By: Dr. Utsav Mehta, MHA-Health (2011-13)
Health sector in
India is growing at an enormous rate. During 1990s the growth of Indian health
sector was at a rate of 16 %. Today the value is equivalent to around $34
billion which is projected to rise up to around $45 billion in 2012. This is
equivalent to around 6-7 % of GDP. This
creates a sense of illusion that the rise in health care sector adds to the
health of the country which actually is not the case. The recent growth of
health sector in India is confined to the private sector and this comes at a
time when public spending on health is 0.9 % of GDP (sixth lowest in the world).
India is now one of the top 20 of the countries with high private fund
spending. Around 82 % of health expenditure in India is Out of Pocket. As
a result 40 % of hospital admitted patients have to borrow money or have to
sell their assets. A major population falls below poverty line due to their
costs of medical care.
Alleyne says '
If patients were consumers and health care workers were providers, then there
was a possibility that injustice could be committed if health care was
relegated to being an ordinary commodity that was exchanged between providers
and consumers in the market place.' The problem in India is health has got the
status of a 'commodity' which has ever lasting demand and every one is bound to
pay for it. Here comes the issue of equity and justice as whether the growing
health sector really cares about those who cannot pay for it ? Not only the
affordability but the availability and accessibility is a major concern.
Consider example of one of the major province of India, Madhya Pradesh. A study
shown 75.6 % of doctors and 72.1 % of paramedical staff worked in private
sector and a majority of physicians (80 %) worked in urban areas (De costa,
Diwan 2007). Also regarding the rural
urban divide in availability of hospital beds, for one lakh population rural
had 9.85 beds and urban areas had 178.78
beds which was twenty times more than the former (Review of health care in
India, 2005). Another study shows, in India, more than half of the hospitals and
49 per cent of the dispensaries are privately owned (Aljunid, 1995). This too
can be attributed to private health care service providers.
The issue with
private health care providers is that , the private market is driven by market
demand and not by the actual need of population. Here the demand implies
definition which necessarily includes the phrase ‘ability to pay’. There is
actually minimal concern from the private providers for those who are not the
'buyers'. The major equity dimension affected by this is Horizontal equity.
For the same health need the population is not having equal resources. For
instance, for the same need of coronary by-pass, a person who can afford to pay
will have state of the art facility [and we claim it as one of the cheapest in
the world to attract medical tourism, at the same time we forget that 65 % of
Indian population can't afford even this so called cheapest].
The rich and poor
divide is the greatest chunk of all the dimensions of health inequity in India.
In India, child mortality is higher in provinces with larger proportions of
poor people. Within cities also, there is large difference in child survival
between rich and poor neighborhood. For instance, In Madurai, the second
largest city of Tamil Nadu ,children in poor houses were more likely to suffer
from serious physical or mental disabilities as compared to children from the
better section of society.
For addressing the
need for the health care services for poor in India, the public sector still
remains the only major source and that too is not at par in terms of quality of
services, not even the availability of all services particularly in terms of
tertiary care is satisfactory. Poor
public sector performance in health has resulted in exponential growth of
private providers. The health care reforms largely include private provider's
participation which ultimately has led to need for regulatory norms .But regulation
itself needs additional resources and is difficult. The privatization has
merely increased the number of business entities earning out of health
sector and not giving in.
Private
health sector has developed in India but this has happened at the cost of
public sector. To ensure that equity concern is addressed, there is need to
impose more social accountability on private providers to make certain
proportion of services available for the poor. There are already provisions but
those are not properly implemented nor there any regulatory body to check it.
There is strong need of more stringent strategies.
There
can be more strategies which can include options like public financing
that encompass tax policies and tax
evasion (Whitehead,2001) to ensure more effective risk pooling across
population. Direct payments can be changed to social insurance system. This
insurance system can be subsidized by public funds which can also cover costs
of essential drugs. Efforts should be made to eliminate 'informal' payments in
the public system.
The
public sector secondary and tertiary care should be strengthened in terms of
availability and accessibility ensuring quality standards. There should be
guidelines and norms to draw a ceiling for cost of health services provided by
the private sector. The private sector should be made accountable for the
health outcomes of given areas imposing more responsibility over them. There
should be strict check on rules and regulations of private sector regarding
various charges imposed over patients and there should be mechanisms to make
the user-fee policy of the private sector transparent. Measures like displaying
various charges applicable in a private hospital clearly should be implemented and monitored.
Health
care is a human right and it should be dealt accordingly. The more the business
part enters in the heath sector, the difficult is the situation. The commitment towards equity is the
prerequisite for “health for all”.
