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EDITORIAL
Universal health coverage in India: Reality or just a dream? The age-old Indian understanding of health is very positive. The Sanskrit word for the healthy is swa-stha, one who is not dependent on others. This term denotes sovereignty and freedom. Successive Governments of India have failed to transform India’s unsatisfactory health care system. Despite considerable improvements in some health indicators in the past decade, India contributes inexplicably to the global burden of disease, with health indicators that compare unfavorably with other middle-income countries and India’s regional neighbors. Large health dissimilarities between states, between rural and urban populations, and across social classes still persist. A large section of the population is underprivileged because of high out-of-pocket health-care expenditures and suffers the adverse consequences of the poor quality of health care. In India, life expectancy at birth has risen from 62.5 years in 2000 to 66 years in 2013. In 2013, the infant mortality rate was 40 per 1,000 live births compared to 120 in 2003. Between 2001 and 2013, the maternal mortality rate fell from 301 per 100,000 live births to 167 per 100,000 livebirths. The spread of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) has been contained. In March 2014, the World Health Organization (WHO) officially declared India polio-free. In August 2015, WHO declared India free of maternal and neonatal tetanus.[1,2] In 2014, India witnessed the tragedy of sterilization deaths in Chhattisgarh and imposed blindness through botched cataract operations in Punjab. In 2015, we also saw similar calamities as more than 100 people died in Mumbai, Maharashtra from the consumption of illicit liquor. The number of dengue cases increased throughout the country, as compared to the previous year. These episodes are unambiguous reminders of inadequate accountability, poor infrastructure, and low quality health services in Access this article online Quick Response Code Website: www.jscisociety.com
DOI: 10.4103/0974-5009.175440
India’s health care sector. These examples are only the tip of the iceberg of harsh deficiencies in the health care system of India. India accounts for 17.5% of the global population and 20% of the global burden of disease in 2013-only a slight improvement from 21% in 2005. India also contributes to 27% of all the neonatal deaths and 21% of all the child deaths (younger than 5 years) in the world.[3] Chronic nutrition deficiency manifesting as stunting [height-for-age below 2 standard deviation (SD)] continues to affect 38.7% of the children younger than 5 years; 29.4% of the children were underweight in 2013-2014. Additionally, more than 6% of the women are severely undernourished (body mass index less than 16 kg/m2), which is among the highest in low-income countries and middle-income countries. Largely, tuberculosis, lower respiratory infections, diarrheal diseases, malaria, and typhoid continue to be the leading causes of burden among communicable diseases.[4] In India, the proportion of the population aged 60 years and above was 7% in 2009 (88 million) and is expected to increase to 20% (315 million) by 2050. Health requirements of these individuals are notably different from the younger generation. There is a demographic shi from communicable diseases to noncommunicable chronic diseases that contributes to 52% of the disease burden and more than 60% of deaths in the country.[5] More than 1 million deaths every year were caused by smoking alone.[6] The country’s tobacco-related death toll is projected to double by 2030. Nearly 65 million Indians have been diagnosed with diabetes.[7] The average age of a person having his/her first heart a ack is 50 years, at least 10 years earlier than in developed countries. Suicide rates in India are among the highest in the world, and suicide has emerged to be one of leading causes of This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. How to cite this article: Mahishale V. Universal health coverage in India: Reality or just a dream?. J Sci Soc 2016;43:3-5.
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death in young adults. Overall, ischemic heart disease, hypertension, chronic obstructive pulmonary disease, depression, hemorrhagic stroke, diabetes, and lower back pain were among the leading non communicable causes of the burden of disease in 2013.[8,9] The draft National Health Policy 2015 by the Government of India has endorsed the goal of providing “universal access to good quality health-care services without anyone having to face financial hardship as a consequence.”[10] Several key issues challenge this dra as our health care system has many fractured lines. The distributions of the government-run public hospitals are uneven and are always under the scanner for poor quality services. Surprisingly, 60% of the district hospitals do not offer intensive care services, and nearly a quarter of these hospitals continue to struggle with basic issues such as drainage and sanitation. Similarly, emergency obstetric care services are not available in more than 70% of community health centers, and only half the centers offer safe abortion services. A study of the availability of services, clinical staff, training, equipment, drugs, and basic infrastructure in primary care in the country found that “most facilities fall far short of minimum standards, with a long list of facilities, which are barely functioning.” It should be noted that as many as 50% of the public hospital beds are nonfunctional.[11] A consequence of the insufficient reach of the public sector has been the growth of a massive, heterogeneous, and mostly unregulated private health care sector. This poses a great threat as a substantial proportion of, and in some areas even the majority of the private providers might be unqualified or underqualified. At the other extreme of the private sector, thanks to government incentives in the form of tax exemptions and subsidized land allotments, business houses have set up large corporate funded hospitals focusing on specialized services, which are not within the reach of poor people and have mainly become incentive-based business centers. Unethical and irrational practices such as overbilling, unnecessary prescriptions, procedures, and diagnostic tests to generate revenue and meet targets set by the corporate hospital management have also been reported. Kickbacks from referrals to other doctors or from pharmaceutical and device companies are common. Ridiculous profiteering tempts many private practitioners and hospitals to indulge in unnecessary procedures such as computed tomography (CT) scans, stent insertions, cesarean sections and is disheartening. The poor quality is further compounded by huge scandals involving corruption in medical entrance 4
exams at state and national levels.[12] Such practices have flourished because of a weak regulatory climate. Very low public spending on health by both state and central governments is the major concern. Successive governments have promised 2-3% of gross domestic product (GDP) for the public health sector; however, government health expenditure currently stands at 1.28% of GDP. Other strategic issues that have a devastating influence on our health care system are fragmented health information system, irrational use and spiraling costs of drugs and technology, and most importantly weak governance and accountability. In the modern era of growing economies worldwide, it is mandatory for developing countries such as India to develop universal health coverage so as to meet the global standards of living. The successive governments should ensure that public investment in health care is adequate. There should be a strong political will to give priority to health care in India’s development agenda. The false belief that economic growth by itself will lead to sufficient health gains should be abolished. The missing trust between the various sectors concerned with health care such as the public and private health care sectors, the medical and other health professional sectors, and the pharmaceutical and device industries should be restored. Both the central and state governments should jointly launch a campaign to explain the principles and benefits of universal health coverage and engage all concerned stakeholders in an atmosphere of a national mission. There is an urgent need to expand coverage for high-priority health services to everyone and to eliminate out-of-pocket payments by increasing mandatory, progressive prepayment with pooling of funds. It should also be ensured that disadvantaged groups, low-income groups, rural populations, and people living in poorly performing states are not le behind. The private sector should be regulated with appropriate laws. The time has come for everyone including the political leaders and health care providers of the country to play their part in a multisectorial response to develop universal health coverage that is consistent with and dedicated to the promotion of public health and well-being of all the citizens of our country. Vinay Mahishale
Department of Pulmonary Medicine, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India E-mail:
[email protected]
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