Health Sector in India: A Glimpse into Reality

Dibyendu Das

The world is facing a serious crisis from the COVID-19 pandemic. On the 30th of January, 2020, the first case of COVID-19 was reported in India. Then as it spread rapidly. Government declared the first lockdown on 24th March, 2020 which is the longest one for 59 days to stop the spread of the disease. Today, India is ranked 3rd on the list of countries which is worstly affected by this pandemic, with more than 21 lakh infected people and 43000 deaths including 200 Doctors. People of this diverse country should analyze how far and how well we have tackled the pandemic. I shall try to give a glimpse of the situation prevailing in India as well as in Assam. More than 57000 COVID positive cases have been reported in Assam till date and that is increasing in an alarming rate with every passing day.

According to WHO norms, the minimum requirements of proper health facilities for any country are

  1. Doctors to people ratio which is 1 : 1000
  2. Nurses and paramedical staff ratio should be 25 for every 10000 people.
  3. Hospital beds should be 5 for per 1000 persons.

Apart from the above the following factors are also indicative and very much important in respect of the countries’ health care systems

  1. Immunization status
  2. Malnutrition status
  3. Mortality during child birth and child mortality.
  4. Mortality due to other diseases.
  5. Other infrastructure like ICU/ICCU bed, well equipped diagnostic facilities, availability of medicines, vaccines, medical equipment, and well-equipped team to tackle various life-threatening condition are also an important parameter which indicates the condition health sectors of that country.

In India, against a total population of 1.33 billion people there are approximately 1.8 million registered medical practitioners which give us a ratio of 1.34 doctors for 1000 Indians (2017).

Another statistic says in India, there is one government doctor (on government job) for every 10,189 people (the World Health Organization (WHO) recommends a ratio of 1:1000), or a deficit of 600,000 doctors, and the nurse: patient ratio is 1:483, implying a shortage of two million nurses. This has been calculated by taking doctors and nurses who are actually on the role as Government Employee. (But without taking into account the private doctors).

However, replying to a written question in the Rajya Sabah, Union Minister of State for Health Ashwini Choubey, made certain assumption based on number of doctors registered with medical councils and their assumed availability, and said a total of 11,59,309 allopathic doctors were registered with the state medical councils and the Medical Council of India (MCI) as on March 31. Assuming 80-per cent availability, it was estimated that around 9.27 lakh doctors were available for active service, which put the allopathic doctor-patient ratio at 1:1445. (The statistical validity of these assumptions is questionable).

In Assam, there are 3-5 doctors against 10,000 people which brings us to less than 1 doctor per 1000 people which is way below the WHO’s guideline for 1:1000. One should keep an eye on countries like Qatar, Monaco, Cuba, Greece where the ratio is well above WHO’s minimum level and stands at 77.4, 71.7, 67.2 respectively.

Similarly, there is acute shortage of nurses and paramedical staff in Assam which makes the situation worse in comparison to other states of India.

On the other hand the availability of government hospital beds is abysmally low in India which is 0.55 beds per 1000 population (excluding the private hospitals). If we consider the private hospitals the ratio adds up to 0.7. More than 12 states like Bihar, Jharkhand, Gujarat, Uttar Pradesh, Madhya Pradesh, Haryana and including Assam is below the national level. One can easily understand the state of the Health department in Assam where less than 0.55 beds is available per 1000 patients.

In case of Immunization, Assam is the best performing state in India with more than 91% immunization status which is a commendable performance by the health department and a large chunk of the credit goes to all the hard-working people of Asha karmi and Anganwari workers and all the other staff related to the project.

Another important point to address is malnutrition, which is still the most important underlying risk factor for 68% of the deaths among children below the age of 5. A study published by Lancet Child and Adolescent Health stated that Rajasthan, Uttar Pradesh, Bihar and Assam have the highest malnutrition cases in the country. Due to the lack of concern towards malnutrition, today Assam is the state with the highest maternal death during delivery and 3rd highest in child death at the time of delivery. This is really a great concern for any civilized society.

Other issues like shortage of medicines, medical equipment, vaccines, and lack of treatment facilities like dialysis, cardiac care, lung diseases, GI disorders as well as the measures for tackling and controlling rabies, vector borne diseases, etc. have come into doldrums bringing people and the health care system to the brink of collapse. These are still to be addressed by the Government and most of the districts are in abysmal conditions and a lot of work and improvement requires to be done, immediately.

To improve the scenario, the budget allocated towards the health sector must be increase. State Finance Minister Dr Himanta Biswa Sarma presented the budget for the FY 2020-21 in the State Assembly on March 6, 2020 allotting Rs 6,127 crore for the health sector which is nearly Rs 557 core less than the last year’s budget allocation. This is a decrease of around 8.33 per cent compared to the proposed budget allocation of Rs 6,684 core during the FY 2019-20. Moreover, the share of budget allocation in the health sector has declined to 5.90 % of the total budget estimates (Rs 1, 03,761.63 crore) in FY 2020-21 from 6.72 per cent share of the total budget estimates (Rs 99,418.91 crore) in FY 2019-20, though it needed to be scaled up. Publicity and campaigning is necessary but that should be for the benefit of the people of Assam. In a democratic and welfare states, government frames policies and implement them. People of the state can provide suggestions and the government should listen to the voice of the people which is a sign of a healthy democracy. Hope our Government will realize the grave situation and take necessary steps with the help of experts and try to improve the health sector within a stipulated period of time.

The crux of the problem lies in the government expenditure in health care system and also in government expenditure in higher education as well as its expenditure in research and development, which actually produces the qualified manpower and particularly, in respect of the referred issues the highly qualified doctors, nurses and other paramedical staffs. Unless these are improved, nothing is going to be achieved and we will continue to be in these appalling conditions.

In the fiscal year 2018, India has spent 1.28 % of GDP in health care. Compare it with health care expenditure of BRICS countries as percentage of GDP – Brazil 9.2 %, Russia 5.3 %, China 5.0 % and South Africa 8.1 %. The leader of the pack is of course USA with 16.9 %, and European countries (for example Germany 11.2 %, UK 9.8 %) expenditure in health care as percentage of GDP. The world average expenditure in health care is 9.896 % of GDP (2017). We are far below. We cannot claim to be “Vishwa Guru” or aspire to become super power, economy wise or otherwise, with this sort of priorities. 

We must increase our expenditure on health care as percentage of GDP. Even 1 % increase would make visible effect in terms of improving primary health care systems and per capita expenditure for health care.

Let us look at government expenditure in education, which is inter alia primarily responsible for producing qualified allopathic doctors, nurses and paramedical staffs. Indian government spends only 3 % of the GDP education and ranks 149 in the list of 197 countries (Cuba tops with about 13 %, Brazil 6.2 %, Russia 3.7 %, China 4.0 %, South Africa 6.2 %, Germany 4.8 %, UK 5.5 %, USA 5.0 %). In tandem with this, look at the budgetary allocation for higher education and how it has changed – in 2017-2018 the budgetary allocation for higher education was 1.62 % and came down to 1.43 % in 2018-2019.

Quality medical care is highly dependent on research. Without that the health care system does not get strength. The total Research and Development (R & D) expenditure of governments would reflect the position and would compare the countries. India spends 0.62 % of GDP for R & D. USA spends 2.74 %, Europe average is 1.85 %, Brazil 1.28 %, Russia 1.10 %, China 2.06 % and South Africa 0.80 %.

With this sort of priorities in health care, basic and higher education, and in research and development, one cannot expect to produce enough qualified doctors, nurses and other paramedical staffs and create the minimum infrastructure facilities for providing a better and meaningful health care to our 1.33 billion people.

Instead of making our ante up against our neighbours and then spending major share of GDP and budgetary allocation for arms & ammunitions etc., let us change our priorities and increase our expenditure and effort in health care, basic and higher education, and in research and development. Otherwise, the propagandist dream of becoming “Vishwa Guru” will pull us down only.

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Aug 16, 2020

Dibyendu Das

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