New Delhi: Lack of regulation in the private sector, and the need to strengthen resources, governance and quality in the public sector — these are some of the issues in the Indian health system that require urgent redressal, according to a World Health Organization (WHO) review.
It has also cited low public health spend, manpower constraints and drug prices — perennial problems in Indian healthcare — as matters that need addressing.
Authored by Dr Sakthivel Selvaraj from the Public Health Foundation of India (PHFI), Delhi, and Dr Swati Srivastava from the Medical Faculty and University Hospital, Heidelberg University, Germany, among others, the review is part of the WHO’s ‘Health Systems in Transition (HiT)’ profiles, which are country-based reports of health systems. It was published on 30 March.
While the review was critical of India’s drug regulatory system, it lauded the country’s progress on parameters such as infant mortality and life expectancy. It also found that utilisation of government health schemes was higher in richer states than in the poorer ones.
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In drug regulation, ‘poor infra, confusing laws’
Commenting on India’s drug regulatory system, the review stated that, at the sub-national level, it is “characterised by poor infrastructure, lack of skilled personnel, confusing legislation and multiple authorities, contributing to the poor implementation of rules and regulations”.
It also noted that current price ceiling mechanisms of medicines are “geared towards balancing the interests of both drugmakers and patients”.
The report pointed out that most Indian states have not been able to implement the Clinical Establishments (Registration and Regulation) Act [CEA], 2010, because of “stonewalling” by the medical fraternity.
The CEA requires all health establishments to be registered, and aims at enforcing common minimum standards for diagnosis and treatment.
According to the report, nearly 70 per cent of all outpatient visits, about 58 per cent of all inpatient episodes, and approximately 90 per cent of medicines dispensed, and diagnostic facilities in India, are currently catered to by either for-profit or not-for-profit providers in the private sector.
The quality, cost and effectiveness of services vary considerably across providers, the report further said.
‘Double public health spending’
According to the authors, the doubling of public health spending should be a priority.
“Doubling public health spending, contributed by both central and state governments, in the next five years to reach the target of 8 per cent from the current 4-5 per cent of government expenditure, ought to be prioritised along with mechanisms to strengthen the public financial management system, so that funds allocated are used efficiently and equitably,” the report said.
It further stated that given the “huge shortfalls”, a “significant share of this increased health sector investment fund must be used to recruit and train health professionals, especially nurses and allied healthcare professionals, to deliver primary care effectively”.
The report also recommended that “pooled procurement of medicines and supplies” as well as “improved supply chains in the public health system” can increase efficiency and cost-effectiveness.
Sharp rise in life expectancy
The report said that in India, “remarkable success” has been achieved in the form of increased life expectancy at birth — an average Indian’s life span went up by over 20 years in 2020, as compared to 1990.
India’s infant mortality rate (IMR) came down to about 32 per 1,000 live births in 2020 from 88 in 1990. Similarly, the maternal mortality ratio (MMR) declined to 113 per 1,00,000 live births in 2016-2018, from 556 in 1990.
However, the progress has been uneven, with economically weaker states continuing to report higher rates, the report said.
The report linked IMR and MMR to the sharp rise in life expectancy. “The number of years an average Indian can expect to live at the time of their birth has increased sharply, from 47.7 years in 1970 to 69.6 years in 2020, a gain of more than two decades.”
This was impressive even though it is lower than other nations in the middle-income range, like Sri Lanka (74 years), Brazil (74 years), China (75 years) and Costa Rica (80 years), the report said.
“Life expectancy at birth among Indian women increased by 24 years between 1970 and 2016, more than that of men, who experienced an increase of 20 years over the same period. In addition, at 60 years of age, the average life expectancy for men is 15 years compared to 17 years for women,” it added.
The highest gains in life expectancy over the 1970–2020 period was seen in states such as Uttar Pradesh, Tamil Nadu, Odisha, Himachal Pradesh, Gujarat, Bihar, Assam and Andhra Pradesh.
In Uttar Pradesh alone, during the 50-year period, the gain in life expectancy was about 22 years.
‘PMJAY utilisation higher in richer states’
Launched in 2018, the Pradhan Mantri Jan Arogya Yojana (PMJAY) was envisaged as a scheme that would reduce impoverishment of households because of health expenses. It assured eligible families an annual health cover of Rs 5 lakh.
However, the authors went through PMJAY utilisation data and found that “utilisation is much smaller in poorer states than richer ones”. By volume, the share of claims was highest in Tamil Nadu (28 per cent), followed by Gujarat (17 per cent) and Chhattisgarh (15 per cent).
The Covid-19 pandemic led to additional challenges, the authors wrote: “The stringent lockdown led to utilisation of hospitalisation dropping by almost two-thirds compared to the pre-lockdown period… A sharp drop was reported for care related to cataracts or joint replacement, although planned and critical care such as haemodialysis declined only by 6 per cent…”
The report also said that “though beneficiaries can access services anywhere in the country irrespective of their state of residence, care sought outside the state of residence accounted for just 1 per cent of the cases covered by PMJAY, with Madhya Pradesh, Uttar Pradesh and Bihar being the states that had the maximum demand for facilities outside the state”.
(Edited by Gitanjali Das)
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