India, the world’s largest democracy, is represented by a population of more than 1.25 billion people and is expected to be the largest populous nation by 2050. It is a nation with tremendous diversity with respect to ethnicity, socio-cultural practices, customs and norms spread across a vast landmass in South Asia. India has different climatic regions, varied ecosystems, rich biodiversity and wildlife, along with great variations in creeds and cultures, languages, religions, food habits and dresses – unique compared to anywhere else on this planet. Such variation and massiveness, no doubt, creates an extremely challenging environment with respect to proper funding allocation, as well as in providing quality services efficiently and effectively, especially for something as complicated as healthcare.
This enormous population is spread across metros, cities and towns, municipalities, districts, panchayats, remote rural settlements close to the borders and other less accessible locations. India has densely forested areas, mountainous areas, deserts, islands, coastal settlements and other extreme terrains with poor connectivity and infrastructure. It is not only extremely challenging to rule such an ethnically diverse nation with so many distinctly different religions and languages and socio-cultural traditions but also extremely difficult to provide equal quality services to all citizens under the present circumstances. India is a federal republic of different States and Union Territories with various State Governments operating independently under a national Union (Federal) Government. The responsibility of State and Union Governments are well described in the Indian constitution, and health is a joint area administered by both State and Union Governments.
It can easily be described as one of the most challenging responsibilities for both State and Federal Governments to cater to the health needs of more than one billion people efficiently. The result is what can be expected under such circumstances: an ailing and over burdened healthcare system that is poorly funded and monitored, and thoroughly mismanaged. Both State and Federal Governments have highly ornamented and decorated independent Health Ministries with, many Indians believe, poorly trained and ill informed bureaucrats under supervision of equally incapable Health Ministers. The nation, including these ministries, has no long-term, comprehensive plan to resolve the healthcare crisis across India and to provide deliverable healthcare services to a substantially huge population.
A majority of the Indian population (both in urban and rural areas) visit Government run hospitals and rural health centers. Many of these State-funded and managed hospitals and health centers do have state-of-the-art modern treatment facilities, diagnostic tools and instruments, advanced diagnostic laboratories, operation theaters, pharmacies, highly qualified doctors, well trained nurses and associated medical staff to assist in hospital duties and management. Many of these hospitals are also connected to Medical Colleges making them premier State-run hospitals in the country. Unfortunately, these health facilities are overburdened with heavy patient pressures well beyond their actual capacity to handle them. Often the rural or district health centers and hospitals try to avoid handling critical cases and refer them to hospitals in the district headquarters or metro cities or private nursing homes, thus increasing the work pressure of these larger institutes several fold and making their efficient management critically challenging. Furthermore, medical transportation system being weak, negligent, and in some areas non-existent in India, seriously ill or critically injured accident victims oftentimes die on the way to such institutes, separated by only few hundred kilometers.
The weakness of the State-run healthcare system has encouraged simultaneous establishment of private healthcare facilities across India. They are either owned by profit making agencies or managed by charitable, religious organizations. The latter have earned global reputations and accolades for serving a substantial section of both urban and rural poor, as well as the growing middle class communities of the nation. The former, or profit making private health care systems, is run in a corporate style and usually caters to the higher income groups and elites, and is largely inaccessible to the poorer section of society. Some of these private hospitals have often been criticized and recently dragged to court with charges of maltreatment, negligence and over billing to increase profit margins unethically without actual medical needs. Many have been charged or are under trial for recommending unnecessary expensive diagnostic tests and treatments for patients not in need of such tests or treatments, all purely for higher profit returns. Lack of proper monitoring by the State health agencies allows these private healthcare facilities to charge patients any way they like.
However, the State-run healthcare system, which caters mostly to the poor section of the Indian society, marginalized communities and low income groups, cannot alone provide healthcare in an efficient manner to all members of the society with a billion plus population. Hence, a serious need exists for private healthcare systems to operate in parallel with the Government healthcare system in order to cater to different sections of the society. This is a question of moral responsibility, credibility as well as accountability. The overburdened Government healthcare system has been run down by agents, who many believe cheat and misguide helpless patients flocking to such facilities. Without paying a percentage or commission to these agents, who supply many of the low level temporary hospital staffs, patients could not access healthcare facilities. These agents also help some patients to jump queue to reach the desired physician or receive credible medical attention in exchange for a certain percentage. The system has been plagued with nepotism, corruption, malpractice and mismanagement; and it needs serious and immediate attention.
Although the number of medical and dental colleges has been increasing across the nation; quality of education and training provided in some of these is highly questionable. A number of private medical and dental colleges are under serious scrutiny for their alleged involvement in accepting huge donations in exchange for admitting poor quality students with low credibility or ability to participate in a robust curriculum designed for top students. Many such institutions have special quota seats, which they sell under the table to overseas students with Non-Resident Indian (NRI) backgrounds, but sizeable bank accounts in lucrative foreign currencies deposited in overseas accounts. The important question to ask is how can this empower the ailing healthcare system of India or create credible outcomes?
Both the Federal and State Medical Associations across the nation are biased toward their members and are usually run by special committees that often fail to execute their duties when members behave negligently toward patients, particularly if those patients are poor or represent economically disadvantaged classes. It is only recently that the High Courts and Supreme Court of the nation have been able to deliver landmark judgments dealing with cases related to medical negligence leading to death or related medical complications. If one would carefully follow the intimate details of the court proceedings, he/she would be astonished to note that most of these offending medical professionals were initially provided clean sheets by their respective medical associations without any form of proper investigation or professional accountability.
The greatest challenge for the health sector in India is the acute shortage of medical professionals with respect to catering to an immense, unmanageable population with no comprehensive policy or direction on future healthcare management. The crisis in availability of well educated, well trained and highly experienced medical professionals is not only limited to major and minor cities, district towns and municipalities but also rural India, where the challenge is greatest. In those areas there is an extreme lack of medical professionals, especially those in specialty areas, other healthcare workers, shortage of operating theaters and lack of medical supplies, including emergency medicines like snake venom. This is an ongoing problem that has never been resolved in order to address the core concerns of an acute shortage of medical professionals across the nation.
This has been the scenario since the independence of the nation in 1947. Although the country is booming with huge economic growth and is attracting significant foreign investments, it has failed to pay proper attention to its ailing healthcare system. The main take home lesson from a review of the last 10 years of Indian Federal and State annual budgets is that the nation has allocated only a small percentage of its GDP to develop the national health infrastructure. It is surprising to note that India has one of the lowest healthcare budgets per patient compared to all other countries in South Asia with much smaller size and populations.
India does have many premier health institutes with international recognition and accolades like the All India Institute of Medical Sciences (AIIMS) at New Delhi, which has excellent treatment facilities and highly qualified medical professionals. But few of these premier institutes are available to ordinary Indian citizens or a poor community member. Several NGOs, charity and religious organizations run hospitals and nursing homes that have been successfully catering to a wide section of Indian society and can be used as a model for upgrading the current healthcare system.
However, lack of serious interest and initiatives, directions, objectives and strong political will continue to deteriorate further the existing Indian healthcare system. Unless serious attention is paid to revamping and correcting the system, it could continue its downslide into major collapse and catastrophe. Accessible and affordable healthcare for all is the crying need of the time, particularly for India’s poor. Unfortunately no solution seems to be arriving soon, nor are there any on the distant horizon.
