Article | September 25, 2013, 5.01 PM IST

Why is India's healthcare system in such a sorry state?

R Srinivasan's credible government document on healthcare in India titled 'Health Care in India – Vision 2020' draft published in 2004, sub-titled 'Issues and Prospects', has suggested four criteria that make a just healthcare system -

1. Universal access, access to an adequate level, and access without excessive burden.

2. Fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity and a constant search for improvement to a more just system.

3. Training providers for competence empathy and accountability, pursuit of quality care and cost effective use of the results of relevant research.

4. Special attention to vulnerable groups such as children, women, the disabled and the aged.
Srinivasan is an M. A. (Economics), M.Phil (Public Economics), Ph.D (Public Economics) and part-time Planning Commission member for the state of Tamil Nadu. His draft is dated; but the criteria are relevant even today as India’s healthcare system remains in a very sordid state.
A recent study by IMS Institute of Health Informatics (19 July, 2013) has revealed that 72 percent of the rural Indian population has access to just one-third of the country’s available hospital beds while 28 percent of urban Indians have access to 66 percent of the total beds. The study also notes that those living in remote pockets have to travel more than five kilometres to access an in-patient facility, 63 percent of the time.

Country Total % of GDP spent on Healthcare Private Expenditure % Per capita spent on Healthcare (USD) Per capita government spent on Healthcare (USD)
India 4.1 70.8 132 39
USA 17.9 46.9 8362 4437
UK 9.6 16.1 3480 2919
South Africa 8.9 55.9 935 412
China 5.1 46.4 379 203
Brazil 9 53 1028 483
Pakistan 2.2 61.5 59 23
Nigeria 5.1 62.1 121 46
Russia 5.1 37.9 998 620









Source: WHO

Evidently, the country's historical spend on healthcare, apart from immunization programmes, has not been enough. WHO statistics show the total expenditure on health is 4.4 percent of the GDP, for a population of 1.27 billion. As a result of a low healthcare spend and lack of special attention towards this sector and absence of concrete regulatory policies, India’s healthcare system is in shambles.

Here is a picture of the current healthcare scenario:
Universal Access and Financial Costs: The IMS study noted that long waiting time and absence of diagnostic equipment at public facilities has caused an increasing number of patients to rely on private healthcare facilities.  Quality of treatment is also a reason why patients switch to private centres. However, this shift from public to private care is posing an affordability challenge to poor patients.
Training and distribution of Health workforce: Statistically speaking, Indian cities have four times the number of doctors and three times more nurses than in rural areas. Meanwhile, almost 80 percent of the medical colleges are located in South and West India. The direct impact is a dearth of trained professionals practicing in rural India.

Health HR Doctors Specialists AYUSH* Nurses ANM** Pharmacists  Total
Numbers graduating annually 30,000 18,000 30,000 54,000 15,000 36,000 163,000




* Practitioners of Ayurveda, Yoga, Unani, Siddha and Homeopathy

** Auxillary nurse miidle-wife (for childbirth)


Vulnerable Groups: Children and women in India are at the receiving end of the poor healthcare framework. Lakhs of babies do not survive the first day due to limited or no access to quality healthcare. Thousands of mothers die while giving birth. Child marriages have led to complications in early child birth, owing to poor maternal health and lack of sex education. The infants that survive such complications are more likely to be underweight and stunted due to malnutrition and lucky if they survive beyond the age of five, reported a study by The Lancet last year. This has led to higher maternal and infant mortality rates as well as severe disabilities.
Besides, has reported that 2.1 million avoidable deaths attributed to tuberculosis, malaria, diarrhoea, dengue, Japanese Encephalitis, Kala Azar, nutritional deficiencies, perinatal conditions and maternal conditions in India.
Since these are essentially water-borne diseases, it is difficult not to worry about India’s sanitation facilities and poor hygiene. The current standards of sanitation facilities in India look dismal with 33 percent of people having no access to toilets, and 50 percent of the entire Indian population defecating in the open.
Meanwhile, non-communicable diseases (NCDs) like cardiovascular disease, cancer, chronic respiratory disease, diabetes, and mental health conditions are adding to India’s woes. Cancer cases in India are on the rise. Unfortunately, here, they are detected at an advanced stage which calls for sophisticated cancer diagnostic equipments. On the other hand, most NCDs are lifestyle diseases and contrary to the popular belief, these are affecting more poor than the rich in the country.
A survey in the KG Halli region of Bangalore showed three-times higher prevalence of NCDs like diabetes and hypertension in city slums, in comparison to the affluent class. Also, older people and women were more likely to report chronic conditions. Published in international BioMed Central (BMC) Health Services Research medical journal, the survey also stated that over 80 percent of the poor patients were referred to a private healthcare centre or super-specialty hospitals by PHCs.
Improved delivery in services at primary healthcare levels would require improved medical technology installed at PHCs. However, rising costs can impede such plans. The costs of NCDs like heart disease, stroke and diabetes alone could reduce the GDP in India, Russia and China by one to five percent within five years, as predicted by WHO. Besides, for medical technology to be accessible by both, urban and rural poor, we are in dire need of frugal yet breakthrough innovations in the health sector.

The economic burden due to poor health conditions can cripple a country. Partnership between public and private players is the answer to solving some of these critical health issues of the country - partners who have the expertise, infrastructure, talent and willingness to partner to solve these issues. General Electric (GE) has been working towards healthier India partnering with many state governments to improve high end diagnostic imaging equipment in government hospitals through public-private-partnership (PPP). The company has one of the world’s largest innovation centres in India and has been developing affordable and accessible healthcare technology solutions.















Source: WHO

Clearly, Indians need more than roti, kapda aur makaan-
1. An umbrella of universal insurance, Medicaid and Medicare like that in the West
2. Healthcare on top of the priority list, medical infrastructure accessible to all with best utilisation of healthcare workforce
3. PPPs to boost the development of medical IT and infrastructure
4. Specialised research and development towards vulnerable groups
Arun Maira, Planning Commission member, aptly summarises the state of affairs in the IMS report, “Fixes to only parts of the system cannot produce the systemic changes required. In fact, some fixes to only a part, without considering their effects on other parts of the system, can backfire as indeed some are”.

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