Despite many programmes, healthcare delivery has not improved in rural areas. Our primary healthcare centres are in tattered state. Facilities at these centres must be improved to achieve the aim of Universal Healthcare Coverage, writes Dr Shuchin Bajaj, Founder Director, Cygnus Hospitals for Elets News Network (ENN).
India is a land of vast inequalities. On the one hand we are sending probes to Mars with the latest cutting edge technology, on the other, we are struggling to provide reliable public transport to our teeming urban swathes. On the one hand, we have condominiums, villas and gated communities, on the other we have urban slums sprawling out as far as our eyes can see. On the one hand we have arguably the best technology minds in the world, on the other, we are struggling to make digitisation an integral part of our healthcare scenario.
As we stress on globalisation and privatisation, a quarter of our population is slipping through all safety nets, to land in debt and resultant poverty. Almost 50 million people slip below the poverty line every year due to healthcare costs. We have more than a quarter of a billion people living with a burden of disease estimated at $30 billion, about 5 per cent of our GDP.
About 60 per cent of our healthcare expenses are out of pocket, which is one of the highest in the world. Such is the lack of trust in the public health system that not only do 80 per cent of the wealthy seek treatment in the private sector, but a similar percentage of the poor also goes to private practitioners, even though the treatment may be of low quality and provided by untrained practitioners.
Some unfortunate statistics reflect this state of affairs:
• One quarter of hospitalised Indians slip below the poverty line because of hospital expenses alone.
• Hospitalised Indians spend more than half of their annual expenditures on healthcare.
• More than 40 per cent of those hospitalised borrow money or sell assets to cover expenses.
• The poorest 20 per cent Indians have more than twice the rate of mortality, malnutrition and fertility of the richest 20 per cent.
To address this gap in our healthcare delivery, the perception would be to first take care of the affordability, and thus the budgetary provison of the National Health Plan providing Rs five Lakh insurance cover to 50 crore Indians seems the panacea that we have all been waiting for. But is it really the answer? Rather than spending the little money that is available for the health budget on insurance schemes that benefit only corporate hospitals, wouldn’t it be more prudent to spend it on improving our primary healthcare system? Has digitalisation made this onerous task, which earlier involved sending reluctant doctors into far flung villages, easier?
We are spending about 1.1 per cent of our GDP on healthcare. Regardless of the growth numbers paraded by the various agencies to us, be it 6% or 8% or 9%, the health budget always remains the same. We have left the cores of our development, i.e health and education, at the mercy of the easily corruptible and frequently incompetent, private sector. Countries like Thailand, Brazil, Sri Lanka, Turkey etc., which were way behind us at the time of independence, have surged ahead of us in all outcomes and indices, by their focus on primary healthcare in their initial years of development. Why have we not been able to do it? Have we been spending the wrong way? Have we forgotten that the foundation for development is not airports, flyovers or roads, but health and education, which all Governments have been neglecting completely?
We have also forgotten that poverty has a multi-dimensional impact, related to sanitation (including access to clean drinking water), nutrition and housing. Lack of these things will continue to create an unsustainable disease burden for the community. An unhealthy community, suffering from diarrhea and malnutrition, cannot lead to a fast growing healthy economy.
Our contribution to inclusive healthcare development agenda and commitment to ‘universal healthcare for all’ mission, have to be an integral part of our service delivery within the entire healthcare ecosystem, by ensuring free medicines and discounts on pharmacy, consultancies and surgeries to the economically weaker population of the society.
We also have to mobilise the larger community on various facets of health awareness through health/medical camps for rural outreach on issues such as diabetes, joint replacements, emergency medical first-aids, maternity, cardiology, preventive care etc leading to socio-economic justice and poverty alleviation.
Our limited amount of money has to be invested intelligently in a way that we get maximum returns. Primary healthcare, which focusses on preventing people from getting sick, is the only way out. Every time we set up a Cardiac Cath Lab in a small town, I always ask this question from the people who are at the inauguaration. “Would you want to have a heart attack and be treated really well at our centre, or would you rather not have a heart attack at all?” Unsurprisingly, the answer is always the same. Nobody wants to have that heart attack but expectedly, our Government machinery refuses to see this. We have a large scheme offering free dialysis to many communities, but we forget that more than three quarters of kidney failures are caused by uncontrolled diabetes and hypertension, which can easily be treated at the primary health centre level, if we have the will to do it.
We can look at the example of the National Health Scheme (NHS) of the UK, where more than 85 per cent of diabetics, hypertension and COPD (Chronic obstructive pulmonary disease) patients are treated at the primary care level. This figure was less than 15 per cent in the early 1980s. The progress made by the NHS is largely due to the focus on primary healthcare and empowerment of general practitioners and nurse practitioners.
So what is stopping us from treating people at the village level. Infrastructure is one of the major reasons. It is very difficult to attract doctors to work in villages when more than 25 per cent of our PHCs don’t even have electricity and water connections. Absence of overall urbanisation, lack of schools and recreation facilities also are a dampener to the relocation plan of doctors to small towns and villages.
So how can digitalisation help in this scenario? We have to forget the doctor centric healthcare scenario, and focus on the patient centric one with the doctor available for consultations digitally as per need.
We should keep in mind that for our 650 thousand villages, we have more than one million ASHA workers. Why can’t we upskill them and give them the support of diagnostic and pharmaceutical decision making through digital means? Digiceuticals is an upcoming field which has the potential to transform healthcare delivery completely. If the ASHA worker can impart nutritional education to school girls, we can prevent a lot of malnourished children, which later, go on to suffer from various disorders like obesity, hypertension and diabetes. Digital platforms can easily help in this endeavor.
We should also look at upgrading our nurses into nurse practitioners and involving the Ayurvedic and Homeopathic practitioners in healthcare delivery to underserved communities.
Digital platforms can help in upskilling these health practitioners moving them from the periphery of healthcare delivery to the centre of the action.
We have to flip the balance of healthcare from curative, which takes up more than 80 per cent of the total health expenditure of the country, to preventive healthcare, which currently uses only nine per cent of the total health expenditure.
Sustainable development goals lay a lot of emphasis on health, but the sheer size and scale of our country means that the success of global goals to a large extent depends on the progress made by India.