Know our health care system and it's shortcomings

Marina Seyie *

The health care system in India is primarily administered by states. Healthcare system comprises of hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism and health insurance. The states are responsible for organizing and delivering health services to their residents.

The central government is responsible for international health treaties, medical education, prevention of food adulteration, quality control in drug manufacturing, national disease control and family planning programs. India's Constitution tasks each state with providing health care for its people.

Healthcare is the right of every individual but lack of quality infrastructure, dearth of qualified medical functionaries and non-access to basic medicines and medical facilities thwarts its reach to 60% of population in India. India's GDP for health is less than 1.5 per cent and is one of the lowest in the world. India ranks 145th among 195 countries in terms of both, quality and accessibility of healthcare.

The Government of India is planning to increase public health spending to three percent of the country's GDP by 2025. We consider 70% of India lives in rural areas, average number of doctors per thousands in India becomes 1:9,200. Presently, 31.7% villages still don't have primary healthcare centres in India.

While about 70 percent of India's population lives in rural areas, only 20 percent of hospital beds are located in rural areas. Many primary healthcare clinics in rural areas are devoid of electronic systems to maintain patient records. Lack of quality infrastructure, shortage of qualified medical practitioners and non-access to basic medicines and medical facilities thwart its reach to more than 60 % of population in India.

A paradigm shift from provision of essential to quality health care at the primary care level is on the anvil. Subcenters are being transformed into Health and Wellness centers (H&WC) which is expected to improve utilization of public-sector primary care services and improve the health of communities served.

There is general reluctance among the health workers to be located in the interior rural areas and when appointed in these areas, they choose to remain absent for longer duration from their duties. It is also well known that many doctors are not willing to work in the rural areas due to lack of facilities, even if they are paid high salaries.

Private administration playing a substantial role in Indian health sector, According to National Family Health Survey, the private health sector remains the primary source of health care for 70% households in urban areas and 63% households in rural areas. Due to rapid urbanization of cities post liberalization and globalization, about 75% of the infrastructure and resources investments were allocated in urban areas.

India has a mixed health care system inclusive of public and private health care service providers. However, most of the private health care providers are concentrated in urban India, providing secondary and tertiary health care services.

India has roughly 20 health workers per 10,000 population, with allopathic doctors comprising 31% of the workforce, nurses and midwives 30%, pharmacists 11%, AYUSH practitioners 9%, and others 19%. The ultimate goal of the central government should be to achieve Universal Healthcare Coverage (UHC). For this, government need to cut down the out of pocket expenditure of hospitals as well as of outpatient departments (OPD).

Ayushman Bharat-National Health Protection Mission as a centrally Sponsored Scheme contributed by both center and state government at a ratio of 60:40 for all States, 90:10 for hilly North Eastern States improving coverage of immunisation in the country. The Ayushman Bharat scheme has allocated 12 billion in the Union Budget in 2018 for upgradation of subcenters into H&WCs.

These wellness centers will provide comprehensive healthcare for the management of noncommunicable diseases with lifestyle modifications, maternal and child care, adolescent health, nutritional and health education, promotion of menstrual hygiene, and free essential drugs and diagnostic services. Basic dental, ENT and ophthalmology services will also be provided at these centers.

The integration of Ayurveda and Yoga will further promote a holistic approach toward the health of the community. All India Institutes presently functional are AIIMS New Delhi, Bhopal, Bhubaneshwar, Jodhpur, Raipur, Patna and Rishiksh.

Established new All India Institute of Medical Sciences (AIIMS) to provide health insurance worth Rs 500,000 (US$ 7,124.54) to over 100 million families every year. All India Institutes of Medical Sciences is owned and controlled by the central government. These are referral hospitals with specialized facilities.

the private sector is the dominant player in the healthcare sector in India. Almost 75% of healthcare expenditure comes from the pockets of households, and catastrophic healthcare cost is an important cause of impoverishment.

There is a renewed governmental focus on hygiene sanitation (Swachh Bharat Abhiyan), housing (Pradhan Mantri Awas Yojana), clean indoor air by provision of clean fuels (Ujjwala Yojana providing free liquefied petroleum gas connections to below poverty line families), and expansion of immunization service and coverage (Mission Indradhanush Kavach).

All these initiatives that influence the health of the poor, vulnerable, and underserved population have achieved excellent success in their respective domains. We all are very well aware that the healthcare infrastructure as well achievements in health of the country is not satisfactory.

The healthcare system in India is functioning on the basis of model mentioned below:-

1. Sub centres - A Sub Centre is designed to serve extremely rural areas with the expenses fully covered by the national government. Mandates require health staff to be at least two workers (male and female) to serve a population of 5000 people (or 3000 in a remote, dangerous location). Sub Centres also work to educate rural people about healthy habits for a more long-term impact.

2. PHC - Primary Health Centres exist in more developed rural areas of 30,000 or more (20,000 in remote areas) and serve as larger health clinics staffed with doctors and paramedics. Patients can be referred from local sub centres to PHCs for more complex cases. A major difference from Sub Centres is that state governments fund PHCs, not the national government. PHCs also function to improve health education with a larger emphasis on preventative measures.

3. A Community Health Centre is also funded by state governments and accepts patients referred from Primary Health Centres. It serves 120,000 people in urban areas or 80,000 people in remote areas. Patients from these agencies can be transferred to general hospitals for further treatments. Thus, CHC's are also first referral units, or FRUs, which are required to have obstetric care, new born/childcare, and blood storage capacities at all hours everyday of the week.

4. District Hospitals are the final referral centres for the primary and secondary levels of the public health system. It is expected that at least one hospital is in each district of India,

5. Government Medical Colleges are owned and controlled by the respective state governments and also function as referral hospitals.

Challenges for health care system which need to be mitigated are:-

1. Low quality care is prevalent due to incorrect diagnosis, under trained health professionals and the prescription of incorrect medicines.
2. India's public healthcare system pays salaries during absences, leading to excessive personal days being paid for by the government.
3. Clinics are overcrowded and understaffed without enough beds to support their patients.
4. Primary health centers (PHCs) lack basic infrastructural facilities such as beds, wards, toilets, drinking water facility, clean labor rooms for delivery, and regular electricity.Twenty-seven percentage of doctor posts at PHCs are vacant.
5. Overcrowding also increases the likelihood of diseases spreading, particularly in urban crowded areas of cities.
6. Improper sanitation and waste disposal even within clinics, can lead to an increased incidence of infectious diseases.
7. Public health services have low cost or work at free of cost. Since the government provides these services, they don't charge any extra money to serve the patients.
8. Governmental failure to initiate and foster effective partnerships between the public and private healthcare spheres results in financial contracts.
9. Both social and financial inequality results in barriers of access to healthcare services in India.
10. Services aren't accessible for the disabled, mentally challenged, and elderly populations.
11. Mothers are disadvantaged and in many rural areas there is a lack of abortion services and contraception methods.
12. Public clinics often have a shortage of the appropriate medicines or may supply them at excessively high prices, resulting in large out of pocket costs.
13. Lack of awareness on facilities provided under various government schemes.
14. Barriers to access in the financial, organizational, social, and cultural domains can limit the utilization of services.
15. Escalating prices of essential medicines.

Best ways to improve health care system:-

1. A well functioning healthcare system requires a steady financing mechanism, a properly trained and adequately paid workforce.
2. Well maintained facilities, access to reliable information and no waiting lists.
3. Compulsory health insurance for all persons.
4. Combines private, subsidized private and public healthcare systems to provide its citizens with a large network of qualified doctors, best-equipped medical facilities and hospitals.
5. Funding comes from two sources: financing based on taxes that is used to provide primary healthcare services and National Health Insurance (NHI), which is financed with compulsory fees.
6. NHI must fund private healthcare, occupational healthcare and outpatient care.
7. A simple computer-aided symptom based diagnostic application is needed to improve the delivery of health services in rural areas, to guide the paramedic/nurse in handling common ailments directly by administering simple remedies; and only refer to secondary care for the more complex problems.
8. Using the interactive voice response (IVR) technology, the existing hospital phones can be configured to act as automated telephone answering machines, which give instructions to the patients to book appointments and provide guidelines.
9. Assure an adequate local public health care Infrastructure.
10. Promote healthy Communities and healthy behavior and prevent the Spread of communicable Disease.
11. Protect Against environmental health hazards.
12. Prepare and respond to emergencies.
13. Use Mobile Clinics to go to the patient. Mobile clinics include clinics that provide primary care services, preventive care services or dental care services from a van, truck, or bus equipped with all of the necessary technology to provide clinical services in underserved areas both rural and urban.
14. Establishing Student Run Clinics. Student run clinics affiliated with medical college are also taking medical care where it is needed. They not only give medical students experience in providing preventive care to vulnerable populations but they are often located in extremely impoverished areas, which provides those individuals with free and easily accessible care.
15. There is an urgent need to invest in building healthcare infrastructure including modern amenities.