Public Health in India
At about 1.28% of its gross domestic product (GDP), India’s spending on public health (as of 2017–18) is one of the lowest in the world. In the first year after coming to power, the Bharatiya Janata Party (BJP) government reduced the health budget by around 15%. The budget allocated for the National Health Mission has declined between 2014 and 2020, and the government’s insurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY) continues to be riddled with inefficiencies.
Meanwhile, significant developments have been made in terms of reducing the maternal mortality rate by about 77%; there has been progress in achieving immunisation coverage, and the urban–rural divide in institutional deliveries has been bridged to a great extent. However, much remains to be done to ensure and safeguard people’s right to health. The specificity of the Indian situation lies in the fact that it has not been able to overcome many of the “older” diseases like malnourishment as well as some of the deadly infectious diseases like tuberculosis among the poorer sections of the population, and yet, at the same time, economic development has led to an epidemic of newer diseases, the so-called “diseases of industrialisation” like diabetes, cardiovascular diseases, accidents, addictions, etc.
There is a significant shortage of doctors, especially in rural areas. Health workers are often poorly paid and poorly treated. Medical costs in both urban and rural areas are skyrocketing, with high out-of-pocket expenditure, leading to inequity in healthcare services. Mental health care and rehabilitation facilities for persons with disability remain relegated to the margins of government policy.
A National Health Policy was announced in 2017. It proposed raising public health expenditure progressively to 2.5% of the GDP by 2025 and advocated a major chunk of resources to primary healthcare, followed by secondary and tertiary healthcare. However, it remains unclear where the resources will come from and little is said about the changing family structures and limited income security.
In this resource kit, we cover 10 aspects of public health that have received scholarly attention in the pages of the EPW between 2014 and 2020.
In the months leading up to the 2019 general elections, the Association for Democratic Reforms surveyed over 2.7 lakh eligible voters to find out “what voters want.” Nearly 35% of respondents said access to better and more affordable healthcare was of prime importance, second only to employment opportunities. The previous United Progressive Alliance government had failed in its promise to increase healthcare spending to 3% of the GDP. Unfortunately, the BJP has promised even less. The first union budget released by them in 2014 slashed healthcare expenditure by 20% and the NITI Aayog believed that India could achieve its health objectives by spending as little as 1% of GDP on healthcare. While the National Health Policy, released in 2017, aimed for healthcare expenditure to achieve 2.5% of GDP, it also saw the withering away of healthcare as a public good by relying upon the private sector to provide medical care. The AB PMJAY, the government’s flagship health insurance scheme, which was released in 2018, made this transition explicit: it promised up to Rs 5 lakh health cover for over 10 crore people by relying on private hospitals for care and treatment. The Indian Medical Association, however, has questioned the central government’s outlook towards healthcare, stating that “no hospital” would be able to function under the PMJAY’s proposed rates.
The functioning of healthcare professionals and institutions is mired in controversy. In India, the respective medical councils for allopathic, ayurvedic, homoeopathic and Unani systems of medicines are legally empowered bodies meant to ensure that all members of these councils follow the code of conduct laid down by these medical councils. However, these bodies have failed to do so. For example, in Maharashtra, through a right to information query, it was revealed that between January 2014 and September 2015, the Maharashtra Medical Council received 193 complaints against doctors, out of which not a single one was decided till October 2015. The medical councils and their functioning need a huge overhaul, including the continuing medical education courses conducted by them.
Despite the publicity that surrounds schemes that are (re)launched by the current government, the approach is often piecemeal and selective, the goal being optics rather than action. The COVID-19 pandemic has laid bare the structural failures of the country’s healthcare system and the absence of a concrete central policy to provide a road map for the country’s future and the health of its citizens.
The healthcare system in India is characterised by an expanding private sector and prohibitive out-of-pocket (OOP) health expenditures that hinder access to healthcare, particularly for the poor and the vulnerable. There has been an increased push towards universal health coverage, which is sought to be achieved primarily through private health insurance that serves the commercial interests of the insurance companies, pharmaceutical companies, and the private sector, which are all improperly regulated. Private hospital chains have burgeoned in metropolitan, tier I, and tier II cities, and are characterised by heavy expenditure on marketing to lure patients, practices of giving “cuts” to doctors, and an approach to maximise profits when recommending treatment.
Pricing of medicines (essentials) has been an issue of concern for successive governments, but nothing much has been done at the statutory level to ensure free medicines for the poor. The policy overtone is historically preponderated by “price control,” which, as of 2018, could encompass even less than a quarter of the domestic pharmaceuticals market. A major impediment to drug price control in India lies in the structure of the domestic pharmaceuticals market, which is highly concentrated with the top 10 companies, accounting for more than two-fifths of the total sales. At the same time, deficient supply chain management prevents the utilisation of low-cost generic drugs from picking up. Procurement delays, errant supplies, counterfeit drugs are rampant. Research indicates that except for a few non-communicable diseases—including cardiovascular diseases, hypertension, diabetes and cancer—it is mainly the market demand that dominates over the public health priorities in drug discovery in India. Much of India's nutrition agenda is also driven by the private sector through public–private partnerships and so-called multi-stakeholder dialogues.
The private sector also dominates Indian medical education, and this has led to regional inequality in the production and distribution of doctors. Even though empirical evidence may be lacking, except in very rare cases, private colleges providing professional education (medical education in particular) run on “capitation fees,” a large sum of money changing hands without accountability.
The current paradigm shift towards demand-side financing of healthcare is indicative of the fact that the government is striving to limit its role in facilitating access to healthcare while leaving the provisioning to the private sector.
The fissures in India’s rural healthcare system are stark.
The National Health Mission has been one of the worst affected programmes due to budget cuts imposed by various state governments in the health sector. In rural areas, in particular, there are persistent issues with input utilisation. For instance, in Maharashtra, during 2017–18 till the end of January 2018, only 56% of total public health expenditure had been utilised by the state government, and for medicines, the expenditure was only 27% of allocations. A study of the implementation of the Mahatma Jyotiba Phule Jan Arogya Yojana also found a worrying lack of awareness regarding the scheme among intended beneficiaries along with a prevalence of agents who sought bribes from patients in need.
In addition to this, as per the rural health statistics of 2016–17 by the Ministry of Health and Family Affairs, there is a severe shortfall in health workers and doctors both at the primary health centre (PHC) and the community health centre (CHC) levels, with respect to the required number. In some states, the doctor–population ratio is as worrying as 1:21,016, especially given the WHO-mandated ratio of 1:1,000.
Despite provisions for tribal development, nutrition status of adolescent girls and women is largely worse in tribal regions compared to non-tribal regions. Lack of connectivity and the state of healthcare establishments have marred progress in terms of institutional deliveries and neonatal care. Access to menstrual products as well as awareness regarding menstrual health also remains poor.
Access to safe drinking water remains a concern in rural areas across states. In terms of food and nutritional security, while some states have done well in the implementation of the public distribution system (PDS), researchers have raised concerns regarding a possible link between the quality and type of rations and a rise in the incidence of Type II diabetes and cardiovascular diseases in rural India.
The central government, with whom the responsibility of controlling the spread of infectious diseases rests, is yet to articulate a concrete framework for disease control. This is despite the country’s recent history with epidemics: since the turn of the century, India has seen the outbreak of Severe Acute Respiratory Syndrome, Japanese encephalitis, chikungunya, H1N1, and more recently, the Nipah virus and the COVID-19 coronavirus. Despite this, a competent policy framework to deal with outbreaks remains elusive. The World Health Organization in 2015 also noted that in the event of an outbreak, the Indian state did not even have a standard operating procedure in place to combat its spread—this perhaps explains why the nationwide lockdown in March 2020 was called with seemingly no prior warning and without a comprehensive exit strategy.
While the elimination of polio in 2011 was commendable, other infectious diseases are yet to be curtailed. The strength of healthcare systems to deal with such diseases is extremely poor: nearly 5 lakh people still fall victim to tuberculosis each year. Cholera, a rarely reported disease, saw a high number of cases being recorded as recently as 2017, with the WHO warning that India was at risk of an outbreak. Diseases such as dengue continue to claim lives each year, with the more marginalised sections invariably bearing the brunt of the state’s healthcare failures. While the centre should be learning from states—Kerala successfully curtailed the spread of the Nipah virus as well as controlled their COVID-19 curve—and working in tandem with them to create constructive policy, politicking continues even during a pandemic.
Since October 2014, the Government of India has worked towards the goal of eliminating open defecation by 2019 through the Swachh Bharat Mission. Although rural latrine ownership increased considerably over this period, open defecation continues to be very common in Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Open defecation in India is particularly threatening for health because of the high population density. Slum populations in particular are widely exposed to faecally transmitted infections (FTIs), with children and pregnant women being the most vulnerable. This risk is exacerbated by inadequate water supply and sanitation infrastructure, lack of water linked to inadequate hygiene, poor personal and environmental hygiene and faecal-oral pathogen loads in the environment. Studies find that most people do not recognise open defecation as a threat to health. Few households construct affordable latrines, many people who own latrines nevertheless defecate in the open, and people in households with government-provided latrines are particularly likely to defecate in the open.
Improper disposal of household waste is also a major concern in both urban and rural areas. In particular, increased lifespan, the rise of non-communicable diseases, the growing buying power, and better access to healthcare have resulted in the increased generation of household biomedical waste.
Water availability, its access by urban poor and water quality have emerged as key concerns for urban planners. Making safe drinking water available and accessible to the urban poor requires integrated public health action involving individual behavioural change, community action and a different approach by government agencies, whose concerns are only limited to laying pipes for water supply. The total economic cost of water-related diseases includes the cost of treatment and income loss in case of working members, and this is particularly worrying in the case of poor households with limited resources.
Health problems stemming from high pollution levels are serious in dozens of cities in India. There is no consensus on the details regarding the sources of the pollutants. Estimates suggest that over half of India’s population lives in areas that exceed the Indian National Ambient Air Quality Standards for fine particulate pollution. Reducing pollution in these areas to achieve the standard is estimated to increase life expectancy for these Indians by 3.2 years on average.
In India, there are only 20 healthcare workers (HCW) per 10,000 people. Even though an estimated 56,748 doctors are said to graduate from medical colleges across the country each year, this rise is meagre, especially when compared with India’s population growth rate—an estimated 26 million per year. Moreover, the geographic distribution of doctors is highly uneven: In urban areas, the concentration of doctors is nearly four times than in rural areas, despite these areas consisting of only 29% of India’s population. If these numbers are not stark enough, a WHO report in 2016—albeit based on the 2001 census—found that over 50% of India’s HCW lacked any sort of medical qualification.
While the praising of HCWs is seen as a nation-building exercise amidst a pandemic, the fact remains that most secondary and tertiary HCWs have long been ignored and systemically marginalised by the state. Their duties—which remain integral to a patient’s well-being and recovery—often fall outside the ambit of what one considers to be “work.” The accredited social health activist (ASHA) workers, for example, play a vital role in stemming the spread of infection through timely interventions and are often on the front lines of a disease outbreak. Every government health programme is implemented by ASHA workers, yet they do not receive fixed wages.
Today, with inadequate HCWs and poor infrastructure—ranging from medical centres to basic equipment—and an increasing number of COVID-19 cases across the country, the future looks bleak; when those on the front lines fall ill, there is no one to replace them.
Despite having the world’s largest nutrition programme, eliminating child malnutrition remains a distant dream in India. Approximately 25 million children are considered wasted (low weight for height), of which 8 million are said to be severely malnourished. Furthermore, malnutrition accounts for 69% of deaths among children less than five years of age. Why do nutrition delivery systems still fail to reach children? The issue is largely structural: the Integrated Child Development Scheme (ICDS)—the BJP government’s flagship nutrition scheme—excludes the poorest households from accessing its benefits. This means that while the overall instances of malnutrition may be reducing, states with poor nutrition statistics continue to fare poorly. Together, Bihar, Chhattisgarh, Odisha, and Uttar Pradesh account for 45% of stunted children in India. Children there remain undernourished, despite government schemes to improve nutrition delivery in these states as well as across the country. Moreover, the 2020 Budget has been criticised for underfunding the ICDS.
The Midday Meal programme that is supposed to provide all schoolgoing children with cooked meals free of cost, suffers in terms of both coverage and quality of food provided. Hundreds of children have either died or been hospitalised through this intervention. There is a clear absence of monitoring the quality of food—from the purchasing of provisions to the method of cooking.
Social security schemes, while well intended, have clear, systemic flaws and are in urgent need of review.
There have been significant improvements in the utilisation of maternal healthcare services in India over the last two decades, especially in augmenting institutional deliveries and reducing maternal and infant mortality. Financial assistance through schemes, such as the Janani Suraksha Yojana, has encouraged women to approach public health facilities for childbirth. But, most of the deliveries, even uncomplicated ones, happen in district hospitals. Several studies have also shown a persistently high level of out-of-pocket expenditure on maternal healthcare and the growing inequity in utilisation of these services. It is also established that poor and vulnerable women are systematically deprived of antenatal and postpartum care.
A large number of women continue to be deprived of reproductive choice. The poorest sections of the population who have the highest unmet need for contraceptive services are the worst affected. For several decades now, women in India have been the primary acceptors of contraception and bear most of the burden of fertility regulation. The phasing out of male health workers at the grassroots level suggests that the government’s policy has resigned itself to this trend. Overall, men’s participation in women’s healthcare is generally low.
Women's suffering and pain is often not taken seriously by doctors and medical establishments. Gynaecology practice in most parts of the country continues to validate the patriarchal and binary language of normal and abnormal women. Confidentiality, non-judgmental consultation, and proper explanation of medical procedures are rarely followed as norms by gynaecologists, even in metropolitan cities.
Women who migrate for work, particularly in the unorganised and informal sector, face multiple reproductive health problems, due to the back-breaking work and poor sanitation and hygiene conditions, including menstrual hygiene. This situation, along with the absence of accessible public health facilities, allows a fertile and lucrative ground to private healthcare facilities to provide unnecessary and extreme treatments, even for minor gynaecological ailments. Sex selective abortions and unnecessary hysterectomies are prime examples of this. Women in rural India still face challenges in acquiring hygienic menstrual products, clean water for washing and a private space for changing. Even poor women in urban areas are often forced to opt for unhygienic ways to catch the flow and hide signs of menstruation.
The proportion of underweight women has gone down in the past 10 years, and this decline has been relatively higher in the poorer populations. However, the numbers are still high, along with the prevalence of anaemia and other nutritional deficiencies even among urban middle-class women. The functioning of nutrition programmes is often undermined by other procedural or budgetary lapses, such as inadequate or weak planning for nutrition interventions for pregnant women, delayed approval of budgets and release of funds, and shortage of staff and infrastructure.
Medical termination of pregnancy, while legal in India, is still restrictive. The rights of surrogate mothers and the impact of assisted reproductive technologies on women’s bodies continues to be debated. Mobile health (mHealth) initiatives have received a fillip, with increased cell phone ownership and improved network coverage all over the country. However, gendered asymmetries have so far been taken into account poorly in planning mHealth services.
Violence against women in India is increasingly being recognised as a public health issue. Studies find that intimate partner violence has adverse impacts on pregnancy outcomes, maternal and newborns’ health and related healthcare access. There is an urgent need for public hospitals and healthcare professionals in both urban and rural areas to intervene and prevent violence against women since these are often the first points of contact for affected women.
Three groups among the population are the most neglected in terms of policy coverage, availability of healthcare infrastructure and utilisation—persons with disabilities (PWDs), the elderly and those engaged in hazardous occupations.
In India, PWDs are usually able to access proper medical surgeries, but much-needed post-surgery medical care like physiotherapy is seldom available and accessed. Studies have found that most of the PWDs did not have enough awareness about artificial limbs and other adhesives required as aids to persons with amputation. PWDs also face gross negligence and apathy from service providers in the system. Many are found to not even be aware of the disability certification process. Locations for receiving assistance are often inaccessible and the aids provided are of poor quality. Overall, there is an alienation from the rehabilitation system because PWDs are rarely involved in the planning and implementation of any such facilities for them. While the Rights of Persons with Disabilities Act, 2016 is laudable in its intent and procedural detail, it is largely silent on disabilities among the elderly.
India’s elderly population (60 years or more) is growing three times faster than the population as a whole. The increase in life expectancy over the last few decades, however, has not translated into a healthier life. There is a growing menace of non-communicable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes among the elderly. This is likely to have disastrous consequences in terms of the impoverishment of families, excess mortality, lowering of investment, and consequent deceleration of economic growth. This is true more so because these demographic changes are taking place in the context of changing family relationships and severely limited old-age income support. In India, dementia is the primary cause of chronic disability among the elderly community. However, early clinical diagnosis of dementia remains a challenge.
Safety of workers is often perceived to come in the way of “ease of doing business” because of added costs of safety equipment and coverage of healthcare costs in the case of accidents, death or disability. Even though poor availability and access to occupational health services are likely to cause huge economic losses, there is an absence of any long-term comprehensive healthcare for workers. Workers are often found using their own preventive measures, especially in the construction, mining and cement industries. Nationally, there is a serious shortage of trained occupational health professionals, including occupational physicians, industrial hygienists, occupational nurses, and safety specialists.
“To treat or not to treat?” In India, it is the latter. The National Mental Health Survey, conducted in 2015–15, estimated that around 83% of Indians with mental illnesses have not received any form of treatment. Amidst the COVID-19 lockdown, which has isolated many in various parts of the country, experts have predicted an imminent mental health epidemic. But, for people who do require help, how do they access it? Notwithstanding the stigma and other social barriers that are associated with mental health and constructive conversations surrounding it, good psychiatric care remains unaffordable for many.
Moreover, public discourse tends to sensationalise issues of mental health, perhaps in an effort to treat it as an exception rather than as a function of the times we live in. Public directives too, are banal and lack sensitivity: the Ministry of Health and Family Welfare’s recent directives on coping with depression drew flak from professionals because, ironically enough, it did not state seeking professional help as a viable solution. The Mental Healthcare Act, 2017 states that professional help should be made accessible to all, but does not consider the infrastructural shortcomings—trained psychologists are already few and the centre has not set aside any budgetary allocations for this endeavour.
Curated by Sohnee Harshey and Kieran Lobo
Design inputs by Vishnupriya Bhandaram
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