Healthcare for all: scopes and challenges in Indian scenario

International Journal of Community Medicine and Public Health Barman DD et al. Int J Community Med Public Health. 2022 Jan;9(1):384-388 http://www.ijcmph.com pISSN2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20215019

Review Article

Healthcare for all: scopes and challenges in Indian scenario

Dipayan Deb Barman1*, M. I. Glad Mohesh2

1Department of Forensic Medicine and Toxicology, 2Department of Physiology, Shri. Sathya Sai Medical College and Research Institute, Chennai, Tamil Nadu, India Received:19August 2021 Accepted:16September 2021 *Correspondence: Dr. Dipayan Deb Barman, E-mail: dipayandebbarman@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT Health for all may have become a reality in many developed countries but developing economies are still striving hard to achieve that long cherished dream for their people. India as a developing country and as one of the fastest growing economies is also working hard to achieve health for all. There are problems which continue to grapple the Indian health sector services. India has successfully launched various health programs in the past few decades and has achieved success in improving on a few major issues such as maternal and child mortality. India has been declared polio infection free nation by World health organization in February 2012. There is tremendous potential for India to reorganize its health care sector through participation of both public and private sector and developing a competent and trained workforce. In order to enable the country to grow in all parameters it is important that health for all citizens must be ensured and by doing this India will be able to have a healthy population which will be productive and will therefore effectively contribute to the economic growth of the nation. Keywords: Health care, Economy, Public spending, First referral unit

INTRODUCTION

Health for all may have become reality in many developed countries; however developing economies are still striving hard to achieve this long cherished dream for their people. Inaction of the governments of various third world countries have to incur a cost of an estimated that 7 trillion dollars on non communicable disease burden by 2025.1 India is one of the fastest growing economies, and health for all is a much awaited dream to come true for all Indians. According to a United Nations report on world population projection published in 2019, it has been reported that by the year 2027, India is going to become the most populous nation in the world by even surpassing China.2 The current updated figures of the World health organization global health expenditure database shows that from the year 2000 till the year 2016 of India, allocation and expenditure on health care has been

significantly dismal and in the year 2016, India spent just 3.66% on health care out of its total gross domestic product and this is in stark contrast even with a country like Afghanistan which spent 10.20 % of its gross domestic product on health care.3

The World Bank organization in the year 2019 June has projected a growth rate for the Indian economy at a rate of 7.5%.4 Even though the economy is seeing a growth, expenditure on health care was not been placed at pace with the economic development. This again has happened because of very improperly placed priorities that has not been able to keep in pace with the economic development. For the realization of the ultimate goal of a healthy India, successive Indian governments have launched several health care schemes in the past few decades, and this include schemes such as: the Indian health care scenario is changing at a very poor rate. There are two aspects of the scenario, on one side we have a

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tertiary care system involving private players involving corporate hospitals which has improved and developed as the hub of all modern diagnostic and therapeutic procedures. This has made India as a destination for health tourism in the world, earning foreign exchange. On the other side we have a problem riddled government health care system which forms the mainstay of support of the public health care delivery system. As per report in India the public health sector actually encompasses about 18% of the total out patient care and 44% of the total in patient care respectively.5 India has a public and private health care system and the public health care system is state government financed by tax payer money.6 The public health care system which was once the dominant arm of health delivery system of India has been finally overtaken by the private sector, and the reports of the National Family Health Survey-3,suggests that the private medical sector now remains the primary source of health care for 70% of all households and 63% of households of India in urban and rural areas respectively.7 Problems which grapples the health care delivery system in India includes lack of skilled health care workers, doctors, nurses, poor infrastructure in majority of the government hospitals, primary health care centres. A report of the WHO says that about one third of the total world's population still do not have reliable access to required essential medicines and the situation is even bad when it comes to developing countries.8 According to reports published by the WHO and in a report in India spendit was estimated that around 469 million people in India are striving to get even regular access to essential medicines.9,10

Public spending on health and ground reality

India at present is staring at a scenario of proposed cuts in health care allocation rather than the much needed financial stimulus to the ailing public health care delivery system of the nation. A systematic well planned investment in health care sector is one important way to have a good and vibrant human resource development and here the role of public expenditure is crucial. It is a well known fact and has been well argued that true empowerment of people comes when there is achievement of freedom from poverty, hunger, malnutrition, and this in turn improves the ability to work and lead a healthy life and thereby contributing positively towards the development of the country.11 Diabetes, heart disease, infectious diseases, cancer etc are some of the health problems which have been posing serious challenge to the Indian populace, and also the health care givers and health policy makers. Now a major part of the public health care spending has to go for developing a robust and sustainable infrastructure and manpower set up in the rural setting. The data of the rural health statistics of 2017 shows thatin India the total requirement of female and male health workers at sub centres are 1,81,881 and 1,56,231 respectively.12

India has a total 3076 first referral unit (FRUs) and out of these 2458 has got more than 30 beds for patients and that is 79.9%. And of these first referral units 2897 (94.2 %) are equipped with operation theatre, 2962 FRUs have labour room (96.3%) and, 2120 (68.9%) have blood storage facility for blood transfusion.13 As the majority of India’s population lives in rural areas public sector health care system needs more push and allocation from the government.

Figure 1: National Health programs launched by Govt

of India.

Opportunities for India

As India wants to be a 5 trillion economy by 2025 as envisaged by the government of India, along with economic development, health care of the population is also a priority and for that health care spending has to increase and needs proper allocation. The national rural health mission (NRHM) has already been launched in the year 2005 and it has also been proposed to launch a National urban health mission (NUHM) in similar lines to cater the urban population which is seeing a surge in migration of work force from rural areas. In order to effectively make these schemes successful this would need the collaboration of public and private sector. Indian government in the year 2018 announced the Ayushman Bharat scheme providing upto 5,00,000 Indian rupees per family per year and this would be available at any government or even empanelled private hospitals in India. There is an excellent opportunity to give a major boost to the health care sector. India has already achieved the WHO recommended doctor patient ratio of 1:1000 in the year 2018.14 One thing which is very interesting with respect to the Indian states is that a geographically land locked remote region called the north eastern part of India comprising of eight states namely Assam, Arunachal Pradesh, Meghalaya, Manipur, Mizoram, Nagaland,

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Tripura and Sikkim has witnessed remarkably low infant mortality rate and better life expectancy at birth compared to other parts of India. The IMRs in NE states were way lower at 31.2 in 2006-10 and 28.7 in 2011-15 however they were 54.3 and 49.2 respectively as evidenced by reports of the same period in overall India.15 This could point to two things one, adequate spending on health sector by the respective state governments of the NE states and two population wise distribution and availability of doctors and nursing staff. Now given the different geographic location and socioeconomic conditions of different Indian states a more robust health policy designed for that particular state has to be conceived and with participation of all stake holders such as central, state governments, health experts from state and central levels and even private health care sector. There is also a need to incentivise the private sector players inorder to invest and build a well developed sustainable health care system catering to the rural population. With the medical council of India planning to revamp the medical education policy in India by implementing a competency based medical education (CBME) program, there is a great scope to harness this tremendous potential and pool of young doctors who will be added to the Indian health care system.

Resource, manpower allocation challenges

Twenty first century brings major health challenges and these include a burgeoning population, scarcity of resources, migration of rural population to cities and overcrowding, poor infrastructure and technical difficulties in taking health care services to the door step of the citizens. Since majority of the people have not been able to access to quality healthcare and also it is a fact that this sometimes act as impediments to get access in economical, organizational, societal domains which deprives the population.16 Communicable diseases and outbreaks remains a major cause of concern and in the coming decades will continue to pose major challenges at the national and as well as international level.17 HIV, hepatitis, tuberculosis, malaria, encephalitis remains major health challenges. The congregation of most of the doctors and hospitals in urban areas as compared to rural area is a big matter of concern and this comprises only just 20% of the total population of India. The nurses-to- physician ratio in India is about 0.6:1, as against the nurses-to-physicians ratio of 3:1 in some of the developed countries, already WHO estimates acknowledges a global workforce shortage of over 4 million health workers.18 Medical students after their graduation usually prefer to work in urban areas for better quality of life and this is a problem which creates inequality in rural areas. However, this again cannot be blamed entirely on the doctors, as issues such as poor connectivity, infrastructural inadequacy in rural hospitals coupled with shortage of man power is actually compounding the situation. There is a need to train grass root level health care professional who when armed with proper patient care protocols, have low cost diagnostics tool available with them and

increasingly mobile phones, they are being reinvented as a new trained, paid cadre of health worker will be able to provide care including advice and treatments for a limited range of common conditions (mostly maternal and child health, HIV and TB treatments).19 For the rural poor population additional barriers to health care such as long distance to seek care and the associated costs of travel and treatment make situation more difficult.20

What has India been able to achieve in past several decades?

Since its launching in 2005 the National health mission which subsumed the National rural health mission and the National Urban Health Mission as per a 2015 report had made significant levels of improvements to hospital infrastructure across the country.21 In 2005, where there was just one hospital bed for every 2,336 people, the data of 2015 shows that after ten years following an expansion of hospital infrastructure, there was one for every 1,883 people in India.22

India has made commendableachievements in significantly lowering the maternal mortality rate (MMR) by lowering MMR from 556 per 100000 live births in 1990 to 130 per 100000 live births in 2016.23 Another WHO report shows that following establishment of wider maternal health services coverage number of antenatal check visits, correction of nutritional anaemia, and institutional deliveries has increased from 18% in 2005 to 52 %in 2016.24 In India overall 75 % of child births are supervised compared to 89% in urban areas.[24]Key government policies such as Janani Suraksha Yojana and with support of UNICEF the national ministry of health and family welfare (MoHFW) developed a evidence- based guidelines and protocols such as the maternal and newborn health toolkit, maternal death review guidelines and technical treatment protocols.25 India has been able to successfully overcome the polio endemic and transformed from a polio hyper endemic state to a polio free state. The transmission of wild polio virus has been interrupted in India and this has sustained and since February 2011 no single case of poliomyelitis was reported. The World health organization (WHO) on February 25, 2012, removed India from the list of ‘polio-endemic’.26 The overall life expectancy in India is now higher than before. A recent report shows that Indians have gained 10 years in life expectancy since 1990. However there is variation among the various Indian states in terms of overall progress. Now the life expectancy for Indian male and female is 66.9 and 70.3. Since the 1990s India has made great improvements and substantial gains in health, with reports showing that the overall health loss from all diseases and conditions has declined by about one-third per person in 2016 than in the 1990.27 Now the road ahead for India as it wants to become a major world power is full of challenges and responsibilities. To develop a world class health care delivery system there is also a need to invest and incorporate newer technologies into healthcare. As the world is witnessing a major transformation

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through incorporation of artificial intelligence in all sectors similarly India also has the opportunity to adopt and incorporate use of artificial incompetence in the field of health care sector. To achieve all heath goals which is eluding India there is a need to work relentlessly to overcome all the basic difficulties that have traditionally plagued the healthcare system. The entire health care delivery system of the country has to be galvanized by means of well planning and proper distribution of resources.

CONCLUSION

Given the challenges of the twenty first century, India needs to brace for the challenges and short comings. However, the areas where the country has progressed need to be sustained and simultaneously the areas of health care where the country has lagged behind has to be covered and this can be achieved by suitable application and allocation of resources. The nation needs to tackle the health care issues which continue to plague the health care sector. As there is a saying that, twenty first century will be Asia’s century, now India could become the leader and guide for the rest of the world. To achieve this health for all citizens is the most important goal which India has to achieve as a healthy population will be productive and can effectively contribute to the economic growth. There lies a tremendous opportunity before India to address all outstanding health problem solutions which have remained elusive till now

Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required

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