We will certainly have more to say on India's health system before our return in May, but we wanted to start writing down some impressions as we pass the half way point of our India sojourn. We have spent a lot of time on India's health issues, and it has been great for the two of us to work on it together and compare notes. We have met with lots of Delhi experts, and in Kerala and in Tamil Nadu we've visited health facilities, public and private agencies and insurance providers. We are in and out of the Public Health Foundation of India. We've also met with academics and international development folks focused on health. And we have read a ton of stuff.
Bottom line? Health care delivery is certainly getting better over time and health outcomes are improving. But very slowly. India's health and nutrition indicators compare unfavorably to those of comparable countries. For example: 28% of Indian births are low birth rate, compared to 13% in sub-Saharan Africa and 8% in Latin America.
Health care is another area where neoliberal thinking has permeated government action. For years, India has called for increasing public support for health overall, but public health as a share of GDP has hovered at 1% for the past couple decades, all during the period of massive economic growth. This is dramatically lower than most comparable nations. Many nations, including China and most of Latin America, spend 3-4% of GDP on public health.
Actually, India's overall spending on health is not all that dramatically lower than many countries, but what is different is where the money comes from. Well over two thirds of India's health expenses is financed directly out of the pocket of its citizens. No wonder health care is the #1 reason for financial calamities for Indian families -- a health event is a real financial catastrophe. Think twice before you get treatment! If you like "consumer-driven" health care, then India is a great experimental site.
India does finance a large public primary care system, but it has been starved for cash for decades. Underfunded and deteriorating public facilities, often very poorly run, lack the necessary health care personnel, medications, and supplies. In the rural areas it is difficult, even with incentives, to attract and retain doctors. There is a shortage of nursing personnel. And when health personnel don't show up for work (a regular occurrence), the population goes without care and there are no consequences for the "non-providers".
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| A rural public health center in Tamil Nadu -- a fairly deteriorated place. While it is available to all residents, only the poor use the public facilities. |
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| The Center's labor and delivery wing. A couple of women were resting in the labor room at the time. |
The public is voting with their feet, shifting over to private facilities, even though all the studies show that many of the private facilities provide a lower level of care than the public facilities. Some private facilities for the poor do seem to be doing great work (below):
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| One of 7 Health Centers run by a non-profit in Tamil Nadu - a model that they hope to grow to include 500+ clinics. |
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Everyone seemed wonderful. The woman on the left is a health extension worker who registers families in the cachement area, collects health info, draws blood for tests and provides education to those who come to the clinic for care. The second person on the left is the ayurvedic doc who was provided with 3 months of training in allopathic (Western) medicine by the non-profit and follows a protocol which recognizes both practices. The woman in the middle was with us all day; she got her PhD from the University of Florida and then returned home to Tamil Nadu to try to improve the health care system here. The woman on the right is the office support person who helps individuals with their records, etc. In India AYUSH trained doctors are plentiful because their training is far shorter and less expensive than allopathic training. The clinic here is trying to use this lower level, nursing model (using the AYUSH docs) to provide basic care. They are hoping that they can provide health care in areas where MD's are mostly unavailable.
A cost sheet of the tests that are provided in the clinics. So figuring on 60 rupees (Rs) to $1.00 means that 80 cents buys a malaria test -- incredibly cheap by US standards and much cheaper than most high class private facilities in India.
Below is the other end of the private health care system:
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| The top 10% of the population has access to great health facilities, as Ken can attest. |
The Indian government calls for a substantial increase in public support for health care. Rahul Gandhi, the Congress Party heir apparent, calls for India moving from 1% up to 3% of GDP for health. But the political climate seems to call for more fiscal retrenchment at least in the short term.
“…it is not only a question of giving the health system more money… What is clear is that the country can ill afford to move ahead on parallel tracks – expanding financing of both the demand and supply sides without a clear notion of coordination and clear convergence.”
---L.C. Goyal, Secretary, India Ministry of Health
So if resources are to expand (and we do believe that they will in the years ahead), should India continue in the current direction of privatized health care and health insurance, or instead develop a strong foundation of public provision? This is a red hot debate in policy circles, with many on the Left strongly opposed to the former, but many others in favor of private health. This is very, very hard for us to sort through.
It is very hard to envision a dramatic reversal of private insurance and delivery in India. But it is also hard to see how an unregulated private system will provide quality, affordability, access and efficiencies to the average Indian -- the rickshaw driver, the construction worker, the farmer, etc.
The Indian system has some similarities to the US system, with a reliance on a public-private system of care as well as a mix of direct public delivery and health insurance mechanisms. We all know how poorly the US manages its health systems -- and costs!! In India, this public-private system will create huge management challenges for central and state governments. The required governance and regulatory systems have not yet been built or if they have been instituted they have deteriorated over time.
There is a lot of exciting stuff going on in health but no easy answers. More later...
There are health facilities everywhere you look in the cities.
Some are super specialty facilities. Some focus on medical niches.
Here to the right is the entrance to an Arurvedic hospital that focuses on
ancient Indian treatments.
Health is big business. In india, almost all care is paid for out of pocket.
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