Growing Private health Sector in India: challenge for equity..?

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”.