Indian Healthcare System: The Past, Present and Future

Pandemics have had a significant socio-economic cost to humanity over centuries and have troubled civilizations throughout history. While outbreaks occur frequently, every outbreak does not amplify into a global pandemic like the Novel Coronavirus (COVID-19) has. The COVID-19 Pandemic has severely strained the health care system of our country. The rapidly increasing demand for medical facilities and workers threatens to leave our country’s health care system overstretched.

Current State of Indian Healthcare Sector:

According to a Brooking study by Prachi Singh, Shamika Ravi and Sikim Chakraborty published in March 2020, which used data from the National Health Profile-2019, the total number of hospital beds in the country was 7,13,986. This translates to 0.55 beds per 1,000 people. India’s doctor-to- population ratio stands 1:1445, well below the level recommended by the World Health Organization. The WHO says that the ideal ratio is 1:1,000. As per an estimate, India has a shortage of about 6 lakh doctors, 20 lakh nurses and an even greater number of supporting medical staff.

The problem intensifies, as a recent study published in the British Medical Journal states that 54% of health professionals in India — including doctors, nurses, paramedics, and midwives — do not have proper qualifications, while 20% of adequately qualified doctors are not part of the current workforce. Of the currently working health professionals, around 25% do not possess the necessary qualifications as laid down by professional councils. The scarcity of trained doctors has led to the emergence of untrained medical practitioners. It is estimated that these unlicensed practitioners in the country outnumber qualified medical doctors by at least 10:1.

Low Government Expenditure:

Despite being the 4TH largest economy in the world, India’s general expenditure on the health care sector is generally low. India’s total healthcare spending (out-of-pocket and public), at 3.6% of GDP, as per OECD, is way lower than that of other countries. The average for OECD countries in 2018 was 8.8% of GDP. Developed nations — the US (16.9%), Germany, France and Japan — spend even more. Compounding this problem of poor health infrastructure and low spending, is India’s dependence on imports for medical devices. India imports 80% of its medical devices and remains highly dependent on imports for higher-end products that include cancer diagnostics, medical imaging, ultrasonic scans and PCR technologies. This is especially problematic in the current scenario that has caused significant disruptions to global supply chains. Budget 2021 has also failed to address the problem of low government expenditure as the allocation of funds to India’s health ministry has only increased by 10.16% from Rs 67,112 crores in 2020–2021 to Rs 73, 931.77 crores in 2021–2022. Furthermore, there were no attempts to decrease the import duty on medical devices which would have reduced the cost of healthcare service for the citizens.

Affordability of the Healthcare sector:

Apart from the availability of medical resources, the affordability of medical services is also a great concern. In India, out-of-pocket expenditure (OOP) payments form a disproportionately large component of total health expenditure. It has been estimated that 80% of total health expenditure and 97% of private health expenditure is born through OOP payments. In the absence of financial risk protection, the high OOP expenditure affects the poorer population adversely as the poorest rural quartile spends 87% of the OOP expenditure on medicine, while the same for the richest urban quartile is comparatively down at 65%.

Impact of Covid-19 on the Healthcare sector:

Nationwide lockdown and re-routing of resources towards the curtailment of COVID-19, has caused a severe disruption of non-COVID essential health services that are indispensable towards maintaining progress in health indicators. In March alone, there has been a disturbing drop in maternal health services, with a significant decrease in attended skilled home delivery and institutional delivery. The outpatient treatment of major non-communicable diseases such as oncology and heart ailments fell by 64% and 51.8% respectively. A large number of children have missed out on vaccination since the pandemic began. This is a disturbing trend in India, as the leading causes of child mortality can be attributed to diseases such as pneumonia and diarrhea, which can be prevented by vaccination. This stresses the need for the prevention and management of child health protection.

Solutions:

Given the resource constraints of both the Central and State governments, it is clear that government hospitals alone will not be able to manage the fallout. There is a need to involve the private sector as well. However, the affordability and quality of the health care services by the private health care sector due to increase in untrained medical practitioners is a great concern.

1. To increase the capacity of private hospitals, additional strategies such as the use of financial incentives to ensure adherence to treatment protocols per national programmatic guidelines can also be implemented. This is similar to the National Strategic Plan for TB Elimination (2017–2025), which talks about providing the private sector TB care providers monetary incentives to promote TB case notification.
2. Capacity building of the informal health professionals is possible though proper skill-based training and thereby mainstream them as mid-level service providers. The concept of mid-level service providers as put forward by the National Health Policy (NHP) (2017) aims at developing a cadre of frontline health workers in the community who are not doctors but who can be trained through competency-based short courses and equip them with skills to provide services at the sub-centre and other underserved areas.
3. Attempts must be made to reduce the increasing OOP payments. Three different payment methods, i.e., (a) Flexible Fee Schedule (FLFS), (b) Fixed Fee Schedule, and © Fee Sharing System are prevalent in the urban private hospital sector. But these methods, by capping or fixing the fees, reduce the incentive for the private service provider to provide their services. A more effective way to reduce the OOP expenditure would be a voucher system wherein the customer holding the voucher gets the required treatment and the service provider is later reimbursed by the government.
4. With the virus completely transforming the way we approach different activities, like washing hands and social distancing are becoming social norms, promoting teleconsultation can go a long way in reducing the burden of the health care sector. Given the poor availability of resources in the healthcare sector, telemedicine is expected to become a viable business proposition. Regulatory guidelines have already been issued by the Ministry of Health and Family Affairs and NITI Aayog to promote telemedicine in India. Odisha has been the first state to offer teleconsultation.
5. Finally, formulation of standards similar to the Indian Public Health Standards (IPHS) for the private health sector will help in maintaining the quality of care. This would ensure uniformity of treatment protocols, thereby preventing unnecessary OOP, antimicrobial resistance, and unnecessary referrals causing a delay in treatment initiation and thus achieve the ultimate target of universal health coverage for the millions of citizens of India in near future.

It is the need of the hour to ensure that this pandemic doesn’t dent the goal of health for all. Despite all the problems, the response to this pandemic provides us with an opportunity to bring about structural change in our health care policy, with less reliance on imports for medical devices and promoting greater technology use in the health care sector.

About The Author

Samarth is currently pursuing Masters in Economics from IIFT delhi. He is an eco nerd with an inclination towards Public Policy and Politics.