A POLICY FRAMEWORK FOR REFORMS IN
HEALTH CARE
3. PERSPECTIVES ON HEALTH CARE IN INDIA
3.1 Basic Indicators of Health
India has multiplicity of treatment regimes. These range from the
allopathic system to traditional healing and home remedies. The advantage of
standardisation, packing and storage, documentation and different methods of dispensation
has ensured that allopathic system is more acceptable.
Quality of life in relation to health can be gauged by morbidity
information. NCAER’s study reveals that the short duration morbidity prevalence rate
(diarrhea, cough and cold, unspecified fevers) is 122 per 1000 population. The prevalence
rate of major morbidity (epilepsy, heart disease, hypertension, tuberculosis, diabetes,
mental disorders and leprosy) is found to be 46 per 1000 population.
Short term morbidity and major morbidity are disproportionately high
among the vulnerable population groups including wage earners and those with low levels of
income. About 20 per 1000 children in the 0-4 age group and 29 per 1000 population in the
5-12 age group suffer from physical disabilities such as bitot spot, visual impairment,
hearing impairment, speech impairment and locomotor disability.
Almost 80 % of the diseases in India are water borne or are caused by
water bodies – cholera, diarrhoea, typhoid, hepatitis A, malaria and filaria. It is
primarily the poor who are most affected. About half of all villages in India do not have
any source of protected drinking water. Clearly, quality of life from a health stand point
is far from satisfactory.
3.2 Guiding Principles of Health Care by Bhore Committee, 1946
In 1946, the Bhore Committee established the guiding principles for
provision of health care to the citizens of India. They are:
That no individual should fail to secure adequate medical care because
of inability to pay for it.
The health programme, must, from the very beginning, lay special
emphasis on preventive work with consequential development of environmental hygiene.
The health services should be placed as close to the people as possible
in order to ensure the maximum benefit to the communities to be served.
The doctor – the leader of the health team should be a social
physician, who should combine remedial and preventive measures as to confer the maximum
benefit on the community and the future doctors should be trained to equip them for all
such duties.
3.3 Health for All
In Alma Ata (in the erstwhile USSR), a global initiative towards
health-related research and action was held in 1978. All the participants, including
India, affirmed to ensure health for all by the year 2000, with primary health care as
their top priority. However, after 22 years, we are far off from achieving this goal.
3.4 Status of Health Care in India
India has worked continuously to improve its health care system in
the last several decades, and considerable progress has been made in expanding the public
health system and reducing the burden of disease. Other notable achievements include the
establishment of an extensive network of Government health care facilities both in the
rural and the urban areas and determined efforts to upgrade the skills of health care
workers, particularly in rural areas.
In just over five decades, life expectancy in India has doubled, and
the infant mortality rate halved. However, during the same period India’s birth rate
has declined by only 25%.
Nevertheless, its performance requires much improvement in comparison
with other emerging economies, including most comparable nations in the region.
Deficiencies persist with respect to access, affordability, efficiency, quality and
effectiveness, despite the high level of overall private and public expenditure on health.
3.5 Performance on Selected Health Indicators
India’s life expectancy was
49.1 years in 1970. This has increased to 62.6 years by 1997. The infant mortality rate
(per 1000 live births) has decreased from 130 in 1970 to 71 in 1997. The details of the
health indicators are presented in Table 3.1.
3.6 Trends for Demand in Health Care
The burden of disease is the cost a society bears - measured in death
and disability - from illness and disease. The health care system must anticipate and
respond to this changing burden of disease, ideally through preventive as well as curative
measures.
The demand for health care will be driven primarily by demographic
changes and changes in epidemiological profile.
India’s population is currently around one billion and is still
experiencing high population growth rates, at 1.3% per annum, which is high compared to
most emerging nations. Moreover, there is expected to be a significant change in the
demographic profile.
Typically, in low income countries, the greatest burden of disease
typically results from communicable disease (respiratory illness, measles), malnutrition
and complications of pregnancy and childbirth. In higher income countries, the burden of
disease is greatest from non-communicable conditions - heart disease, cancer, and
accidents. Developing countries typically experience an epidemiological transition from a
communicable disease profile to one characterised by non-communicable diseases on their
path to economic development.
The worst possible scenario is a partial transition wherein a large
part of society makes the transition and begins requiring costly hospital treatment for
chronic illness. On the other hand, the very significant balance remains mired in an
earlier (communicable) disease profile. India is currently in this stage.
3.7 India’s Agenda for Health Care
It is imperative that India avoids merely investing in health care that
addresses diseases of development. In order to accelerate economic development and prepare
for an inevitable surge in health care demand and costs, India must complete its current
primary health care and safe motherhood agenda, in order to afford the future demand of
health care.
On the other hand diseases of development, including life-style diseases are on the
rise in India. The country’s health care system must deal with a rising prevalence of
non-communicable diseases, such as cardiovascular diseases and cancer.
3.8 Major Challenges for Health Care
India faces a formidable challenge in providing health care
services to its people for several reasons. There is still an unfinished agenda in India
for addressing childhood and maternal morbidity and mortality, and communicable diseases.
These health problems are largely preventable.
The World Development Report (1993) calculated the leading causes of
Disability Adjusted Life Years (DALYs - a measure of death and disability caused by poor
health) lost annually in India. The leading causes were maternal and prenatal causes (35
million DALYs), respiratory infections (33 million DALYs), diarrhea diseases (28 million
DALYs) and tuberculosis (11 million DALYs). In addition, the risk of infection from
communicable diseases, such as malaria and leprosy, remain high. Health problems of
mothers and children, and communicable diseases, take a heavy toll on individuals and on
society as a whole.
The leading causes of DALYs is presented in Table 3.2.
3.9 The Changing Disease Profile
A large number of Indians still
suffer from a crushing burden of infection, maternal mortality, under-nutrition and
premature death. Certain other sections of population suffer from non-communicable and
life-style diseases such as cancer and cardio-vascular illnesses.
Communicable diseases still dominate in rural
India
As evidenced by a study conducted in four States (Andhra Pradesh,
Karnataka, Punjab and West Bengal) the burden of communicable diseases in rural areas is
significantly higher when compared to urban areas. The details of the DALYs lost per
thousand population in these four states is presented in Exhibit 3.1.
Tuberculosis
Tuberculosis remains one of the leading causes of disease and death in
India, in spite of a National TB Program (NTP) being in place for over 30 years. The low
impact of NTP is largely due to a low awareness about the disease and its treatment.
Other diseases are coming to the fore
In addition, to the above diseases, several others are increasingly
having a larger impact on the disease profile of the nation.
Tobacco is a costly health hazard worldwide, and is a major factor
underlying illness and disability in India. Globally, tobacco use is the single most
important preventable cause of premature death. Tobacco causes cancer, heart disease, lung
diseases, skin diseases, and increases complications in hypertensive and diabetic
patients. It is estimated that by 2020 tobacco will cause 13.3% of all deaths globally.
Tobacco is a major cause of morbidity and mortality in India, and is
very widely used - 70% of all adults and 12% of children use tobacco. Failure to reduce
the use of tobacco already imposes a serious cost, and will in future consume considerable
health care funds.
The other major illness is AIDS. This is likely to be a leading cause
of mortality and morbidity in India in the future. AIDS has been growing at exponential
rates since it was first reported. There are an estimated 2 to 5 million people infected
with HIV in India today. The prevalence of HIV infection has been on the rise in
practically all states and all population groups in India. The disease is spreading as
rapidly in rural India as it is in urban areas.
In addition, new health problems such as drug resistant forms of
several communicable diseases have emerged, including malaria and tuberculosis (TB).
3.10 Higher Life Expectancy’s Impact on Health Care
Improvement in key health indicators has brought new challenges for the
Indian health care system. Gradual improvements in crude birth and death rates have
increased life expectancy. The number of people aged 60 years and older is growing
rapidly, and the middle aged population (people 35-59 years old), who are growing most
rapidly, will soon begin moving into old age. This will lead to continuous growth of the
population aged 60 and above. People in middle and older age groups typically have longer
illness episodes, and as they age, begin to have several long-term or chronic conditions,
with corresponding costs. Typically, people aged 65 and above use 3.5 times the health
care, the cost per episode is higher, and their use of pharmaceuticals is 2.5 times higher
than the average. They are the main users of health care, and therefore their growth will
increase both health care demand and costs.
3.11 Impact of Economic Development on Health Care
India is currently undergoing a
socio-demographic shift - although the majority of India’s population falls into the
lower class/lower middle class brackets, the fastest growing segments are the upper middle
and upper classes. These groups will place growing demands on the health care system
because their expectations are higher and they can forcefully articulate their desires.
3.12 Other Determinants of Demand for Health Care
Health care is only one contributor to the health status of the
population. Development of health is a holistic process and is closely linked and
dependant on certain other factors, such as poverty, literacy and educational levels,
nutritional status (especially in childhood and pregnancy), sanitation and environmental
hygiene.
Poverty
Poverty is correlated with poor health and the need for increased
health care. Between 1978 and 1988 the population below the poverty line is estimated to
have decreased both in absolute numbers (307 million to 238 million) and also in
percentage terms (48.3 % to 29.9%).
The prevalence of poverty continues to be more pronounced in rural
areas than in urban areas. The bulk of the rural poor are landless agricultural laborers,
small and marginal farmers and non-agricultural households without landholdings including
poor artisans who are progressively losing their traditional occupations. The urban poor
is in large part an outflow of the rural poor into urban areas.
Literacy
Low literacy is closely related to poverty and disease, as seen in many
Indian States. Despite ongoing initiatives, India compares poorly to other similar nations
in literacy and education. In 1997 only about 62 % of people in India could read and write
with understanding.
Nutrition
Nutritional deficiency is a major cause of poor health and need for
health care. According to the National Nutrition Monitoring Bureau the per capita
availability of nutrients has been declining. Due to poor income levels, the average
dietary income intake in India is 2280 calories, which is less than the minimum dietary
intake required and recommended (2400 per capita per day).
Due to the lack of food and nutritional security for the poor, about
30% of all infants born in India are born weighing less than 2.5 kg., which is the WHO
cut-off level to determine low birth weight with a lower chance of survival.
Sanitation
Despite investments made annually in this area, poor sanitation
persists throughout India, and is a major contributor to morbidity and demand for health
care. Facilities for drainage, sewage and solid waste management are inadequate in urban
areas and almost non-existent in rural areas.
Water supply
Although over 90% of the Indian population have community water supply
facilities, health benefits have not been commensurate with the investments made. Water
sources are often polluted due to a variety of factors. Consequently water-borne diseases
are a major contributing factor to morbidity, mortality and health care need.
Housing
More than 25 % of Indian families live in houses made of grass and mud.
The proportion of such households is even higher (one third) in rural areas. A comparison
of housing in urban and rural areas over the last 10 years suggests that while the
proportion of brick and mortar houses has increased over time, the provision of basic
services has not improved. For example, in 1991, only 42% of Indian households had
electricity, 62% had safe drinking water and 24% had toilet facilities. Poor living
conditions drive up health care demand because they foster the spread of preventable
communicable illnesses - respiratory conditions (including tuberculosis), diarrheal
disease and other diseases spread by poor hygiene and close contact.
Quality of household fuels
There is a large number of ailments associated with poor quality of
household fuels. This is especially true of the rural population. Though several efforts
have been made to improve the availability of quality fuels and reducing the pollutant
content in the fuels, India has a long road to traverse in this direction.
3.13 Government’s Role in Health
Care
In India, Government health services follow a traditional model of
health funding and provision. The Government is both the financier and the provider of the
public health care facilities. The State Governments determine health allocations
according to their policies and budgets.
The states spend more than 80 %
of the total expenditure on curative cure. The Central Government spends more than 70% of
the total expenditure on preventive and promotive health care.
The traditional model however has its limitations as it does not
provide sufficient incentives for efficiency and innovation. The performance of states in
health care innovation has varied, with some states showing more initiatives than others
in devising new delivery and funding models.
The private sector health care delivery system is largely fragmented
and uncontrolled, with larger private facilities concentrated mainly in urban areas and
single practitioners dominant in rural areas.
3.14 Government Spending on Health Care
India’s overall health spending as a percentage of GDP (5.6%) is
substantially high when compared to other developing nations. However, Government’s
stake in health care spending is comparatively low – less than 25% of total health
care spending. As a percentage of GDP, India’s public expenditure on health is about
1.2% of GDP as compared to an average of 2.2% of GDP in other developing nations.
When compared to other emerging economies, India performs poorly on
most health indicators even though it spends a fair amount on health care. With a per
capita health spend that is almost 50% less than that in India, China compares well on key
health indicators.
3.15 Individual Spending on Health Care
More than 75 % of the health
care spending in India is done by individuals. This results in a very high burden of
costs for most segments of the population. According to NCAER estimates, the direct annual
expenditure on health works to about 3.4 % of the total income. The total expenditure
including travel and diet for health care works out to over 4.5 %. The household
expenditure on health care ranges between 2% and 8% of monthly household. The comparison
of the spending on health care by rural and urban areas under different income groups is
presented in Table 3.4.
3.16 Insurance Schemes
In addition, India has introduced very few financing options for
meeting health care needs compared with other emerging economies in Asia. Private health
insurance in India has very low penetration with only about 3 million policies. Social
insurance schemes available in India, such as the Employee State insurance Scheme (ESIS)
and Central Government Health Scheme (CGHS) have restricted coverage to a very small
segment of the population, around 3%.
A recent study of spending patterns on health care by NCAER states:
"Of the total estimated hospitalisation days of public services
consumed during 1995-96, the richest 20% of the population accounted for 38.6%, whereas
the bottom 20% accounted for only about 6.6%. Moreover, the bias in access to public
services appears to be more marked for the utilisation of hospital beds in the public
sector than for consultation visits. Thus the top 20% of the population accounted for
24.2% of all treated episodes at public facilities, and the poorest 20% an estimate
15.2%."
In essence, the rich benefit more from Government health subsidies
through their higher use of hospital beds, which are significantly more expensive than
out-patient consultations.
3.17 Rural-
urban Disparity in Spending
The composition of the total health spending varies greatly the rural
and urban areas. The per capita expenditure on non-hospitalised illness in the rural
household is Rs.90.48 and in the urban household it is Rs.113.93. The per capita
expenditure for hospitalised illness for the rural household is Rs.1044.49 and in the
urban household is Rs.1196.87.
People in the rural areas have poor access to health care services. As
a result a substantial portion of the total expenditure incurred on health by the rural
population is incurred on incidental expenses such as transportation and bribes, which do
not directly contribute to any health gains.
The details of the expenditure and the distances to be traveled for
treatment are presented in Table 3.5.
3.18 Availability of Hospital Beds
India lags behind
in the availability of hospital beds compared with most other emerging economies. However
this may not be as serious an issue as the urban-rural distribution of hospitals beds. As
India begins to adopt more efficient hospital management practices, patients’ length
of stay in hospital will decline rapidly, and many conditions will be treated on an
ambulatory basis. However, accessibility of services is likely to remain a problem in
rural areas for some time to come, unless urgent measures are taken to correct this
imbalance.
India has one bed for every 1489
people for a total of 6,90,000 beds. 74 % of these are owned by the Government.
3.19 Rural-urban Disparity in Infrastructure
There is a wide disparity between urban and rural areas in the
distribution of physical infrastructure and human capital. The gap is more pronounced in
States in which the population is geographically dispersed. 84 % percent of
hospitals in India are situated in urban areas, which only account for approximately 35%
of the population. The details of the hospital beds in the rural and urban areas in nine
selected states is given in Table 3.6.
Though the number of trained doctors and nurses have gradually been
increasing over the past two decades, there exists a large disparity in their availability
between the urban and the rural areas.
75 % of allopathic doctors are located in urban areas. In Maharashtra
State, 60% are located in Mumbai, which contains only 11% of the state’s population.
The maldistribution of medical professionals, with few willing to work in rural areas , is
at the heart of the poor health care access of rural areas. The details of the doctors in
rural and urban areas for a select nine states is presented in Table 3.8.
3.20 Skew in Public Spending
The public health system is characterised by an almost exclusively
curative urban sector and a rural sector focussed on both promotion and prevention. Public
health investment is concentrated in expensive, curative medical facilities and
professionals in cities on the one hand; and doctors and paramedical personnel based in
Primary Health Centres in rural areas.
Government-funded primary health care facilities in rural areas are
under-utilised, while public hospitals in regional centers and cities are crowded and used
inappropriately by those whose needs could be met in more basic health centers. The
referral system between the primary and secondary medical care system does not operate
effectively to ensure that patients seek care at the appropriate levels of the system.
3.21 Private Spending in Health Care
The health
care provision by private providers largely comprises of small independent facilities and
providers and is largely urban centric. Private health care facilities have grown in a
fragmented manner with services being delivered from a vast number of small dispensaries
and nursing homes and hospitals, with average number of beds being less than 20. Many
small, unregistered private facilities operate unobtrusively in areas in which they can
obtain water and electricity at domestic/lower rates.
Delivery of health care by private providers appears to cost less than
delivery by the public sector. The higher per episode costs in the public sector could be
due to systemic inefficiencies. As per a study by Voluntary Health Association of India,
the total cost of treatment by the public system is Rs.2501 and through the private system
is only Rs.1994. However, it must be noted that the total cash cost to the patient in the
public system is almost 50 % of the cost in the private system.
3.22 Service Delivery Mechanism
Hospitals are built assuming long in-patient stays often extending
through the various stages of an illness episode - diagnosis, treatment, and
rehabilitation - with long lapses of time between activities. This model has long been
superseded in many countries by shorter, discrete periods of ambulatory and in-patient
treatment.
While extended lengths of stay may suit rural patients who travel long
distances to urban specialty hospitals, long lengths of stay utilise facilities
inefficiently, inflate costs and easily lead to hospital-induced infections and
complications. A high percentage of time spent in hospitals may be unnecessary and even
undesirable.
This service delivery model leads to unnecessary over-capitalisation of
physical infrastructure.
3.23 Free Health Care Implementation
Free health care essentially meant for lower income strata is utilised
by all income groups. Government lacks an effective administrative mechanism to monitor
dispensing of free medical services to the needy population or to collect user charges
from those who can afford to pay. As a result services are utilised disproportionately by
wealthier patients.
In an analysis of health care use in five Indian states, patients from
higher income brackets often receive hospitalisation free of charge. Between approximately
one-quarter and more than two-thirds of these wealthier patients paid nothing for their
hospital bed-stay, regardless of whether they were treated in urban or rural hospitals.
3.24 Utilisation of Health Care Based on Income
The wealthier segments of the society are receiving more treatment
by the current health care system – both private and public. A comparison of Average
Lengths of Stay (ALOS) in different types of health care facilities for maternity delivery
shows clear differences among socio-economic groups. Without exception the wealthiest
groups tend to stay longer than those in the two bottom quintiles - reflecting the much
higher health care consumption by wealthier groups.
The wealthier the patient, the more health care they consume while in
hospital, regardless of the type of hospital. Wealthier groups receive more treatment, or
at least more expensive treatment, when they are hospitalised. The most marked
differentials occur, not only in private hospitals as expected, but also in public
hospitals - which are meant primarily to be serving the poor. In fact, data shows that
wealthier groups are receiving more treatment (or at least more costly treatment) in
public hospitals.
3.25 Indigenous Systems of Medicines (ISM)
India’s vast numbers of ISM practitioners, many of whom have
formal training, are not being utilised effectively to provide low cost medical services,
especially in rural areas. Some states have given ISM personnel training in primary health
care, but this approach could be used much more extensively to compensate for deficits,
especially in Government primary health care services.
Of the total Government’s health spending, less than five percent
is spent on ISM in India, whereas China which also has a rich tradition of traditional
medicines spends more than 10% of its total health spend on the same. At the State level,
the proportion allocated to ISM ranges from about 1% in West Bengal to 13% in Kerala. The
average spending on ISM is around 2% of the health budget.
India has more than 600,000 registered medical practitioners in the
various systems of traditional medicine. However, most ISM practitioners practice a mixed
form of medicine. The current policies towards ISM and its application are fragmented and
effective standards, norms and guidelines for its use do not yet exist.
3.26 Human Capital
The skew of health care personnel availability is a major issue, but
there are other equally important constraints in India’s health care system. The
continued reliance on medically trained personnel (doctors) as the backbone of the health
care system is impractical, and alternatives will be required, especially for rural areas.
The dependence on doctors rather than nurses - the inverse of the
health personnel structure of modern health care systems - will retard the development of
contemporary hospitals. Well-trained and skilled nurses, with advanced managerial and
decision-making abilities, are necessary for an appropriate division of labour and high
levels of patient care in hospitals
National institutions and policy bodies do not effectively cover the
range of health issues, research and policy needed to stimulate development of
India’s huge and diverse health care system.
3.27 Regulatory Mechanism
Three broad categories of regulations cover health care:
drug-related regulations, practice-related regulations and facility-related regulations.
All are not uniformly applicable throughout the country e.g. the Nursing Home Regulation
Act is applicable only in certain places like Mumbai, Delhi etc.
3.28 Accreditation
Accreditation or quality certificates covering service safety,
quality, and efficacy (ISO standards, accreditation) is optional. Consumer protection
legislation has not been developed specifically for health care, which is the norm in most
developed countries. There is no routine monitoring of health care facilities, and in
general, regulations, including practice-related regulations, are seldom enforced.
There is no requirement for Indian health services or facilities to be
accredited or certified for quality (e.g., accreditation or certification). That is,
hospitals, nursing homes and clinics have no obligation to establish that they adhere to
basic quality norms and standards.
However, interest in formal accreditation and quality systems has been
growing in India over the past two years, and some major hospitals have obtained quality
certification.
3.29 Use of Technology
There is no distinct Government
policy in India governing the purchase, operation and application of health technology.
The import and export of health equipment has been governed by India’s industrial
policy and reflects similar economic and profit oriented concerns. These regulations,
while appropriate for other sectors, do not address the peculiarities of health care, in
particular the well-established pattern that technology availability fuels demand for its
use.
3.30 Quality Issues
The
performance of the health facilities of the government is neither benchmarked (against each other or to similar services in the private sector) nor
are they rewarded for exceeding performance targets. Mechanisms used elsewhere to
produce greater efficiency, accountability, and more responsible governance in hospitals
are not yet employed in India.
The quality of medical services currently being offered by the private
sector is uneven and unmonitored. Few health care facilities in India have formal quality
assurance systems. There is an urgent need to monitor the clinical effectiveness and
quality of services offered at both public and private facilities.
Many of the quality problems in Indian health care are very basic:
Regulations requiring evidence of quality
standards are not comprehensive and rarely enforced.
Few services are delivered in a patient-focussed way.
The application of advanced technology is not governed by a relevant
and effective system of norms and standards.
Consumer knowledge about health and health care is very poor, and
consumers generally do not have high expectations of service and quality.
Overall awareness of health and illness and its appropriate treatment
is low.
Consumerism has not reached health and health care in India.
3.31 Government Insurance Schemes
The Employees State Insurance Scheme (ESIS) operates as an
independent organisation, covering 7 million employees, a total of 27.3 million
beneficiaries, and operates 145 of its own hospitals and 1266 dispensaries. It employs
5082 doctors.
The Central Government Health Scheme (CGHS) is run by the Ministry of
Health and Welfare and covers 3.5 million beneficiaries.
Other Central Government departments and others agencies operate
independent health systems that do not coordinate amongst themselves: railways, defense,
post and telecommunications, etc. However, there is no coordination between these
agencies, which could lead to potential economies of scale.
3.32 Pressure on Primary Health Workers
Separate country-wide vertical
programmes for the prevention and eradication of communicable diseases were progressively
established to combat the main health problems in India. These programmes addressed
smallpox, malaria, tuberculosis, leprosy, filariasis, trachoma and cholera. Subsequently
nutrition deficiency disorders such as goitre and some non-communicable diseases such as
mental health was also brought under these programmes. The existence of separate chains of
command, converging on primary health workers, constrains the impact of these programs,
and undermines organisational commitment.
3.33
Inter-sectoral Linkages
Factors affecting health and the
use of health care are rooted in sectors other than health, and therefore inter-sectoral
linkages, especially in promotive and preventive services, require appropriate levels of
investment in effective strategies. The inter-sectoral linkages are poor.
In addition to the longstanding inter-sectoral issues affecting health
and health care, new issues are emerging. For example, road trauma and accidents are
increasingly important reasons for health care utilisation. Yet effective strategies and
program funding, to prevent road accidents, and to promote safety at work, are at a
rudimentary stage.
3.34 Marketing Indian Health Services Abroad
Research and development in low-cost medicines and bio-medical
technology are logical new commercial activities for India’s health industry. These
activities, coupled with comparatively low-cost treatment of overseas patients, would
contribute to the development of the health sector as a growth industry, and contribute to
India’s economic development. However, there are as yet no effective Government
policies and incentives for investment in these activities.
3.35 Social Taboos
There is a large-scale belief in superstitions both in the rural and urban areas.
However, it is prevalent more in the rural areas. Though Governments have taken concerted
efforts in health care education, the impact of this is far from the desired levels.
3.36 Summary
While the overall level of funding allocated for health care on a
national basis is comparatively high (5.7% of GDP)
Government’s funding for health care (1.7% of GDP) is low compared
to other emerging nations
Adequate health care is unaffordable for the vast majority of
India’s population
Moreover, funding for health care is largely individual, rather than
collective: there are few effective financing mechanisms like insurance
Current funding is being used sub-optimally and is not directed to
maximising health gain
Significant disparities exist between urban and rural areas; between
different States; and between poorer and wealthier segments of the population
The current structure of the health care delivery system, specially
public, does not provide enough incentives for improvement in efficiency
There are stark deficiencies in health care quality and regulation is
weak and is seldom enforced.
Table 3.1
HEALTH INDICATORS OF INDIA –1997
Parameter |
Value |
Infant
mortality rate (per 000) |
72 |
Life
expectancy – males |
62 years |
Life
expectancy – females |
63 years |
Total
fertility rate (per 000) |
3.1 |
Maternal
mortality ratio (per 00,000) |
570 |
Malnutrition
(< 5 years) |
52 % |
Health
expenditure (1995 figures as a % of GDP) |
5.6 % |
Table 3.2
IMPROVEMENTS IN INDIA’S BASIC INDICATORS SINCE 1951
Year |
Crude birth
rate (per 000) |
Crude death
rate (per 000) |
Infant
mortality rate (per 000) |
Life
expectancy (years) |
1951 |
39.9 |
27.4 |
146 |
32.1 |
1961 |
41.2 |
19.0 |
129 |
41.2 |
1971 |
36.9 |
14.9 |
129 |
45.0 |
1976 |
34.5 |
15.0 |
115 |
49.5 |
1981 |
33.9 |
12.5 |
110 |
54.4 |
1987 |
32.1 |
10.8 |
95 |
56.0 |
1990 |
30.2 |
9.7 |
80 |
58.2 |
1994 |
29.0 |
12.0 |
72 |
61.3 |
Source : Health Care in India, Foundation for research in community
health, 1997
Table 3.3
LEADING CAUSES OF DEATH, COMMUNICABLE AND NON-COMMUNICABLE
DISEASES - INDIA
Causes of
death |
Number of
deaths (000) |
Percentage |
Communicable |
4059.7 |
43.3 |
Infectious and
parasitic |
2188.4 |
23.4 |
Respiratory
infections |
1096.1 |
11.7 |
Maternal
causes |
129.4 |
1.4 |
Prenatal
causes |
645.9 |
6.9 |
Non-communicable |
4700 |
50.2 |
Malignant
neoplasm |
775.8 |
8.3 |
Diabetes |
144.5 |
1.5 |
Nutritional
endocrine |
187.5 |
2.0 |
Neuro-psychiatric |
178.9 |
1.9 |
Cardiovascular
diseases |
2385.9 |
25.5 |
Respiratory |
272.4 |
2.9 |
Digestive |
353.3 |
3.8 |
Genito-urinary |
144.5 |
1.5 |
Musculo-skeletal |
24.4 |
0.3 |
Congenital |
181.3 |
1.9 |
Injuries |
611.3 |
6.5 |
Unintentional |
506.6 |
5.4 |
Intentional |
104.7 |
1.1 |
Total |
9371 |
100 |
Source : Health Care in India,
Foundation for research in community health, 1997
Exhibit 3.1
DALYS lost per '000 population by major cause groups
Source : New Directions in Health Sector Development, World Bank 1997
Table 3.4
AVERAGE EXPENDITURE ON HEALTH AMONGST VARIOUS INCOME GROUPS
Household
income group (Rs./annum) |
Average
annual household income (Rs./annum) |
Average
annual household health expenditure (Rs.) |
Expenditure
as a % of income |
Per capita
annual expenditure on health (Rs.) |
Rural |
18716 |
988.4 |
5.28 |
183.87 |
<18000 |
10946 |
855.84 |
7.82 |
167.81 |
18000-54000 |
29033 |
1195.44 |
4.12 |
206.36 |
> 54000 |
76039 |
1722.33 |
2.27 |
246.10 |
Urban |
30184 |
1294.09 |
4.29 |
257.64 |
<18000 |
12832 |
908.18 |
7.08 |
194.58 |
18000-54000 |
32147 |
1352.33 |
4.21 |
262.66 |
> 54000 |
78504 |
2313.20 |
2.95 |
406.81 |
Overall |
21931 |
1074.1 |
4.9 |
203.56 |
<18000 |
11303 |
865.75 |
7.66 |
172.53 |
18000-54000 |
30233 |
1255.93 |
4.15 |
226.51 |
> 54000 |
77431 |
2055.84 |
2.66 |
328.53 |
Source : Household survey of healthcare utilisation and expenditure,
NCAER 1995
Table 3.5
BREAKDOWN OF HEALTH CARE EXPENDITURE, RURAL AND URBAN HOUSEHOLDS PER
EPISODE
| |
Fees and
medicine |
Surgery |
Hospitalisation |
Clinical tests |
Diet |
Rituals |
Transport |
Misc. exp. |
Total expenses |
Non-hospitalised
illness |
|
|
|
|
|
|
|
|
Rural (Rs.) |
64.51 |
|
|
3.95 |
7.34 |
0.80 |
13.10 |
0.77 |
90.48 |
Rural (%) |
71.3 |
|
|
4.4 |
8.1 |
0.9 |
14.5 |
0.9 |
100.0 |
Urban (Rs.) |
88.42 |
|
|
7.89 |
9.31 |
0.56 |
7.42 |
0.31 |
113.93 |
Urban (%) |
77.6 |
|
|
6.9 |
8.2 |
0.5 |
6.5 |
0.3 |
100.0 |
Hospitalised
illness |
|
|
|
|
|
|
|
|
Rural (Rs.) |
539.97 |
89.73 |
43.49 |
152.85 |
79.4 |
1.11 |
125.93 |
12.02 |
1044.49 |
Rural (%) |
51.7 |
8.6 |
4.2 |
14.6 |
7.6 |
0.1 |
12.1 |
1.2 |
100.0 |
Urban (Rs.) |
602.81 |
106.45 |
93.22 |
251.57 |
72.38 |
3.84 |
57.45 |
9.15 |
1196.87 |
Urban (%) |
50.4 |
8.9 |
7.8 |
21.0 |
6.0 |
0.3 |
4.8 |
0.8 |
100.0 |
Source : Household survey of healthcare utilisation and
expenditure, NCAER 1995
Table 3.6
AVERAGE DISTANCE TRAVELLED FOR SEEKING OUTPATIENT TREATMENT
(Distance in kilometres)
Type of
treatment |
Rural |
Urban |
Government
hospital |
10 |
3.1 |
PHC/CHC/Government/Municipal
dispensary |
3.6 |
1.9 |
ANM/MPHW/Anganwadi |
1.7 |
|
Private
hospital/nursing home |
12.6 |
2.9 |
Private
practitioner |
5.3 |
1.8 |
Medical shop |
1.8 |
0.4 |
Faith healer |
2.0 |
1.8 |
All |
5.9 |
2.2 |
Source: Health Expenditure Patterns in
selected major States, article by
Ravi Duggal, 1995
Table 3.7
AVAILABILITY OF HOSPITAL BEDS IN RURAL AND URBAN AREAS OF
SELECT 9 STATES
(hospital beds per 100,000 population)
State |
Rural |
Urban |
Urban/Rural
Disparity (times) |
Andhra Pradesh |
9 |
203 |
23 |
Gujarat |
22 |
346 |
16 |
Kerala |
198 |
481 |
2 |
Madhya Pradesh |
4 |
145 |
36 |
Maharashtra |
21 |
308 |
15 |
Punjab |
68 |
233 |
3 |
Tamil Nadu |
12 |
237 |
20 |
West Bengal |
17 |
264 |
16 |
All India |
|
|
15 |
Source: Health Expenditure Patterns in
selected major States, article by Ravi Duggal, 1995
Table 3.8
AVAILABILITY OF DOCTORS IN RURAL AND URBAN AREAS OF
SELECT 9 STATES
(Doctors per 100,000 population)
State |
Rural |
Urban |
Urban/Rural
disparity (times) |
Andhra Pradesh |
13 |
144 |
11 |
Gujarat |
20 |
115 |
5 |
Kerala |
39 |
117 |
3 |
Madhya Pradesh |
3 |
55 |
18 |
Maharashtra |
24 |
117 |
5 |
Punjab |
76 |
260 |
3 |
Tamil Nadu |
18 |
202 |
11 |
West Bengal |
27 |
155 |
6 |
All India |
|
|
8 |
Source: Health Expenditure Patterns in selected major States, article by Ravi Duggal,
1995
|
