Friday, July 16, 2010

Problems of Public Health System in India


Core problems of public health system

Indian public health system and overall health care system’s failure is characterized by following things:

• High out-of pocket expenditure
• Failure of Primary Health System
• Collapse of Secondary Level System
• Overloaded Tertiary Level System
• Regional inequality in terms of Health Indicators
• Unregulated Private Health Sector

HIGH OUT-OF POCKET EXPENDITURE

Public health expenditure is shared between centre and state governments. The state or local governments incur about three-fourth of the expenditure on public health and the remaining one-fourth of the total expenditure is spent by the central government.

The government (state, local or central) provides publicly financed and managed curative and preventive health services from primary to tertiary level, throughout the country and free of cost or highly subsidized rates to the consumer. These account for about 17.8% of the overall health spending and 0.9% of the GDP. However, a fee-levying private sector that plays a dominant role in the provision of individual curative care through ambulatory services accounts for about 82% of the overall health expenditure. It has been found that private health services are directed mainly at providing primary health care and financed from private resources, which could place a disproportionate burden on the poor

As compared to the rest of the world, Indian health system is one of the least publicly funded health systems. It is also one of the highest privatized, unregulated and characterized by very high out of pocket expenditure. Comparable countries with India in these dimensions are- Cambodia, Georgia, Myanmar and Afghanistan. According to UNDP Human Development Report, 2002 and The World Health Report of 2000; India’s per capita health expenditure ranking (in $ terms) was 133 and corresponding Health DALE Ranking was 134.In all developed countries, public expenditure on health as a share of GDP is very high compared to India where only 0.9% of GDP is publicly spend on health.

Country Public health expenditure Private health expenditure
as share of GDP as share of GDP


Norway 6.5 1.1
Sweden 6.2 1.8
Japan 5.9 1.8
United Kingdom 5.9 1.4
United States 5.8 7.3
Egypt 1.8 2.3
Sri Lanka 1.8 1.9
India 0.9 4.3

Even this short amount of 0.9% of GDP spent on public health does not benefit poor people in adequate extent. Public expenditure on curative services favors rich. According to the study - ‘PROPORTION OF PUBLIC EXPENDITURE ON CURATIVE SERVICES, BY INCOME QUINTILE, ALL INDIA, Year 1995-96’: “for every Re.1 spent on poorest 20% population, Re.3 spent on the richest quintile.” This denotes high disparity in public health service delivery.
 Hospitalized Indians spend 58% of their total annual expenditure on health care.
 Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses.
 Over 25% of hospitalized Indians fall below poverty line because of hospital expenses.

This emphasizes great need of providing security net for poor and protecting them from financial ruin out of high hospital expenses. Also there is urgent need to decrease dependence on private health sector by strengthening of public health system with better delivery mechanism. There is also need of proper allocations of this meager amount of resources. Right now, only 3% of public health budget is spend on capital expenditure while 97% goes to consumption expenditure. While 60% amount goes to paying salaries, only 35% is spent on material and equipments while Indian public health system has insufficient health infra structure. Public curative services where we spend 60% amount, are not showing good results on other hand 26% amount is spent on public health and family welfare. We need to improve budget allocation along with keeping its cost-effective analysis in mind.
Public and Private sector use for Patient care-All India distribution:

OUT PATIENT CARE RURAL URBAN
Public sector 20% 19%
Private sector 80% 81%
IN PATIENT CARE RURAL URBAN
Public sector 45.2% 43.1%
Private sector 54.7% 56.9%

(Source: David.H.Peters, Abdo.S.Yazbeck, Rashmi R. Sharma, G.N.V. Ramana, Lant H. Pritchett, Adam Wagstaff, Better Health System For India’s Poor -Findings Analysis and Options, The World Bank, 2002, Washington. p.5)

Reason for this high dependence upon private health care despite of its very high cost is failure of public primary health care system. This situation is compounded by total collapse of secondary health care system that in turn leads to overloaded tertiary health care system.


PRIMARY HEALTH CARE SYSTEM

Primary health care system in India is suffering from following main problems:

ACCESSIBILITY:
Primary health service in many parts of country especially in rural India is inaccessible for some vulnerable sections of society due to discrimination on basis of gender, caste and class etc. women and children, people from scheduled castes and scheduled tribes with overall poorest section of society can not get proper benefits of public health system.

ABSENTEEISM AND RETENTION OF DOCTORS IN RURAL AREA:
It is very grave problem. Doctors are not willing to into rural areas and even if they go, it is characterized by chronic absenteeism.
Reasons:
• Though we have adequate buildings for PHCs in rural area; they lack facilities like toilet, water supply, and electricity.
• There is lack of good schools for children of doctors, Para medical staff. Also, there is lack of appropriate transport and communication facilities.
• It is also found that doctors serving in rural areas get relatively less salary in comparison to their urban counterparts, if we take into the consideration, less availabilities of facilities in rural areas.
• There is less control and monitoring of doctors serving in rural areas.
• There is less personal growth in terms of positions held, monetary increments in government health services. There is high difference in income of private practioners and public doctors, resulting in less availability of doctors for government services especially for difficult postings in rural areas.
• In this phase of Globalization, lots of opportunities for personal growth are available. Just compare income levels of private medical practioner, Public health doctor, engineers, and management persons. A doctor with high intelligence will be always attracted towards lucrative private practice rather than serving for government for meager amount of money, that too in rural area.

POOR QUALITY OF CARE
There is lack of interest on the part of doctors and absenteeism leading to- development of similar kind of attitude in paramedical staff. It leads to docility, irregularity and neglect towards duty in all staff members. It is found that many times pharmacists attend OPDs instead of doctors. This along with irregularity leads to poor delivery of health care to the people.

LACK OF CREDIBILITY
Today this is biggest problem of public health system. This is a barrier, which should be overcome for better delivery of primary health services. In fact, better delivery and regularity in service provision can remove this hurdle.

INADEQUATE AND UNDER-UTILIZATION OF INFRASTRUCTURE
Already there is inadequate health infrastructure in rural areas but due to above mention factors it leads to under-utilization of this infrastructure.



SECONDARY AND TERTIARY PUBLIC HEALCARE SYSTEM
There is total collapse of secondary level system and because of this tertiary level system is overloaded.

Reasons -• Less number of functional secondary hospitals
• Lack of sufficient equipments, drugs
• Most importantly, lack specialists for these hospitals due to very less pay scale. Averagely at all India level, there are about 90% shortfalls of specialists.
• Tertiary hospitals are over loaded along with there is poor up gradation of equipments, lack of sufficient allocation for functioning tertiary hospitals.
• Though population increased exponentially, number of tertiary hospitals is quite stagnant leading to further overload of patients. This leads to poor quality of services.

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