Tag Archives: Socioeconomic

Are common patients in India just as the pawns of the game of chess or the victims of circumstances or both, in the socio-economic milieu of the country?

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“Public healthcare in India has the power to deliver improved health outcomes, as demonstrated by a growing number of national and international examples. However, supportive policies need to be put in place in order to change traditional determinants of health,”said Professor Sir Andrew Haines, Director, London School of Hygiene and Tropical Medicine at the third foundation day function of the Public Health Foundation of India (PHFI), not so long ago.The healthcare industry of India has indeed this power, which can catapult the industry to a growth orbit to generate an impressive revenue of around US$.150 billion by 2017 as estimated by India Brand Equity Foundation (IBEF) in November 2009. This growth will be driven primarily by the private investments in country.Be that as it may, the current healthcare standard and infrastructure in India, as we all know, is far from satisfactory. Though we have some healthcare centers of excellence spread sporadically across various cities and towns of India, public healthcare facilities are grossly inadequate to satisfy the current healthcare demand of the common man of India.

Healthcare spends in India:

Although total health spending of the nation is around 6 percent of its GDP being one of the highest within the developing countries of the world, public expenditure towards healthcare is mere 0.9 percent of the GDP and constitutes just a quarter of the total healthcare cost of the nation. According to a World Bank study, around 75 percent of the per capita spending are out of pocket expenditure of individual households, state and the union governments contribute around 15.2 percent and 5.2 percent respectively, health insurance and employers contribute just 3.3 percent and foreign donors and state municipalities contributing the balance of 1.3 percent.

Out of this meager allocated expenditure only 58.7% goes for the primary care.

Four essentials in Primary Healthcare:

When it comes to Primary Healthcare, following are the well accepted essentials that the government should effectively address:

1. Healthcare coverage to all, through adequate supply of affordable medicines and medical services

2. Patient centric primary healthcare infrastructure and networks

3. Participative management of healthcare delivery models including all stakeholders with a change from ‘supply driven’ to ‘demand driven’ healthcare program and policies

4. Health of the citizens should come in the forefront while formulating all policies for all sectors including industry, environment, education, deployment of labor, just to cite a few examples.

It is unfortunate that most of these essentials have not seen the light of the day, as yet.

The key reason for failure:

Inability on the part of the central government to effectively integrate healthcare with socio-economic, social hygiene, education, nutrition and sanitation related issues is one of the key factors for failure in this critical area.

Moreover in the healthcare planning process, health being a state subject, not much of coordinated planning has so far taken place between the central and the state governments to address the pressing healthcare related issues.

In addition, budgetary allocation and other fiscal measures, as stated earlier, towards healthcare both by the central and the state governments are grossly in adequate.

National Rural Health Mission (NRHM) – a good beginning:

To address this critical issue, the National Rural Health Mission (NRHM) was conceived and announced by the government of India. NRHM aims at providing valuable healthcare services to rural households of the 18 States of the country namely, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarkhand and Uttar Pradesh, to start with.

The key objectives of this novel scheme are as follows:

• Decrease the infant and maternal mortality rate
• Provide access to public health services for every citizen
• Prevent and control communicable and non-communicable diseases
• Control population as well as ensure gender and demographic balance
• Encourage a healthy lifestyle and alternative systems of medicine through AYUSH

As announced by the government NRHM envisages achieving its objective by strengthening “Panchayati Raj Institutions” and promoting access to improved healthcare through the “Accredited Female Health Activist” (ASHA). It also plans on strengthening existing Primary Health Centers, Community Health Centers and District Health Missions, in addition to making maximum use of Non-Governmental Organizations.

NRHM is expected to improve access to healthcare by 20 to 25 percent in the next three years:

To many the National Rural Health Mission (NRHM) has made a significant difference to the rural health care system in India. It now appears that many more state governments are envisaging to come out with innovative ideas to attract and retain public healthcare professionals in rural areas.

On January 11, 2010, the Health Minister of India Mr. Ghulam Nabi Azad, while inaugurating the FDA headquarters of the Western Zone located in Mumbai, clearly articulated that the NRHM initiative will help improving access to affordable healthcare and modern medicines by around 20 to 25 percent during the next three years. This means that during this period access to modern medicines will increase from the current 35 percent to 60 percent of the population.

If this good intention of the minister gets translated into reality, India will make tremendous progress in the space of healthcare, confirming the remarks made by Professor Sir Andrew Haines, Director, London School of Hygiene and Tropical Medicine, as quoted above.

Is NRHM scheme good enough to address all the healthcare needs of the country?

NRHM is indeed a very good and noble initiative taken by the government to address the basic healthcare needs of the rural population, especially the marginalized section of the society. However, this is obviously not expected to work as a magic wand to resolve all the healthcare related issues of the country.

Are patients the pawns of the game of chess or the victims of circumstances or both of the socio-economic systems?

Currently, some important stakeholders of the healthcare industry seem to be using the patients or taking their names, mainly for petty commercials gains or strategic commercial advantages. They could be doctors, hospitals, diagnostic centers, pharmaceutical industry, activists, politicians or any other stakeholders. It is unfortunate that they all, sometime or the other, want to use the patients to achieve their respective commercial or political goals or to achieve competitive gains of various types or just for vested interests..

‘The Patient centric approach’ has now become the buzz word for all – do we ‘walk the talk’?

There does not seem to be much inclusiveness in the entire scheme of things in the private healthcare system, excepting some odd but fascinating examples like Dr. Devi Shetty, Sankara Nethralaya etc. As a result, excepting the creamy layers, patients from all other strata of society are finding it difficult to bear the treatment cost of expensive private healthcare facilities.

I personally know a working lady with a name Kajol (name changed) whose husband is suffering from blood cancer. One will feel very sad to watch how is she fast losing all her life’s savings for the treatment of her husband, pushing herself, having no alternative means, towards an extremely difficult situation day by day. There are millions of such Kajols in our society, who are denied of effective public healthcare alternatives to save lives of their loved ones.

If all stakeholders are so “patient centric” in attaining their respective objectives, why will over 650 million people of India not have access to modern medicines, even today? Is it ALL for poor healthcare infrastructure and healthcare delivery system in the country? If so, why do we have millions of Kajol’s in our country?

Consumer awareness and pressure on healthcare services and medicines in India will increase – a change for the better:

With the winds of economic change, rising general income levels especially of the middle income population, faster awareness and penetration of health insurance among the common citizens, over a period of time Indian consumers in general and the patients, in particular, like in the developed countries of the world, will start taking more and more informed decisions by themselves about their healthcare needs and related expenditure through their healthcare providers.

As the private healthcare providers will emerge in India, much more in number, like the developed world, they will concentrate not only on their financial and operational efficiencies exerting immense pressure on other stakeholders to squeeze out the best deal at the minimal cost, but also to remain competitive will start charting many uncharted frontiers and explore ways of enhancing the ‘feel good factors’ of the patients through various innovative ways… God willing.

Conclusion:

All stakeholders of the healthcare industry need to think of inclusive growth, not just the commercial growth, which could further widen the socio-economic divide in the country, creating numbers of serious social issues. As we know, this divide has already started widening at a brisk pace, especially in the healthcare sector of the country

It is hightime for the civil society, as well, to ponder and actively participate to make sure that the inclusive growth of the healthcare sector in India takes place, where like primary education, primary healthcare should be the ‘fundamental right’ for ALL citizens of the country.

By Tapan Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Healthcare reform process and policy measures to reduce socio-economic inequalities should be implemented in tandem for optimal economic progress of a nation.

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Important research studies indicate that health of an individual is as much an integral function of the related socio-economic factors as it is influenced by the person’s life style and genomic configurations.It has now been well established that socio-economic disparities including the educational status lead to huge disparity in the space of healthcare.Healthcare preventive measures with focus just on disease related factors like, hygiene, sanitation, alcohol abuse, un-protected sex, smoking will not be able to achieve the desired outcome, unless the underlying socio-economic issues like, poverty, hunger, education, justice, values, parental care are not properly addressed.

It has been observed that reduction of social inequalities ultimately helps to effectively resolve many important healthcare issues. Otherwise, the minority population with adequate access to knowledge, social and monetary power will always have necessary resources available to address their concern towards healthcare, appropriately.

Regular flow of newer and path breaking medicines to cure and effectively treat many diseases, have not been able to eliminate either trivial or dreaded diseases, alike. Otherwise, despite having effective curative therapy for malaria, typhoid, cholera, diarrhoea/dysentery and venereal diseases, why will people still suffer from such illnesses? Similarly, despite having adequate preventive therapy, like vaccines for diphtheria, tuberculosis, polio, hepatitis and measles, our children still suffer from such diseases. All these continue to happen mainly because of socio-economic considerations.

Following are some research studies, which I am using just as examples to vindicate the point:

• HIV/AIDs initially struck people across the socio-economic divide. However, people from higher socio-economic strata responded more positively to the disease awareness campaign and at the same time more effective and expensive drugs started becoming available to treat the disease, which everybody suffering from the ailment cannot afford. As a result, HIV/AIDS are now more prevalent within the lower socio-economic strata of the society.

• Not so long ago, people across the socio-economic status used to consume tobacco in many form. However, when tobacco smoking and chewing were medically established as causative factors for lung and oral cancers, those coming predominantly from higher/middle echelon of the society started giving up smoking and chewing of tobacco, as they accepted the medical rationale with their power of knowledge. Unfortunately the same has not happened with the people of relatively lower socio-economic status. As a consequence of which, ‘Bidi’ smoking, ‘Gutka’/tobacco chewing have not come down significantly within people belonging to such class, leading to more number of them falling victim of lung and oral cancer.

Thus, in future, to meet the unmet needs when more and more sophisticated and high cost disease treatment options will be available, it will be those people with higher socio-economic background who will be benefitted more with their education, knowledge, social and monetary power. This widening socio-economic inequality will consequently increase the disparity in the healthcare scenario of the country.

Phelan and Link in their research study on this issue has, therefore, remarked:

“Breakthroughs in medical science can do a lot to improve public health, but history has shown that, more often than not, information about and access to important new interventions are enjoyed primarily by people at the upper end of the socioeconomic ladder. As a result, the wealthy and powerful get healthier, and the gap widens between them and people who are poor and less powerful.”

Conclusion:

Though healthcare reform measures are essential for the progress of any nation, without time bound simultaneous efforts to reduce the socio-economic inequalities, it will not be easy for any nation to achieve the desirable outcome.

By Tapan Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Increasing socio-economic inequality within the healthcare delivery systems of India

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Increasing inequality between the wide diversity of population of ‘haves’ and ‘have-nots’ in the socio-economic and cultural set up of India, clearly gets reflected in the healthcare delivery system of the country. Many research studies on this subject have established a clear relationship between healthcare services and socio-economic inequality. Several lakh of Indians still perish in the country because of this reason.
Economic growth needs to be inclusive – better said than done:
Initiation of financial reform measures since 1990 and the process of globalization during this period have spurred the economic growth of the country, the rate of which comes just next to China in the global scale of comparison for the same. However, many people strongly believe that this reform process has not been as inclusive as it should have been. Otherwise why will the country continue to witness worrisome instances of abject poverty within a large section of the society with an abnormally high rate of mortality?

Healthcare sector in India – huge socio-economic inequality:

According to the Investment Commission of India, the healthcare sector of the country has experienced rapid growth of around 12% since last 4 years and is expected to be of U.S. $ 280 billion industry by 2022.

However, due to socio-economic inequality, this growth has not been evenly distributed. As a result, 65% of the population of India still do not have access to modern medicines and a vast majority of the population experience poor healthcare facilities. Around 10 lakh women and children die in India either due to poor access to healthcare services or they cannot afford the healthcare expenses.

Centers of excellence – but not for all:

In the healthcare sector, despite having many centers of excellence of global standards, which are also attracting ‘medical tourists‘ from across the world, healthcare needs of a large number of population of the country are not being addressed adequately. About 700 million of population have no access to specialists’ care even today. The Government of India alone will not be able to address this problem of gigantic proportion without workable and time-bound Public Private Partnership (PPP) initiatives with an investment of over U.S $ 20 billion at least for next five years. For example, in terms of availability of hospital beds per 1000 population, India stands at 0.7 against 3.96 of world average.

“Fortune at the bottom of the pyramid” – anybody follows in India?

Professor C. K. Prahalad’s famous dictum, “Fortune at the bottom of the pyramid” has not been realised yet by many within the global healthcare industry, perhaps with the solitary exception of Andrew Witty, the young CEO of GlaxoSmithKline.

As per data available from the Government publications, the bottom of the pyramid where a large proportion of the Indian population is located, reflects a huge socio-economic inequality even in the healthcare sector as follows:

• Overall spending on healthcare in India is around 6% of GDP (Public and Private sectors put together). However the public expenditure is only 0.9% of the total spending.

• In rural areas per capita expenditure on healthcare is seven times lower than urban areas.

• In rural areas the ratio of hospital beds to population is fifteen times lower than the urban areas.

• In rural areas the ratio of doctors to population is almost six times lower than the urban areas.

• The rate of Infant Mortality in the 20% of the poorest population is 2.5 times higher than the richest 20% of the population in rural areas.

• Despite more health issues an individual from the poorest quintile of the population is six times less likely to access hospitalization than a person from the richest quintile in rural areas.

• From the poorest quintile of the population, the child delivery of a mother is over six times less likely to be attended by a medically trained person than during child delivery of a mother from the richest quintile of the population in rural areas.

• On an average 78% healthcare expenditure in India comes as ‘out of pocket payments’ by the people, whereas only 18% of the same is borne by the state followed by 4% by medical insurance.

• Towards public healthcare spending, only five other countries in the world (Pakistan, Burundi, Myanmar, Cambodia and Sudan) are worse off than India.

• Only 38% of all Public Health Centres (PHCs) have essential manpower and only 31% have the essential supplies with only 3% of PHCs having 80% of all critical inputs.

As a result of inadequate and unequal spending on the healthcare infrastructure, healthcare systems, healthcare financing and healthcare delivery, both by the public and private sectors in the rural areas, such inequalities towards access and affordability of the healthcare services,especially in rural India where over 70% of the country’s population reside, have now assumed an alarming proportion .

Access to healthcare is fundamental in many countries of the world:

Most of the developed countries of the world extend comprehensive healthcare access to its citizens. Even our close neighbour Thailand and Fidel Castro’s land, Cuba along with many other developing countries of the world extend basic healthcare facilities to all their citizens.

Urban poor also face the harsh reality of healthcare affordability issue:

Survey results indicate the following facts so far as urban poor are concerned:

• Healthcare facilities though skewed towards urban India, the healthcare cost, lack of culturally appropriate services; social prejudices etc prevent access to healthcare even to the urban poor.

• Infant and under-five mortality rates in the urban slums for the poorest 40% are as high as is prevalent in the rural areas.

• Because of mainly poverty, poor hygienic and almost non-existent sanitation conditions, urban slums have now become the breeding ground for diseases like cholera, malaria, hepatitis, tuberculosis, HIV – AIDS and a large variety of infectious disease.

All these conditions coupled with almost total lack of health education in slums further aggravate the healthcare situation.

Has the National Health Policy delivered?

It is widely believed that Infant and Maternal Mortality rates of a country are the most important indicators of the health of any society. For the year 2000 The National Health Policy of India had set a target to bring down the Maternal Mortality Rate to below 200 per 1 lakh live births. However, even today around 407 mothers die every year due to pregnancy related complications. So far as infant mortality is concerned the figure remain as high as 22 lakh every year.

A very sad state of public healthcare delivery system gets reflected through these very basic numbers, despite various government initiatives and mushrooming private and corporate investments towards healthcare. The privileged class of the society, as a result, is getting better and better private healthcare services and the under-privileged class is denied of, in many cases, even the very basic healthcare facilities. All these bring out to the open the social and economic inequality in our civil society even for the very basic healthcare needs of its citizens.

Growth of Private Healthcare initiatives is welcome, but are they maintaining an urban-rural balance?

Urban centric private healthcare sector in India is growing at a faster pace. However, overwhelming dominance of this sector in absence of robust PPPs will further increase the urban bias with focus on higher profit margin being more important than offering primary and secondary healthcare services to a large number of the deprived population with lesser profit margin. Following published facts may help understand the prevailing situation:

• The increasing cost of healthcare paid predominantly through ‘out of pocket’ is making healthcare unaffordable to a large number of the population.

• The number of people who are unable to seek healthcare services due to affordability issue is growing, despite rapid economic growth of the country.

• The number of people who cannot afford to basic healthcare services has doubled compared to just a decade ago.

• One in three people who need hospitalization and paying ‘out of pocket’ are forced to borrow money or sell assets to cover healthcare expenses.

• Because of ‘out of pocket’ spending on healthcare, over 20 million Indians are pushed below the poverty line every year.

• A World Bank report acknowledges the facts that doctors recommend unnecessary investigations and over-prescribe drugs in private healthcare sector.

• The same report acknowledges the relationship between the quality and cost of healthcare services in the private healthcare system with high priced services being excellent but unaffordable to many.

Conclusion:

All these facts will further establish the prevalent socio-economic inequality within the healthcare delivery systems of India. Rapidly growing urban centric private healthcare initiatives are welcome but these are now just catering to the privileged few, keeping the pressing healthcare issues of India unanswered. Only well planned time-bound PPP initiatives, in my view, are capable to address the humongous healthcare issues of India.

By Tapan Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.