India is the biggest drugs producer but behind the emerging countries healthwise: health workers are too few and poorly trained and costs are too high. But reforms are on the way

In the past 60 years, the health status of Indians has improved markedly. The crude death rate has fallen from 25 in 1951 to seven in 2010 (1). The infant mortality rate has fallen from 120 in the 1970s to 44 in 2011 (2). Life expectancy at birth has risen from 36 years in 1951 to 66 years in 2011 (3). Maternal mortality has also fallen from 400 maternal deaths per 100,000 live births in 1998 to 200 in 2010 (4).

However, despite rapid GDP growth over the last two decades, India has consistently failed to meet national and international health targets, including the Millennium Development Goals, and has changed slower than other Asian countries including China, Sri Lanka, Bangladesh and Thailand. India continues to have high rates of maternal and child mortality from communicable diseases, in addition to poor chronic disease management. A quarter of all child deaths and 20% of all maternal deaths in the world occur in India. People living in rural areas, people belonging to marginalised castes, religious minorities, women and the poor are the first to suffer gross health inequalities.

Under-equipped

India is facing a “double burden” of diseases: large proportions of mortality can be attributed to communicable diseases on one hand and chronic conditions on the other. The former, such as respiratory infections and diarrheal diseases, are predominantly diseases of poverty and disproportionately affect children and the poor. The latter, such as cancers, mental health disorders, diabetes and cardiovascular diseases, mainly cause death among adults. Though they are more frequent in urban areas in the initial stages, poor and rural areas are becoming increasingly affected.

Chronic diseases now account for more than half of deaths in India (5) , but infectious diseases remain a considerable cause of mortality (29%), ahead of injuries (9.9%), perinatal conditions (7.3%), maternal conditions (0.6%) and malnutrition (0.5%). In 2008 a third of all deaths in India were of people under 14 years; 86% of these deaths were due to communicable diseases or perinatal conditions (6). Of adult deaths, about a quarter are from communicable, chronic or degenerative diseases.

Healthcare in India is characterised by poor public infrastructure and human resource management, a growing and largely unregulated private sector, and vast disparity in health access and outcomes between the rich and poor. Indians must choose between unregulated, for-profit private providers or understaffed, under-resourced and poorly managed public clinics (7). The poor frequently delay accessing care, do not access it at all, or fall further into poverty or debt through spending on private care (8).

The vast majority of poor and middle class households are vulnerable to catastrophic health spending, particularly when the sick are earning members of the household. A 2002 World Bank report found that 40% of all people hospitalised in India in a single year sold belongings or took on debt and around 24% fell below the poverty line due to hospitalisation (9). According to the report, hospitalised Indians spend more than half of their total annual expenditure on healthcare.

Growing discontent

Health spending accounts for 4.1% of India’s GDP, fairly average for a lower to middle-income country. However, the government spends only 1% of GDP, less than a quarter of the total healthcare spending. With households paying for over 70% of the health expenses every year, India is far below average. The WHO estimates the average cost of providing essential healthcare in lower to middle-income countries at around 6% of GDP (10).

There is a national shortage of human resources for healthcare. India has 6.5 physicians for every 10,000 people compared with 15 in China and 18 in Brazil. And estimates from the 61st National Sample Survey Office survey suggest that 37% of physicians (63% in rural, 20% in urban areas) had inadequate or no medical training, reducing the proportion of real practitioners to less than four per 10,000 people (11). There are also fewer than 10 nurses per 10,000 people. The estimated density of allopathic physicians, nurses and midwives (13.4) was only about half the WHO benchmark of 25.4 per 10,000 people in 2005 (12).

The health challenge is all the more pressing because of people’s increasing dissatisfaction, and an evolving grass roots public accountability movement.

In this context, the Indian government launched the National Rural Health Mission in 2005 as an “architectural correction” of the public healthcare system. In 2010 the Planning Commission of the Government of India, took the unprecedented step of forming a group of health activists, academics, intellectuals and economists, with the mandate of developing a framework for providing accessible and affordable healthcare to all Indians. This High Level Expert Group (HLEG) submitted its report on Universal Health Coverage (UHC) for India to the government in October 2011. Constituting the HLEG shows that universalising healthcare is now on the national agenda. But no one knows how this goal will be met. There is continued pressure from private healthcare institutions, insurers and investors to continue along the path of increasing privatisation.

India has a long way to go in making healthcare for all a reality. But by now we know that achieving UHC is possible and the only way forward to ensuring healthcare for all. The examples of Thailand, Sri Lanka, Malaysia and Brazil, which have all progressed in this direction, suggest there is no alternative but to strengthen the public health system to ensure access, delivery, quality and affordability.

The obstacles should not be underestimated. In recent years, some donors and developing countries, including India, have been promoting health insurance schemes in the name of UHC. But there is no magic bullet or single blueprint for UHC. The countries that have achieved UHC have each taken their own paths but they do share a common understanding that entitlement to healthcare should be based on citizenship or residency, not on employment status or financial contributions. To successfully scale up UHC, these countries have prioritised government spending for health — on its own or with taxes.

To achieve UHC, India needs to work simultaneously on several fronts: to increase tax-based public spending on health to at least 3% of GDP in the next five years; implement the Indian Public Health Standards effectively; draft a human resources strategy to reach WHO standards in the next 10 years; increase community participation and citizen engagement in the planning, monitoring and evaluation of healthcare systems; initiate necessary institutional reforms to evolve a UHC-ready health system; and ensure full access to medicines and vaccines by providing them free of cost, and rationalise the use of drugs.

‘World’s pharmacy’

India can’t evolve a UHC system overnight, but it’s high time we started rolling out our own plan. According to the WHO, 50-65% of Indians do not have regular access even to essential medicines. This is incongruous for a country that is known as the “world’s pharmacy”. India is the largest producer of generic medicines, but the vast majority of Indians do not have access to them. Medicines account for 72% of their total health expenses. Millions of Indians could obtain better care if the government decided to procure generic medicines in bulk and distribute them free of cost at public health facilities.

Rajasthan, one of the least developed states in the country, is an example: it has been running a free medicines scheme since 2011. The state government spends $50m a year to provide 400 types of free medicines to patients in government hospitals. Every day, some 200,000 people benefit from the scheme. The number of patients going to government hospitals for treatment in the state has increased by 56%. The Rajasthan experience also shows that medicines procured in bulk under their generic names cost far less. This disparity is possible because most of the medicines are not under any price control.

The prime minister, Manmohan Singh, committed to “formulating a scheme for distribution of free medicines through government hospitals and health centres” during his Independence Day speech to the nation on 15 August 2012. But we haven’t seen action yet. Similarly, the government hasn’t taken any concrete steps towards the HLEG recommendations. As many other countries advance towards UHC, India’s own commitment should not remain an empty promise.