Visit to a country of paradoxes—Health Front

Let us take you on an imaginary visit to a large and interesting country. While visiting this country, we are especially interested in understanding the health system prevailing there.

Considerable health care resources …
We are privileged to begin our visit by talking to national health officials. As they begin to tell us about the Health sector in this country, we are impressed to find that it possesses considerable health care resources. This country produces among largest numbers of doctors in the developing world. These doctors are exported to many other countries, and are considered among the best in the world.
This is not surprising, considering the fact that this country has the largest number of medical colleges in the world.
The high standard of medical skill and expertise here is reflected in the fact that this country gets ‘Medical tourists’ from many developed countries. They seek care in its state-of-the-art, high-tech hospitals which compare with the best in the world.
Turning to medicines, we find that this country is the fourth largest drug producer in the world and is among the largest exporter of drugs in developing world.
Of course, all these resources require finances. We find that people here do not lag behind in paying and spend a lot on health care – more than many other developing countries.

Given so many doctors and medical colleges, such high-tech hospitals, so much medical expertise, such large scale production of medicines, the scale of resources that are being poured by citizens into this country’s health system, we would of course expect a high standard of health care for the people, and a good health status for all.

… but poor access to Health care for the majority
Then we begin to move around and talk to some people in the villages and towns of this country and …
… this country turns out to be much more interesting than we had thought!

We are surprised to find that -
Despite all these resources, the majority of citizens have very limited access to quality Health care, and have poor health indicators. There are low levels of immunisation – in fact less than half of the children are completely immunized (added to this, complete immunization coverage has declined in recent years!). Similarly, the minimum of three checkups during pregnancy remains unavailable for half of all pregnant women. There are massive inequities in access to health care – while the rich avail of most modern and expensive health services, the poor, especially in rural areas do not get even rudimentary health care. Hospitalisation rates among the well off are six times higher than rates among the poor! This is a country of paradoxes where women from well off families suffer due to unnecessary cesarean operations – in some urban centres close to half of deliveries are done by operation – while their poorer rural sisters frequently die during childbirth due to lack of access to the same cesarean operation at time of need.
There is large scale indebtedness and inability to afford health care – evidenced by the fact that two out of five hospitalization episodes are paid for by taking loans or selling assets. The proportion of people who are unable to access any form of treatment due to inability to pay is quite large and increasing. Although people spend a lot on health care (the poorest spend one-eighth of their total income on health care), the government proportionally spends much less. Of the total health spending in the country, less than one-fourth is made by all levels of government, while the remaining major portion is shelled out by ordinary citizens from their pockets. This makes the health care system in this country one of the most privatized systems in the world.

Compounding this is the fact that due to the profit motives of private providers, a lot of the health care given is irrational and unnecessary. It has been estimated that almost two-thirds of the medicines prescribed here by doctors are irrational or unnecessary. Nearly half of all outpatients receive injections, which are mostly unnecessary. As noted above, in some urban centres, nearly half of the deliveries have been found conducted by cesarean operation, whereas according to WHO guidelines not more than one out of ten deliveries need such an operation.

You have of course guessed it by now – this is the country where all of us live. This paradoxical country is India, where we have really poor health care at high cost, considerable health care resources but very poor health care access for the majority of people.

What is wrong here? Why do we get such poor health care even though we generate so many resources and we citizens spend quite a bit of money on health care? Let alone the poor, even the middle class cannot easily afford major investigations and hospitalisation. Why are we worse off in this respect even compared to other developing countries? How come the proportion of spending on Public health in India is less than even our poor neighbours, Bangladesh and Nepal? Is there a practical way to do things differently?

Looking at these facts, there seems to be something deeply wrong with our entire Health care system. It is possible to organise our health care system differently, so that today every community, every family and every person in our country can be assured of decent health care. Some other developing countries have shown the way, and have made universal access to decent health care for their population a reality