The evolution of healthcare in India over the past 25 years has been a mixed bag. While key health metrics such as the infant mortality rate (IMR) and maternal mortality ratio (MMR) have come down substantially, healthcare expenses have shot up—a direct fallout of lower public health spending. The government’s allocation to healthcare as a percentage of the country’s gross domestic product (GDP) has fallen to 1.05% in 2015-16 from 1.47% in 1986-87.

IMR has fallen to 41 per 1,000 live births in 2013 from 88 in 1990, according to a United Nations report ‘Levels and Trends in Child Mortality’ released in 2015. Similarly, according to a World Health Organization (WHO) report released in 2014, MMR in India has declined from 560 deaths per 100,000 live births in 1990 to 190 in 2013.

“Evidence from the ground supports this. We have made gains in maternal and child health by establishing public health systems in rural areas. The investments made through National Rural Health Mission (now under National Health Mission) have paid dividends in this area," said Vandana Prasad, national convener, Public Health Resource Network and formerly with the National Commission for Protection of Child Rights.

But India has failed its citizenry when it comes to expenses on healthcare. Health surveys by the National Sample Survey Organisation (NSSO) show that since the 1990s, the dependence of Indians on private healthcare has risen sharply. In 1986-87, 60% of people availed of public health services and the rest private healthcare, according to the 42nd NSSO report. But by 2014, this trend was reversed, with only 41% availing of public healthcare, according to the 71st NSSO report released last year. The decline in dependence on public healthcare is sharper in urban areas—from 60% in 1986-87 to almost 32% in 2014.

The NSSO rounds also show a corresponding three-fold increase in out-of-pocket expenditure or private health expenses of households. People spent ₹ 3,561 per hospitalization in 1995-96, according to the 52nd NSSO report. It increased to ₹ 18,268 in 2014.

“Out-of-pocket expenditure is the main cause of worry for the patients. A number of people fall from above poverty line (APL) category to below poverty line (BPL) category because of this. Nearly 70% of out-of-pocket expenditure is due to medicines. That has to be addressed," said Rajesh Kumar, head of the department of community medicine and school of public health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh.

The rise in out-of-pocket expenditure is a direct outcome of the fall in the government’s budgetary support to healthcare.

“By the end of 1980s, public health spending had increased to 1.5% of India’s GDP. Since then, there was declining trend in public spending on health, which reached to only 0.6% of GDP in the 1990s. Since then, it has improved a little up to 1.2%, but nowhere close to the 12th five-year plan (2012-17) target of 2.5% of GDP," said Ravi Duggal, health economist and country coordinator of non-profit International Budget Partnership. “What this under-financing did was to reduce the credibility of public health institutions among general people. And doctors and nurses left the public health system, creating huge vacancies in primary health centres and public hospitals," he added.

The increasing burden of both communicable and non-communicable diseases, too, is a challenge. While diarrhoea, respiratory infections and pre-term birth complications continue to affect India, lifestyle diseases such as heart diseases, stroke, pulmonary diseases and diabetes are now leading causes of premature death. Non-communicable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes account for nearly 60% of all deaths in India, according to the WHO.

The economic burden of these lifestyle diseases accounts for about 40% of all hospital stays and roughly 35% of all recorded outpatient visits, according to a 2014 report by the World Economic Forum and Harvard School of Public Health. The report further added that the probability of dying during the most productive years—between 30 and 70—from one of the four main non-communicable diseases is a staggering 26%.

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