India has a population of 1.2 billion. The breakup of the population is as follows:
Against this population, India has a doctor-population ratio of 1:1700 against a world average of 1.5:1000. We are ranked 67th among the list of developing countries and a ratio of 1:1000 can only be achieved by 2031. However, India has the highest number of medical colleges in the world at 314.
The Government has set a goal of increasing public spend on health from 0.9 % of GDP (below the global average of 5.5% and the average of 2.8% for low and middle income countries) to 2.3%of GDP. Another way of looking at it is India has 860 beds per million population that accounts for 1/5th of the world average, which is 3,960, according to the World Health Organization. An estimated additional 450,000 hospital beds are required by 2014 to fulfill this gap.
Unhealthy Population-Doctor Ratios
Now let us take a look at the doctor strength in India. The number of allopathic doctors possessing a MCI (Medical Council of India) certificate and registered under the State Medical Councils for the year 2009 and 2010 were 793,305 and 816,629 respectively.
It is a particularly small number if you go by the state wise data, particularly if you were to look at the population-doctor ratios of a few Government hospitals.
It is evident that each Government doctor at least serves a population of 5,000 and more. The situation is grimmer in rural India. The total number of Government doctors for Primary Health Care that India had in its rural areas is 23,982, as on March, 2009.
It’s a similarly dismal figure for the total specialists in the Community Health Centres (CHC). Total Specialists in CHCs in rural India is just 5,789. The total number of Community Health Centres in India is 4,510, as on March, 2009. Thus, the Community Health Centres even do not have two specialists in each centre. However, the definition of rural extends to 638,000 villages and is inhabited by more than 740 million individuals.
A lot of Colleges, Not Enough Doctors
Surprisingly, India has a total of 314 medical colleges and admission in the year 2010-2011 in these colleges has been 29,263. Data was not received for 58 medical colleges. The approximate, annual pass-out rate is 20,000. Health Minister Ghulam Nabi Azad said recently in Parliament that 3,600 doctors had left the country in the last three years, thus around 1,200 doctors go abroad to work or study further every year.
A Brookings Institution study says that looking at the evolution of medical colleges and that these doctors remain active for 30 years, so then India has 650,000 doctors presently. That translates into more than 1,500 people per doctor. Countries like US have 400 people per doctor, in the case of China it is 950. One reason is sheer spend. USA spends 7.1% of its GDP on Health and China spends 1.9%.
We can clearly see that when it comes to expenditure on health, whether
private or public, we are far from the dreams we aim at. As the Brookings
report says, “Whereas private colleges and institutes in engineering,
computer applications and business have mushroomed in response to demand,
the same has not happened in the medical field.”
Now let us take a look at the number of Government hospitals and hospital
beds we provide to our people.
On the other hand, over 75 per cent of the human resources and advanced medical technology, 68 per cent of an estimated 15,097 hospitals and 37 per cent of 623,819 total beds in the country are in the private sector. Of these most are located in urban areas. Such shortfalls in the public healthcare have led to severe effect in many areas.
. Maternal Mortality Ratio: More than 200 is indeed a cause of concern. One reason is that only 37.5% of deliveries in rural areas and 73.5% in urban areas is performed by skilled health personnel.
. Malnutrition: Reportedly, 43.5% children under 5 years are suffering from malnourishment.
. With 17% of the global population, India accounts for 20% of the total global disease burden, 23% of the child deaths, 20% of the maternal deaths, 30% of Tuberculosis cases, 68% of Leprosy cases, and 14% of HIV infections. (NRHM, 2005)
. Almost 41 million Indians are diabetics and the number is expected to increase to 73.5 million by 2025 (PWC, 2007). The incidence of diabetes among urban adults was 2.1% in the 1970s, and now it is up to 12.1%, the incidence being much higher in southern states as compared to northern states.
. O f the 9.2 Million cases of TB that occur in world every year, nearly 1.9 million is in India. We account for one-fifth of world TB cases.
. More than 300 million episodes of acute diarrhoea occur every year in India in children below 5 years of age.
These are just a snapshot of many more issues in healthcare which envelop India. Interestingly Indian Government spending on total healthcare is around 20 %( approx). Private healthcare takes a toll on a country where more than 70% of the population lives in rural settings but 80% of the hospitals are in the urban setting.
However, there are a few successes of the Government too. Government has been steadily increasing its plan expenditure over the years. In the Eleventh Five Year Plan (2007-2012) Government’s investment (public, private) is Rs 131,651 crore, an increase of 6.49% from 3.97 in the last plan. It must be kept in mind that we are highly dependent on the private sector for improving healthcare.
Fund Flow from the private sector stands at 72% and only 27% (1.68% comes as external flow) as per 2008-2009 estimates. The brightest areas are that then Union Health Budget now stands at Rs 21,680 crore, it was a meagre Rs 8,000 crore in 2004-2005. The Government has also relaxed norms in the medical colleges. Strict norms by the Medical Council of India have been highlighted by many as a major impediment from improving healthcare.
The introduction of National Rural Health Mission (NRHM) in 2005 is touted by many as a path breaking model to improving healthcare. Before the NHRM, density of health workers currently stood at a little over 8 per 10,000 population of which allopathic physicians were 3.8 and nurses and nurse-midwives were 2.4 per 10,000 population.
Now, the density of health workers per 10,000 population in urban areas (42) is nearly four times that of rural (11.8) areas. The majority (70 per cent) of health workers are employed in private sector.
Moreover, another issue of pre-NRHM problems can be summed up in these following lines “According to the National Sample Survey Organisation, the year 2004 saw 28% of ailments in rural areas go untreated due to financial reasons, up from 15% in 1995-96. Similarly, in urban areas, 20% of ailments were untreated due to financial reasons, up from 10% in 1995-96”. However, NRHM has been successful in changing the scenario, at least for the time being, which can be termed as success.
. It has led to the appointment of almost 106,949 more skilled service providers in the public health system by March 2010, of which 2,460 were specialists, 8,624 were doctors, 26,993 were nurses, and 14,990 were paramedical. This was one of the largest increments to the public health workforce in recent times.
. Over 4,000 post graduate seats have been increased during this period consequent to revision of teacher-student ratio.
. Rs. 1,350 crores has been approved for funding state government medical colleges to start/increase PG medical seats.
. In infrastructure alone, this period saw new buildings for 9,144 sub-centres, 1,009 Primary Health Centres, 435 Community Health Centres and 57 district hospitals. Another 8,997 sub-centres, 2,081 PHCs, 1,255 CHCs and 357 district hospitals have had their infrastructure renovated or upgraded.
Every public health facility now receives an annual fund as grant for local initiatives. With addition of new human resources and skills over 8,324 PHCs have reached 24×7 functionality status and 2,463 are being upgraded.
. Diseases like Small pox, Leprosy have been eradicated in recent years. Tuberculosis, HIV/AIDS and Measles are showing decreasing trend.
Unfortunately, diseases like Dengue, Chikungunya, Cholera, and Japanese Encephalitis have shown increasing trend. However, we are still far from the healthcare standard of a developed nation. There are severe challenges that the Government is well aware of.
The major challenge that India faces currently is public spending. Presently, it is among the five lowest in the world. For the last decade public spending as percent of GDP is hovering around 1%. It needs to be increased to at least 2-3% of the GDP. In the year 2004-2005, healthcare spending, from all sources, amounted to 4.25% of the GDP, but it came down to 4.13% in 2008-2009. Though it is proudly claimed that public spending is increasing in absolute terms, we must keep in mind that proportionate increase in GDP has basically led to a moderate increase of healthcare spending.
As per the Eleventh Five Year Plan (2007-2012), the public expenditure on health will have to increase to around Rs.1, 60,000 crores by 2011-12 as against the budgeted amount of Rs. 66,000 crores in 2009-10 by the Centre and states put together. Thus, Annual Health Budget needs to be increased by 56% in the next two years.