish too.” The health scenario in rural India would’ve caused him great pain.  The basic problem in this case is the lack of resources – human or otherwise. Initiatives like the National Rural Health Mission (NRHM) or a compulsory Bachelor of Rural Health Care (BRHC) course haven’t made much headway.

Here are some of the stark facts about the lives of our rural brethren:

  • 50% of all villagers have no access to healthcare providers.
  • 37% are chronically starved
  • 10% of all babies die before their first birthday
  • 50% of all babies are likely to be permanently stunted due to lack of proper nutrition
  • 33% people have no access to toilets, while 50% defecate in the open

Source:  Indiafacts.in and India Development gateway

2. Women’s and Children’s Health

 

According to a poll by Thomson Reuters, India is the worst place for women among G20 nations. Female foeticide, unequal rights, dowry killings, poor maternal health and lack of sexual education are just some of the reasons for the same. Here are few stark realities about women in India:

12 million girls were aborted in the last three decades in India
Child marriage has a domino effect since this also leads to lowered education levels and lower levels of awareness
45% Indian women are married before they turn 18. This results in early pregnancies, higher morbidity and mortality rates.
A mother dies every ten minutes in India
The children’s healthcare situation is equally bad. While some diseases have been controlled to a large extent others continue to wreak havoc.

  • Over 1.25 million children die annually in India.
  • 48% of all children have stunted growth due to malnutrition.

Source: Lancet 2011 and Save the Children

  • Only 7% children in India receive the minimum acceptable diet set by the WHO. The other countries we share such a dubious honour with are sub-Saharan African countries and Pakistan.
Country Pakistan Nigeria Congo Mali
% of children who receive minimum acceptable diet 4% 3% 4% 7%

Source: Save the Children

3. Low government spending, high out-of-pocket expenses and lack of insurance

 As we mentioned before, the government spending on healthcare is grossly inadequate. It spends about 1% of the nation’s GDP on healthcare. This has led to very high out-of-pocket (OOP) expenditure for the general public. This means that 78% of all spends on healthcare are paid by the people and 72% of this is on drugs alone. Estimates suggest that 39 million people are forced into poverty because of medical expenditure. Here’s a breakdown of total % of GDP spent on healthcare, percentage spent by individuals and per capita spent by the governments of various developed, developing and under-developed countries.

 

Country Total % of GDP spent on healthcare Private Expenditure % Per capita spent on healthcare (US $) Per capita government spends on healthcare (US$)
India 4.1 70.8 132 39
USA 17.9 46.9 8362 4437
UK 9.6 16.1 3480 2919
South Africa 8.9 55.9 935 412
China 5.1 46.4 379 203
Brazil 9 53 1028 483
Pakistan 2.2 61.5 59 23
Nigeria 5.1 62.1 121 46
Russia 5.1 37.9 998 620

Source: WHO

As we can see we’re nowhere near the top bracket US or UK. We don’t even spend anything close to what our BRICS (Brazil, Russian, India, China and South Africa) counterparts spend. In fact, our spends are even lower than a country like Nigeria’s.

Because of the centre’s negligent attitude, most of the resources lie with the private sector. It currently has 80% of all doctors, 26% of nurses, 49% of beds and 78% of ambulatory services and 60% of in-patient care. It seems audacious not to exploit those resources. To this effect, the Planning Commission had suggested that the public sector tie-up with the private sector to improve the country’s healthcare scenario. However, the proposal was vehemently opposed by health activists who felt that it would‘corporatize’ healthcare.

Another big issue is lack of medical insurance. Only 243 million of India’s 1.2 billion citizens are covered under Govt health insurance schemes and a total of 300 million (25% of total population) don’t have health insurance at all.

Source: Planning Commission Health Division report for the 12th Five Year Plan

4. Medical Education and Healthcare Human Resources

India has some top quality medical institutes which provide quality education and a huge number of medical professionals are added to the task-force every year. While that is indeed a huge number, most of them are based in urban centres resulting in deficit of healthcare services in rural and semi-urban India.

Health HR Doctors Specialists AYUSH* Nurses ANM** Pharmacists Total
Numbers graduating annually 30,000 18,000 30,000 54,000 15,000 36,000 163,000

*Practitioners of Ayurveda, Yoga, Unani, Siddha and Homeopathy

**Auxiliary nurse middle-wife (for childbirth)

Some stats to ponder about:

  • Urban India has four times more doctors and three times more nurses than rural India.
    Only 193 of India’s 640 districts have medical colleges. This has a domino effect on the local community with doctors moving away, either to urban centres with medical colleges or abroad.
    Almost 80% of the medical colleges are located in South and West India creating a dearth of professionals in Central, Eastern and Northern India.
    To bridge these issues, various steps have been suggested -Giving AYUSH docs the right to prescribe allopathic drugs after a one year course.
    A compulsory Bachelor of Rural Health Care course
    AIIMS-like institutions in various parts of the countries. They are going to be located in Patna, Bhopal, Bhubaneshwar, Jodhpur, Raipur and Rishikesh.
    A compulsory bond that will force the docs to return to India after completing their medical education abroad.
    Setting up of a centralised National Commission of Human Resources and Health which will have all other medical bodies in the country under its jurisdiction.
    However, most of these initiatives met vehement criticism and have experienced opposition from the medical community.

    Source: Planning Commission Health Division report for the 12th Five Year Plan

5. High number of avoidable deaths

Avoidable deaths refer to those that could’ve been avoided extremely easily with either the most basic or cheap medication or treatment. Some of the more common avoidable diseases are malaria, tuberculosis, kala azar and Japanese Encephalitis. Deaths from conditions like nutritional deficiencies or perinatal deaths are also considered in this list. A rough estimate suggests that over 2.1 million people died in India from conditions that could’ve been avoided. Here’s how we arrived at the number.

Diseases Estimated deaths in South  East Asia (2008) Est. deaths in India* (2008)
Tuberculosis 405974 357257
Malaria 43200 38016
Diarrhoea 1141586 1004596
Dengue 7064 6216
Japanese Encephalitis 11313 9955
Kala Azar 10130 8914
Nutritional deficiencies 84,123 74028
Perinatal conditions 8,72,676 767955
Maternal conditions 80620 70946
Total 26,56,686 2337884

 *Assuming 88% of these deaths were in India, since it accounts for 88% of the population in this region.

Note: It’s extremely hard to track deaths due to avoidable diseases. WHO estimates over 2.6 million people died in South East Asia in 2008 from these conditions. However, official records show the numbers to be far lesser. For example, India had only around 1000 reported malaria deaths in 2008. However, when the entire SE Asian region is taken the number of estimated malaria deaths is 43,200. Now this region has a total population of 1.3 billion and India had an estimated population of 1.15 billion in 2008. So it’s clearly implausible that despite having 88% of the population it only accounted for 2 percent of malaria deaths. So we’re assuming that 88% of all deaths caused by these diseases are in India. We’re assuming of these 2,656,686 deaths, 2,125,348 occurred in India.

It’s extremely sad that so many Indians are losing their lives to diseases and conditions that could’ve been easily avoided with the most basic of healthcare services.

Rise of Lifestyle diseases

While rural India battles third world diseases like malaria and dengue, rising urbanisation has led to the middle and upper classes being afflicted with ‘developed world’ lifestyle diseases like diabetes and obesity. A fast food culture, increased smoking and alcohol consumption has led to a rise in obesity related diseases like diabetes and cardiovascular ailments.  To read a more comprehensive report about lifestyle diseases click here.

The road ahead 

Most of our healthcare woes could be vanquished if we as a nation simply worked together for it. When I say nation, I mean everyone – doctors and other medical professionals, rural and urban citizens, bureaucrats and politicians, the state and central governments.

It’s a travesty that 66 years after Independence we still can’t make even the basic healthcare services accessible to everyone. Most of us reading this probably haven’t experienced the grim grip of poverty, malnutrition or ill-health. We’ve probably never gone to bed hungry or lost a loved one because we couldn’t afford a drug. Sixty-five years ago we freed ourselves from colonial rule; it’s about time we sent ill-health packing.

Imagine a country where healthcare is accessible to all. Or as Tagore would say, “Into that heaven of freedom my father let my country awake.”  Jai Hind.

First Published: Aug 18, 2012 at 8:50 AM

The first, with funding of $16.4 million, will support the Indian government in establishing quick response teams, which in turn will help the states on the cusp of accelerating their efforts for child survival. The HUPP programme will continue to support the Indian government in implementing its various urban health initiatives. Talking about India’s role in the South Asian region, Biswal said changes in the country can make a huge difference in the region, as well as globally. ‘India has a very important role to play in the region. Because of the scale, it is hard to address challenges in India. The lessons learnt here are applicable at other places as well. Just that India has decided to change something in itself makes an impact,’ she said. ‘The changes in India will have an impact in the region and globally.’ Talking about USAID’s plans for future, Biswal said though the focus at present was on health, this would diversify in future.  ‘Presently 70 percent of our funds go for healthcare. In the course of time, you will see diversity in the partnership,’ she added.

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