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Hunger / HDI | Public Health
Public Health

Public Health

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What's Inside

The report titled 'COVID-19 Third Wave Preparedness: Children’s Vulnerability and Recovery' (released on 2nd August, 2021) is the outcome of a two-part series of online consultative meetings hosted by National Institute of Disaster Management (NIDM, Delhi). These working group consultative meetings largely included  stakeholders from diverse backgrounds -- Central  Government, State  Governments, Civil Society Organisations (CSOs), social workers, humanitarians, academicians, scientists and researchers. Drawing lessons from the first and second waves, through the deliberations by leading experts during these meetings, the NIDM has been able to produce in the form of final outcome, recommendations for the preparedness of the third wave on the issues related to children and women and their well-being. Kindly click here to access the report.

The consultative meetings held by NIDM with various stakeholders strongly recommended: a home care model, ramping up of vaccination especially for parents, nurses and other front-line workers, immediate recruitment of healthcare staffs and medical facilities for children, guarantee food security especially for the vulnerable amongst vulnerable, strengthen the community level engagement and risk awareness and communication, zero tolerance towards sexual abuse of children and women and raising awareness through a massive public outreach campaign. There is a huge gap between urban and rural India in terms of awareness, digitisation and medical facilities. It seems like the pandemic outbreak has only exacerbated social inequities and highlighted shortcomings of our society. Hence, the government must prioritise rural India and vulnerable groups in order to cope with the ongoing pandemic. This special report also outlines the women-children complementarity, suggesting that a child’s inclusive growth largely depends on that of the mother.

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The report titled Inequality Report 2021: India's Unequal Healthcare Story examines the status of inequality across various indicators of health among different sections of the population from 2005-06 to 2015-16. The report analyses the government interventions made in terms of health programmes and its impact on health inequality. It also includes ground experiences of people, particularly the marginalised groups, during the pandemic.

The key findings of the Oxfam India's Inequality Report 2021: India's Unequal Healthcare Story (released on 19th July, 2021) are as follows (please click here to access): 

• Growing socio-economic inequalities in India are disproportionately affecting health outcomes of marginalised groups due to the absence of Universal Health Coverage (UHC), reveals Oxfam India’s Inequality Report 2021: India’s Unequal Healthcare Story.

• The new report by Oxfam India provides a comprehensive analysis of the health outcomes across different socioeconomic groups to gauge the level of health inequality that persists in the country. The report shows the general category performs better than Scheduled Castes-SCs and Scheduled Tribes-STs; Hindus perform better than Muslims; the rich perform better than the poor; men are better off than women; and the urban population is better off than the rural population on various health indicators. The COVID-19 pandemic has further exacerbated these inequalities.

• The public healthcare system in India with its weak and understaffed infrastructure has been overburdened with the consistently rising cases. Private healthcare providers, on the other hand, were charging exorbitant prices, preventing the middle-class and the poor from getting diagnosed and treated until the government intervened to cap their prices. Even then, private healthcare has remained inaccessible to the poor while the rich have easily availed its services. As such, the poor and the vulnerable have mostly been dependent on the overburdened public healthcare facilities — with insufficient number of beds and inadequate human resources — for treatment or have gone without being diagnosed and treated.

• Health inequalities are linked to and reflect socio-economic inequalities. Often times, it is the socio-economically marginalised communities that suffer from ill-health the most. The ongoing pandemic has revealed that the health systems in most countries are under-prepared to cope with any major health emergency and its unequal impact on the have and the have-nots.

• Over the last few decades, India has made great progress in healthcare provisioning. Yet, progressively, the trend has been towards supporting the growth of the private sector in healthcare. This growth has only exacerbated the existing inequalities leaving the poor and the marginalised with no viable healthcare provisions. High costs of health services and lack of quality leads to further impoverishment of the disadvantaged.

• The private health sector provided only 5-10 percent of total patient care when India gained independence. Today, it accounts for 66 percent of hospitalization and non-hospitalization cases and 33 percent of institutional births. This growth has been boosted by government concessions and has attracted domestic and foreign companies to set up tertiary care and super speciality hospitals. Within the country, the private formal sector has a distinct customer base. They are the urban-rich. Dehury et al. writes that private hospitals ‘cater to a pool of patient community having health insurance, corporate tie-ups and referrals from general physicians. Usually, the paying capacity of these patients [are] higher than the common Indian citizen…these hospitals cater to the Indian elite class and organized sector workers having all financial protection.’

• The private sector is geared towards profits whereas the public provisioning of health services ensures that the poor and the marginalised have equal access to quality healthcare services closer to home. India’s public health provisioning has, however, been weak. The public expenditure on health by the central government as a percentage of GDP was a mere 0.32 percent in 2019-20.

• The combined expenditure by state and central government was about 1.16 percent of the GDP in 2019, rising marginally by 0.02 percent from 2018 — falling far behind the goal of making health expenditure 2.5 percent of the GDP. The per capita health expenditure is highest in Arunachal Pradesh at INR 9,854 and lowest in Bihar at INR 697. In the 2021-22 budget, the health ministry has been allocated a total of INR 76,901 crore, a decline of 9.8 percent from the revised estimates of 2020-21 at INR 85,250 crore. 

• Public funds for health has also been invested specifically in secondary and tertiary care rather than in the provisioning of primary healthcare.  

• The public sector has prioritized secondary and tertiary care over primary care. Yet, experts acknowledge that primary care is the cornerstone of achieving equitable delivery and access to quality healthcare by all. While focus has been put on achieving Universal Healthcare in India; the government has selectively adopted the insurance model as a way to universalise healthcare instead of enhancing the primary health care system. As such, access to good quality public healthcare has remained fragmented and India is still far away from achieving universal coverage. The rich can avail healthcare from high-end private providers but the poor are stuck with a difficult choice. They either have to incur debts by availing health care from private providers or depend on a poor public healthcare system.

• The Planning Commission in 2011 had observed that expenditure in secondary and tertiary care was drawing away attention from primary health services. Research studies substantiate this position and it is argued that ‘[s]ubstantial proportions of the health budgets have been spent on…high-end tertiary medical services — all of which largely benefits the middle classes and detracts from the provision of public health services.’ Studies have also attributed India’s high disease burden to the government’s exclusive focus on the urban-oriented curative medical model. The government’s focus on ‘a heavily medicalized and hightech curative medical interventions’ has derailed the goal to make quality and affordable public healthcare accessible to all irrespective of their ability to pay. The result has been a widening of health inequalities along caste, class, gender and geography.

• To make the goals of National Health Mission (NRHM and National Urban Health Mission were subsumed under the NHM in 2013) a reality, there needs to be a strong public health infrastructure in place, even in hard-to-reach areas. Sufficient medical supplies, equipment, drugs and trained medical staff in health centres should be the standard. On the contrary, public health centres remain understaffed with limited supplies.

• Among other things, the Inequality Report 2021 on health has recommended the government to increase health spending to 2.5 percent of Gross Domestic Product (GDP) to ensure a more equitable health system in the country; ensure that union budgetary allocation in health for SCs and STs is proportionate to their population; prioritize primary health by ensuring that two-thirds of the health budget is allocated for strengthening primary healthcare; state governments to allocate their expenditure on health to 2.5 percent of Gross State Domestic Product (GSDP); the centre should extend financial support to the states with low per capita health expenditure to reduce inter-state inequality in health. It has asked to widen the ambit of insurance schemes to include out-patient care. The major expenditures on health happen through out-patient costs as consultations, diagnostic tests, medicines, etc. While the report does not endorse Government-financed Health Insurance Schemes (GFHIS) as a way to achieve UHC and stresses that insurance can only be a component of it, it is imperative that GFHIS widens its ambit to include outpatient costs as a way to reduce out-of-pocket expenditure (OOPE).

• The Constitution of India does not guarantee a fundamental right to health though it does refer to the role of the government in the provisioning of healthcare to all its citizens. Therefore, the right to health should be enacted as a fundamental right that makes it obligatory for the government to ensure equal access to timely, acceptable, and affordable healthcare of appropriate quality, and address the underlying determinants of health to close the gap in health outcomes between the rich and poor.

• With the lockdown aimed at checking the spread of COVID-19, health systems prioritized services related only to COVID-19. Human and material resources like hospitals, beds and intensive care units were diverted towards the management and treatment of COVID-19 patients. Health services catering to non-Covid illnesses were halted, leading to unprecedented hardships and sufferings for chronic patients and those requiring immediate medical intervention such as pregnant women. Accessibility to non-Covid medical services were grimmer for patients in rural and hard-to-reach areas as compared to urban areas due to the unavailability of health centres in the vicinity and the lack of transportation facilities.

• Disruptions in the availability of drugs for non-communicable diseases (NCD), tuberculosis (TB), contraceptive and other essential services were also reported. Telemedicine — the practice of caring for patients remotely — for which guidelines were issued by the Government of India in March 2020 to facilitate access to medical advice made consultations easier. However, for those with no smart phones and internet connectivity, particularly in rural and hard-to-reach areas, seeking medical advice remained a difficult task. The immunization drive was also disrupted. India vaccinates around 20 million children every year and its disruption might add to the largest number of unimmunized children in the world. 

• The National Health Profile in 2017 recorded one government allopathic doctor for every 10,189 people and one state-run hospital for every 90,343 people. India also ranks the lowest in the number of hospital beds per thousand population among the BRICS nations — Russia scores the highest (7.12), followed by China (4.3), South Africa (2.3), Brazil (2.1) and India (0.5). India also ranks lower than some of the lesser developed countries such as Bangladesh (0.87), Chile (2.11) and Mexico (0.98).

• The current expenditure on health, by the Centre and the state governments combined, is only about 1.25 percent of GDP which is the lowest among the BRICS countries — Brazil (9.2) has the highest allocation, followed by South Africa (8.1), Russia (5.3) and China (5.0). It is also lower than some of its neighbouring countries such as Bhutan (2.5 percent) and Sri Lanka (1.6 percent). The low priority given to health expenditure is also reflected in the share in total expenditure of the government, which is only 4 percent whereas the global average stands at 11 percent. In Oxfam’s Commitment to Reducing Inequality Report 2020, India ranks 154th in health spending, fifth from the bottom. This poor spending is reflected in the inadequate health resources and infrastructure. Only around 50,069 health and wellness centres (HWCs), which are envisaged to deliver comprehensive primary healthcare (CPHC) closer to homes, are functional. These centres are only 65 percent of the cumulative target for 2020-21. Moreover, in 2019, less than 10 percent of PHCs were funded as per IPHS norms whereas the rest remained underfunded. 

• Different studies have proved that low public health expenditure yields worse health outcomes. Studies by Barenberg et al. investigated the impact of public health expenditure on Infant Mortality Rate (IMR) and found a negative relationship between the two. Farahani et al. evaluated the relationship between state-level public health spending of India and individual mortality across all age groups using household-level data from the third National Family Health Survey (NFHS-3) showing that a 10 percent increase in public spending on health decreases mortality by about 2 percent, with effects mainly concentrated on women, the young, and the elderly.

• The out-of-pocket health expenditure of 64.2 percent in India is higher than the world average of 18.2 percent. Exorbitant prices of healthcare has forced many to sell household assets and incur debts.

• The global average for life expectancy is 72.6 years but India (69.42) remains below the global average. It is also lower than the neighbouring countries Nepal (70.8), Bhutan (71.8), Bangladesh (72.6), and Sri Lanka (77) and its BRICS counterparts Brazil (75.9), China (76.9), and Russia (72.6).

• A comprehensive provisioning of public health as water, sanitation and primary healthcare is the most efficient and cost-effective way to achieve UHC around the world.

• Evidence from Thailand and Sri Lanka, which have performed better than India with regard to universal access to healthcare, shows that these countries have a high public provisioning of services. Also, evidence from developed countries like Germany, Sweden, Canada and developing countries like Costa Rica reveal that successful insurance-based healthcare system was attained with high levels of public spending and government provisioning of healthcare services.

• The Oxfam India report says that ‘Kerala invested in infrastructure to create a multi-layered health system, designed to provide first-contact access for basic services at the community level and expanded integrated primary healthcare coverage to achieve access to a range of preventive and curative services…[,] expanded the number of medical facilities, hospital beds, and doctors…[and] public health and social development initiatives… aided in creating the environment for a strong and effective primary care system.’
 

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