in the private and public facilities, there are over 9 lakh
beds and 5 lakh doctors. We have about 7.5 lakh nurses.
Our hospital infrastructure is impressive and growing, with
high level of capability for sophisticated medical interventions.
The cost of many diagnostic, therapeutic and surgical procedures
is only a fraction of that in advanced countries. Our pharmaceutical
industry is mature and sophisticated, and has the capacity
to produce drugs to meet our requirements at a relatively
affordable cost. People too are willing to pay for medical
care. About 83% of the health expenditure incurred in India
comes from the people, and not from the government. And
most of this private expenditure is out-of-pocket.
Despite these strengths, the travails of ordinary Indians
who fall sick are unbelievably harsh. Most of the poor and
middle classes have no health insurance. Modern medicine
has seen spectacular advances, but medical care costs money.
a result, the average Indian shudders at the prospect of
sickness. Many studies reveal that on an average, s/he spends
60% of the annual income towards medical costs for a single
episode of hospitalization - whether in private facility
or in government hospital. Consequently, 40% of hospitalized
Indians are forced to sell their properties or borrow at
high interest rates. This results in a good 25% falling
below the poverty line. Most of this burden is borne by
the poor, unorganized sectors of population.
we should realize that 80% of disease burden is a consequence
of failure of preventive and public health care. Therefore,
without improving preventive and primary health care, we
cannot improve the health of the people. Merely spending
more money on hospitals and medical treatment will only
waste resources without yielding results.
we do need good hospital care for two important reasons.
First, the credibility of a preventive and primary health
system depends on the quality of hospital care it is supported
by. Most ordinary people think of health only when they
become sick. If the public hospital cannot help them in
times of sickness, they will have no faith in the preachings
about prevention and good healthcare practices. Second,
no matter how good preventive care is, some people are bound
to fall sick and sickness has catastrophic consequences
to the family's finances, reduces productivity of the individuals
and impedes economic growth.
need more than the current 3100 community health centers.
Only about 15% of the out-patient care, and 40% of the inpatient
care is provided by public facilities. We need at least
one 30-50 bedded hospital for every one lakh population.
That means we need to build 7,000 such hospitals in public
sector as the first level of referral care. Supporting these,
we need larger district hospitals, and teaching hospitals
where specialized care would be available. But hospitals
are not mere buildings. We need adequate doctors, nurses,
paramedics, equipment, laboratories and medicines - all
are necessary for proper patient care.
hospitals already exist, most of them function very badly.
The doctors and staff are not accountable; corruption and
harassment are rampant; hygiene standards are horrifying;
equipment is badly maintained; and drugs are not available.
As a result, even poor people are forced to go to private
doctors and hospitals, and spend enormous sums. Even there,
the treatment available is often substandard.
get the millions of Indians out of the trap of poverty and
disease, we need the following: good quality public hospitals;
mechanisms to reduce the financial burden of sickness on
the poor and make public hospitals function well. China
is implementing a model in which the central government,
local government and citizens pool 10 Yuans each (1 Yuan
= Rs. 5.70); the public hospitals are reimbursed from the
health fund created thus for the medical services rendered.
This cooperative system of medical care has many advantages.
In India too we need to introduce a similar system. We need
to build more community health centers at taluk level. At
the same time we should create a health fund to manage these
hospitals. For instance, the Union government, state government
and individual citizens could contribute Rs 30 each, making
it Rs 90 per capita per year. The individuals will pay their
share to the panchayats or municipalities. Where they are
poor, the government will subsidize their share. We will
thus collect about Rs 9000 crore for all of India. This
money will be kept at the district or subdistrict level
with a local health authority, as health fund. The public
hospitals will be built by the government and proper infrastructure
and equipment provided. But no budget will be allocated
for salaries or maintenance of the hospital and patient
care. The patients will have the choice to go to any public
hospital in their region. The hospitals will have to provide
patient care, and the costs will be reimbursed from the
health fund. This reimbursement will be based on standard
costs decided by experts committees in advance. For instance,
a cataract surgery may get Rs 600 to Rs 1000. Standards
of care also will be prescribed. If the local public hospitals
are not able to handle the caseload, the patients can go
to approved private doctors and small nursing homes; they
too will be reimbursed in the same manner. The government
hospitals will then get patients by good quality care and
reputation. Only then can they pay salaries of staff and
maintain the hospitals.
need such innovative methods to make health care available
and accessible to the poor at low cost. We certainly need
to enhance our public health expenditure from the present
0.9% GDP to 2% or more of GDP. But mere high expenditure
does not guarantee better results. The Chinese model needs
to be emulated to improve hospital care, promote health
and productivity, and save millions of the poor from destitution
and disability on account of illhealth. Choice to patients,
competition among hospitals, better services, cost control
and accountability are the keys to improving hospital care.