Das Taj Mahal in Agra ist das Wahrzeichen Indiens.

28.4.2014 | Von:
Dinesh C. Sharma

Shortage of Services and Medical Tourism

India's Health System

Patienten warten in einem Krankenhaus in Mumbai auf ihre Behandlung.Patienten warten in einem Krankenhaus in Mumbai auf ihre Behandlung. (© picture alliance / Frank May )

The health sector in Indian is a picture full of contradictions. The country has achieved remarkable progress such as becoming polio free in early 2014 and registering an increase in life expectancy from 62.3 to 67.3 years for men and from 63.9 to 69.9 years for women in a span of 15 years. Yet India's performance is very poor when it comes to malnutrition, child and maternal mortality. The country is also facing double burden of disease. On the one hand, malaria and tuberculosis continue to be major public health concerns, while on the other, lifestyle diseases like diabetes and heart disease are taking a heavy toll. Surprisingly, heart disease has emerged as the topmost cause of death among Indians.

As regards healthcare delivery, India has one of the most privatized health systems in the world. The cost of private healthcare is so high that an estimated 2 to 3 percent Indians are pushed below the poverty line every year solely due to health expenses. The government-run health system is weak. Rural areas lack doctors, nurses and health centres, whereas major Indian cities are home to five-star hospitals catering to medical tourists from the West.

Child and maternal health is a key indicator of progress

The status of child and maternal health is a key indicator of any nation's progress and this is where India's performance has been slower than required. The mortality rate of children below the age of 5 has declined from 125 per 1000 live births in 1990 to 52 in 2012. This is expected to fall to 49 by 2015, but this would still be much below the target of 42 to set under the Millennium Development Goals (MDG) framework of the United Nations.

Similarly, the infant mortality rate is 42 deaths per 1000 live births. It is likely to reach 40 deaths per 1000 live births by 2015, missing the MDG target of 27. India's maternal death rate – the number of women dying during childbirth – has dropped progressively from 437 to 178 per 100,000 live births between 1990 and 2011. Yet it is far below the target of 109 set under the MDG. In addition, there is a great variation among states with some of them like Uttar Pradesh reporting maternal mortality figures as high as 300 per 100,000 live births.

It is a worrisome situation because most the infant and maternal deaths occur due to preventable causes. This is a direct reflection of inadequacies in the government run health care system, mainly consisting of health care facilities at the primary, secondary and tertiary levels run by state governments. This system is supposed to provide free or very low cost medical services including child birth and vaccination. The central or federal government provides funds for a number of special schemes which are to be implemented by the states.

Shortage of doctors and nurses as well as inadequate infrastructure

The biggest problem of the government-run health system is the shortage of doctors, nurses and other healthcare workers as well as inadequate infrastructure. The health budget of the central government has gone up by 2.5 times during the Eleventh plan period from 2007 to 2012 when compared to the Tenth plan period from 2002 to 2007 – from 471 billion Rupees (5.6 billion Euros) to 1.2 trillion Rupees (14.2 billion Euros) for five years. Also the health spending of states increased from the Tenth to the Eleventh plan period and went up from Rupees 1.07 trillion Rupees (12,7 billion Euros) to 2.3 trillion Rupees (27.4 billion Euros).

Still the shortfall of primary health centres (PHC) and community health centres (CHC) is huge. For instance, access to safe abortions is not available in all CHC, which contributes to maternal mortality. At the end of 2012, the gap between the number of healthcare staff required and the number actually in position was 52 percent for midwives and nurses, 76 percent for doctors, 88 percent for specialists and 58 percent for pharmacists.

(Click HERE for official data on doctors and nurses presented to Indian Parliament in 2014) http://164.100.47.132/Annexture/lsq15/13/as528.htm EXTERNAL LINK

At the village level, part-time healthcare workers called Accredited Social Health Activists (ASHA) act as a bridge between people and public health system. They are supposed to motivate expectant mothers to go in for childbirth in hospitals (instead of homes), advise them on nutrition and help them in immunization of newborn babies. These workers also handle several other tasks. Currently there are over 900,000 such workers but they are grossly underpaid.

India produces about 50,000 medical graduates in allopathic system from nearly 380 medical colleges. In addition, a large number is trained in Indian systems of medicine such as Ayurveda and Unani. The distribution of medical colleges, however, is uneven, with more colleges located in the Southern and Western states. Few are situated in the North and the East where there is a shortage of medical personnel.

City-educated doctors and nurses are reluctant to serve in rural areas, complaining of lack of facilities and incentives. Many of them migrate to Western countries. Indian doctors constitute the largest number of foreign trained physicians in the United States (4.9 percent of the total number of physicians) and the United Kingdom (10.9 percent), the second largest in Australia (4 percent) and third largest in Canada (2.1 percent), according to one estimate. In order to meet shortage of healthcare workers in villages, the government has proposed a new cadre of community doctors – barefoot doctors – but the plan is being opposed by professional bodies of doctors which feel that it will boost quackery.

The most privatized healthcare systems in the world

The void created by the government health system, both in rural and urban areas, is being filled by private sector health services. The private healthcare system is extensive and covers the entire spectrum of services – individual doctors with their clinics in villages and cities, nursing homes and maternity hospitals run by doctors, mid-sized general hospitals and diagnostic centres in towns, specialty and tertiary care hospitals in cities. Most of the big hospitals are now run by companies and have presence in multiple locations within a city and across cities. Foreign direct investment (FDI) has been allowed in the hospital industry. In addition, foreign-owned clinics and treatment centres in specialties like fertility services have also been opened in several Indian cities.

This elaborate nature of private health system has made the Indian system of the most privatized health systems in the world. Out of the total health spending estimated at 4.1 percent of GDP, public health expenditure accounts for just 29 percent. This means the rest – 71 percent – is being spent by people from their own pockets (which public health experts refer to as 'out of pocket' health expenditure). The lack of proper public health system is forcing even the poor to purchase services from the private sector, resulting in heavy expenditure to them because currently private sector services are completely unregulated.

Even those who depend on public system incur out of pocket expenses, particularly to buy medicines as government hospitals don't stock all medicines. A bulk of the out of pocket expenditure goes to pay consultation fees, purchase of medicines and diagnostic tests – none of which are covered by health insurance. In any case, health insurance coverage in India is pretty low. According to a World bank study, just about 25 percent do have access to some form of health insurance including government-sponsored insurance schemes. All this means that despite both public and private systems being available, affordability of healthcare remains a major issue for majority of Indians.

Medical tourism – A lucrative line of business

Since the objective of corporate hospitals is to provide international class healthcare facilities, the focus is on profit and not affordability. In order to maximize revenues, these hospitals have entered another lucrative line of business – medical or health tourism. By hiring Indian doctors trained in the West and by obtaining international health accreditation, private hospitals have been able to offer their services to medical tourists from the West. Some of them offer facilities like five-star hotels, while others have tied up hospitality and tourism industry.

Affluent medical tourists come to India because of cost advantage and also because of long waiting lists for elective surgeries in government healthcare system in their own countries. The cost difference is simply enormous. For instance, a hip replacement surgery in India would cost 7000 US dollars (5075 Euros) compared to 50,000 US dollars (36,240 Euros) in the United States. A heart bypass would cost about 5000 US dollars (3624 Euros) compared to 100,000 US dollars (72480 Euros). Of late, many Europeans are coming to India for fertility services like surrogacy and other fertility related procedures – partly for cheap costs and partly to circumvent regulatory issues back home. The cost of fertility treatment in India is estimated to be one fourth compared to Western markets. Cosmetic surgery is another area that attracts medical tourists.

It has become big business. According to industry estimates, India gets about 250,000 medical tourists per year with an annual revenues of about 1 billion US dollars (726 million Euros). So while one can understand the motives of private sector to attract medical tourists, the very model of business and open government support to it raises ethical questions in the Indian context. On one hand, the government health system is suffering shortage of manpower, and on the other the government is promoting medical tourism activity which is designed to cater to the needs of foreign nationals.

Government support to medical tourism comes in various direct and indirect ways. Most corporate hospitals in medical tourism business are situated on lands given to them by the government at subsidized rates and they also benefit from other forms of subsidies. Doctors educated and trained in government system are often hired in these medical tourism facilities. The Ministry of Tourism spends public money to help private hospitals attract medical tourists through road shows, seminars and other promotional activities in many countries. The foreign ministry facilitates the business by issuing a special medical visa to medical tourists. Is it ethical for government agencies to support medical tourism in a situation when its own citizens are denied proper medical care for various reasons?

Universal Health Coverage: Equitable access to healthcare for every Indian

With a view to reform the healthcare system, the central government set up a high level expert group in 2011, which recommended that India adopt Universal Health Coverage (UHC) under which a minimum package of health services is to be offered by the state. The goal would be to provide equitable access to healthcare, irrespective of income levels.

The government accepted the recommendation and incorporated the idea of UHC in the Twelfth Five-Year Plan (2012 to 2017). After years of stagnation in public health spending, the government has reaffirmed the important role that the public system could play in providing healthcare. The plan has recognized the need for "substantial expansion and strengthening of the public sector healthcare system." The government feels that good quality and affordable healthcare is essential for the country, while the private sector could continue to operate for those who can afford it. It is felt that as supply in the public sector would increase, it will cause a shift towards public sector ending the dependence on high-cost private care among the poor.

The group has recommended that public expenditure on health should be enhanced from the current level of 1.2 percent of GDP to 2.5 percent by 2017 and to 3 percent by 2022. General taxation should be used as the principal source of healthcare financing, not levying sector specific taxes. Pilot projects have been initiated in some states to test the idea of UHC.

However, there is an apprehension in some quarters that in the absence of a strong public system the government eventually will be forced to rope in private sector to deliver the 'essential health package' under UHC. Till the public system is made robust, private providers may be asked to deliver services as determined by the government and get paid for it by the government. The private sector health system can't be ignored while working out any plan to revamp healthcare in India. The challenge is to devise ways of involving it in way that does not undermine principles of access and equity.

"The health challenge India faces is mammoth"

The state health system – facing manpower and infrastructure shortages – is also not geared to meet the new challenge of non-communicable diseases like diabetes, hypertension, heart disease and cancers which are all seen rising in rural areas also. The disease pattern in India is fast changing – with non-communicable diseases replacing infectious diseases as major killer, as reflected in findings of the Global Burden of Disease study published in 2013.

Since cost of drugs makes up a large chunk of healthcare costs, it may be worthwhile to ensure access to medicines through a number of ways such as promotion of essential and rational drugs, use of generic drugs and special procurement mechanism for government supplies. Public sector drug and vaccine manufacturers may be revived and allowed to play a greater role. The drug regulatory system needs to be strengthened and patients' rights protected while meeting obligations under the framework of the World Trade Organisation. The quality of medical education too needs to be improved, along with training of community healthcare workers to serve in rural areas. Standards should be developed and enforced for quality of care in both private and public sectors.

To ensure the success of UHC, the government will have to work on several fronts simultaneously. Any effort in the health sector would not be meaningful without addressing basic determinants of health such as safe drinking water, sanitation, nutrition and basic education. The health challenge India faces is indeed mammoth.

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