HEALTH CARE

HEALTH CARE At least seven different systems of medicine function in India. Professional skills in some traditional systems are acquired through apprenticeship, and the right to practice is formalized by becoming a registered medical practitioner (RMP) with the relevant board, council, or association. Hence, most Indians move freely from one type of medical science to another. Nevertheless, allopathic (Western) medicine is predominant in the country. It is financed and managed by both public and private sectors. The former is free of charge to the poor, and of nominal cost to all others. It accounts for approximately 18 percent of the overall health spending and 0.9 percent of the Gross Domestic Product (GDP). Responsibilities are shared by local, central (federal), and state governments. The latter provides the services. The central government sustains about 25 percent of public expenses. It focuses on developing and monitoring national standards and regulations, linking states with funding agencies, and sponsoring schemes for implementation by state governments.

Remarkable achievements have been made since independence in 1947. Life expectancy rose from 36.7 to 64.6 years. Eradication of smallpox (1981) and Guinea worm (2000) accompanied steep declines in kala azar (black fever), leprosy, malaria, and polio. The number of doctors increased from 61,800 to 503,900, and nurses from 18,054 to 737,000. By 1991 the country had 22,400 primary health centers, 11,200 hospitals, and 27,400 dispensaries. These facilities form a tiered system that funnels complicated cases into urban hospitals while providing routine treatment in the countryside. By the 1990s the country had approximately 10 hospital beds per 10,000 individuals, a threefold growth in ten years, and 128 medical colleges, a 300 percent increase since 1950.

However, the per capita expenditure on public health in India is half that of other comparable countries. Only 23 percent of Indians have safe drinking water because of inadequate spending on related subjects like hygiene and sanitation. Similarly, little is invested in preventing the adulteration of foodstuffs or controlling pollution. Furthermore, the poorest 20 percent of the population have more than double the rates of mortality, malnutrition, and fertility in comparison with the richest quintile. A 1995–1996 national survey also revealed that tobacco intake and alcohol abuse were highest in the lowest quintile. The plight of the estimated 90 million disabled has, likewise, received little attention.

Health-Care Sectors

The government sector

The cornerstone of the government's health-care system, especially in the countryside, where 72 percent of Indians live, is the primary health center (PHC), as based on the recommendations of the Bhore Committee (1946). The following guiding principles of the committee remain the basis of the government's medical organization for the country:

• No individual should lack access to medical care because of inability to pay for it.
• Special emphasis on preventive methods, and on communicable diseases.
• The establishment of a primary health unit (center) per 10,000–20,000 population with 75 beds, 6 doctors, and an equal number of public health nurses.
• Provide one bed per 175 people, one doctor per 1,600, and one nurse per 600 citizens.
• Build 650 bed hospitals at taluka (300,000 people) level and a 2,500 bed hospital in each district (3 million population).
• No patent protection for pharmaceutical products.
• Fifteen percent of government expenditure on health care.

Slow economic growth, rapid rise in population, and shifts in government priorities were acknowledged fifteen years later by the Mudaliar Committee. Accordingly, the goals of the Bhore Committee were essentially halved: the ratio of PHCs was decreased to one per 40,000 people; the bed strength reduced to one bed per 1,000; and the ratio of doctors was one per 3,000. The committee also recommended that the central government build one medical college per 5 million people. Bowing to international pressure, process patent protection for up to ten years for pharmaceuticals was instituted. The committee was the first to examine the other systems of medicine in the country, and concluded that it was too early to integrate them. The Jain Committee (1966) concentrated on enhancing maternity facilities, enlarging health insurance coverage, and augmenting resources by increasing fees for services. Social activism was an important feature of the Srivastava Committee (1975). It recommended compulsory service for two years at a PHC for every doctor between the fifth and fifteenth year of a physician's career. It also proposed the creation of a Medical and Health Education Commission. Fifteen years after the Mudaliar Committee, Srivastava suggested selective integration of different health systems.

Decline in public expenditure on health was a major concern for the Indian Council of Medical Research-Indian Council of Social Science Research Joint Panel (1980). Consequently, it advocated that 6 percent of the gross national product be spent on medical services. The National Health Policy (1983) aimed for universal primary health coverage by encouraging greater participation of private practitioners and nongovernmental organizaions (NGOs) with the public sector and the utilization of village-based workers to treat simple ailments. Similarly, the National Population Policy (2000) sought comprehensive reproductive and child health care through the collaboration of the government with NGOs and the private sector. Further decentralization of planning and program implementation was intended by involving community groups and panchayati raj institutions. (Panchayats are autonomous village councils with administrative, civic, judicial, and social responsibilities. Over 270,000 elected panchayats are currently operational.)

An important feature of rural health care is the specific "camps" organized by medical colleges, NGOs, and charitable hospitals. Fully self-contained camps are set up for three to five days. Doctors operate on cataracts, fix bones, provide plastic surgery for cleft lip, and so forth. Usually held in winter, when days are short and crisp and working hours long and exhilarating, camps have a festive air about them. In some parts of the country they are a regular feature, and villagers eagerly await their return.

Despite years of planning, the public health infrastructure is modest because of insufficient funding. Hence, hospital equipment is often obsolescent or unusable, buildings dilapidated and overcrowded, and the availability of essential medications, capricious. Furthermore, chronic scarcity in specialties like anesthesiology and radiology results in critical deficiencies in public health services. Nursing care is inadequate, for there is a very low ratio of nursing personnel to doctors and beds. Low staff morale is reflected in poor quality of service and absenteeism. These problems are compounded by inadequate mobilization of private practitioners and NGOs and an excessive focus on sterilization to meet family planning targets.

The private sector

India's reliance on private spending on health is among the highest in the world. Accordingly, primary, secondary, and tertiary care is offered principally through independent practitioners. This sector is largely unregulated and little constrained by medicolegal considerations. For instance, Indians receive three times as many injections (3.4 per year) as Western patients because it is more lucrative for the physician to administer injections than to prescribe oral medicines. About 40 percent of Indians borrow money or sell assets to pay for hospitalization. The private sector accounts for 78 percent of overall expenditure on health and 4.5 percent of GDP.

Civil society

Since the 1980s, increased participation by NGOs and other civil institutions has considerably improved the implementation of national disease control programs. In addition, civil activists and voluntary organizations stimulate awareness and debate on various health issues and take major initiatives in preventive medicine and disaster relief. NGOs are prominent in funding rural camps.

Health insurance

About 15 percent of Indians enjoy some form of health insurance, whether social or private. The latter is small. The largest such insurer, Mediclaim, has a mere 2.5 million subscribers. Social plans such as Employee State Insurance Scheme and Central Government Health Scheme cover another 30 million. Comprehensive health care is also provided to government employees, active or retired, and their dependents. Large companies do the same.

A remarkable success is the ESI Act (Employees' State Insurance) of 1948. ESI is an integrated need-based insurance that provides maternity leave, financial assistance for both temporary and permanent physical disability, vocational rehabilitation, and wages for survivors of workers killed due to employment injury. Factories with at least ten workers and companies with twenty or more employees are covered by the act. By March 2001, there were 238,486 companies in the program. Its hospitals, dispensaries, and other services are efficient and well run. Its beneficiaries are almost 33 million workers and their families. However, the urban and rural poor rely largely on the public health system outlined earlier.

External assistance

South Asia receives the lowest official development assistance per capita in the world, and less than 7 percent of it goes to the health sector. Assistance was largely in family planning, maternity care, and child health. Except for the eradication of malaria and leprosy, other disease control programs received scant consideration. Since 1995, external assistance increased partly in response to the HIV/AIDS pandemic and the rise of other communicable diseases. Another factor was the decision of the International Monetary Fund and World Bank to participate in programs with "a human face." The latter sought collaboration with the International Development Association (IDA) to establish nationwide surveillance of quality controls for foods and drugs.

The World Health Organization (WHO) is the only agency whose funding is outside normal budgetary mechanisms. This flexibility allows WHO to focus on disaster relief, tobacco control, and identification of parameters that increase the responsiveness of health systems to the needs of the poor.

The United Nations (UN) advocates the privilege of good health as one of the fundamental rights of every human being. In India, the UN has largely limited itself to a global fund for the control of communicable diseases.

The G-8 governments (Britain, Canada, France, Germany, Italy, Japan, Russia, and the United States) are assisting with clean water and sanitation projects. The governments also work on mutually satisfactory arrangements for the pharmaceutical industries in India and in the G-8 countries to promote the availability and affordability of lifesaving medicines.

Indian communities abroad are active in donating medicines and equipment, and setting up hospitals and clinics in India. In addition, doctors return to the country to teach, train, and provide specialized services.

India has bilateral health arrangements with a number of countries. USAID supports three major bilateral projects: HIV/AIDS in Tamil Nadu, population control in Uttar Pradesh, and the establishment of the National Institute of Biologicals for the quality assurance of vaccines. Similarly, the Japanese International Cooperation Agency is setting up a children's hospital in Delhi and collaborating on basic research on cholera. Various European and Canadian agencies are active as well.

Key Health Issues in India

Communicable diseases

The resurgence of communicable diseases like malaria and tuberculosis and the emergence of new infections like HIV/AIDS, new strains of cholera, and different forms of viral hepatitis pose serious challenges to India. The following infections greatly impact the country's ecology and economy:

Malaria

Increased insecticide resistance has developed in malarial vectors. The long-term impact of chemical insecticides on the food chain and ecology is a matter of great concern. Meanwhile, the incidence of the more deadly P-Falciparum malaria has risen by about 50 percent.

Tuberculosis

South Asia is home to about 38 percent of tuberculosis patients worldwide. There are 2.5 million new cases and 600,000 deaths annually. There is also a growing threat of coinfection with HIV/AIDS. The financial and human cost is obvious.

HIV/AIDS

Eight million Indians may be infected, but estimates vary widely.

Waterborne diseases

The common waterborne infections—gastroenteritis, cholera, and some forms of hepatitis—contribute to high levels of morbidity in the population. Recent reports of chemical contamination of underground water, especially in West Bengal, may cause significant medical problems in the future.

Disaster relief

Fifty million Indians suffer drought each year. Half as many are flooded annually. In addition, cyclones, earthquakes, and natural and manmade disasters strike millions. In 1980 a Health Sector Emergency Preparedness and Response Program was finally established. Clearly more work remains to be done.

Generic drugs and vaccines

Low-priced indigenously manufactured generic drugs and vaccines are widely available. Both globalization and the Trade Related Intellectual Property Rights System are likely to result in an increased cost of drugs. India's leading role in software development and computer sciences may keep the costs low by triggering innovations in the development, testing, and marketing of new medications. Costs may fall by 50 to 70 percent from the current average of U.S.$250–500 million per development of a new drug, and the lead time from the discovery of a drug to its introduction in the marketplace may decline from twelve years to five. Development of vaccines may be even cheaper, with a shortened lead time. The ongoing Indo–U.S. collaboration in the development of an AIDS vaccine may be the first of many such undertakings.

Geriatric care

Geriatric care is expected to rise substantially as a result of increased life expectancy, breakdown of the extended family, pressures on the nuclear family, and increased urbanization.

Health research

The Indian Council of Medical Research was established in 1911. For more than ninety years, health research in India faced the same two major problems: low spending on research ($300 million in both public and private sectors in 2001); and neglect by international pharmaceutical companies of medical research on therapeutic drugs and vaccines for tropical diseases because of their limited profitability.

Information, education, and communications

Initiatives are needed for the dissemination of the evolving curative guidelines for diseases such as tuberculosis, malaria, leprosy, cataract blindness, as well as for bringing about behavioral changes to prevent HIV/AIDS and other lifestyle diseases.

Lifestyle diseases

Since the 1980s, there is a noticeable increase in mortality through lifestyle diseases such as diabetes, obesity, infirmities associated with cigarette smoking, cancer, and cardiovascular diseases.

Macro- and micro-nutrient deficiencies

The persistence of macro- and micro-nutrient deficiencies, especially among women and children, leads to chronic morbidity. Deficiencies have a multiplier effect, as they result in a higher incidence of low birth weight babies, which in turn causes both mental and physical retardation.

Mental health

Patients are usually confined to mental hospitals, and drug therapy is the rule. Psychotherapy and rehabilitation still have a limited role in the management of these patients. On the other hand, Indian society is generally tolerant of its "eccentrics and lunatics."

Noncommunicable diseases

Over 10 percent of urban Indians have coronary artery disease. Since the 1970s, the average age of the first heart attack in India has decreased by ten years, and about 50 percent of all heart attacks in Indian males occur under the age of 55, with 25 percent under the age of 40. These striking statistics are unheard of in any other population. Similarly, the incidence of strokes and hypertension has increased dramatically during the past thirty years.

Population control

During the twentieth century, India's population increased from 238 million to more than 1 billion despite almost fifty years of attempts at population control; it was the first country in the world (1952) to launch a national program for family planning. However, following excesses committed during the 1975 emergency, the program was not vigorously pursued. Nevertheless, the total fertility rate fell from 6.0 in 1951 to 3.3 in 1997. Consequently, the National Population Policy (2000) reaffirmed the government's commitment to voluntary and informed population control, and set the ambitious target of achieving net replacement levels of population by 2010.

Preventive medicine

In the late 1990s the central government adopted an integrated Non-Communicable Diseases program. It consisted mainly of health education for citizens and the development of protocols for training physicians in preventive medicine.

Trauma

Increase in trauma caused by violence (political, domestic or otherwise), traffic crashes, industrial accidents, or natural calamities is a significant burden on the health-care systems. As elsewhere, women and children bear the brunt of it.

Vaccine-preventable diseases

Infections such as measles, diphtheria, and whooping cough still pose significant risks to children. While efforts to eradicate polio have made tremendous progress in India, there were still 268 cases in 2001.

Traditional Systems of Medicine

In March 1995 the Department of Indian System of Medicine and Homeopathy was established in the Ministry of Health and Family Welfare. It gave belated recognition to traditional systems of Indian medicine that provide at least 40 percent of health care in the country, especially among the poor and in rural areas. By setting up a separate department, the government sought to improve cooperation among the various systems of medicine, and to better regulate the traditional ones.

These systems are generally geared toward the treatment of simple or chronic ailments. The scientific basis of therapy lies in restoration of the balance between the patient, biofactors (nature, ecology), and body humors (secretions). Hence, the systems are holistic and oriented toward lifestyle instead of focusing on specific organs or diseases. Surgical intervention and diagnostic tests are few. Medicines are invariably cheap, derived from natural sources, and have few side effects.

?yurveda is the largest of the traditional Indian systems of medicine. Its origins lie in two of the four Vedas: the Rig Veda and the Atharva Veda (c. 1400–600 b.c.). About sixty ancient treatises form the corpus of ? yurvedic knowledge. The two most prominent texts are the Caraka Samhita and the Susruta Samhita, ascribed respectively to the eponymous Caraka, a physician, and Susruta, a plastic surgeon. Susruta reputedly trained under the legendary Dhanvantari at Kashi (Varanasi), the traditional center for surgical expertise in India. Dhanvantari is acknowledged as the "father of Indian medicine." Related to ?yurveda are Siddha (a Tamil version) and naturopathy (which relies on diets prescribed in ? yurveda). The practitioner is called vaidya, and the profession was formerly hereditary. Modern ?yurveda still emphasizes its eight traditional disciplines of kayachikitsa (internal medicine), salya tantra (surgery), salakya (ear, nose, and throat), kaumarabhrtya (pediatrics, obstetrics, and gynecology), bhutvidya (psychiatry), agada tantra (toxicology), rasayana tantra (nutrition, rejuvenation, geriatrics) and vajikarana (sexology). The universal and timeless applicability of these subjects is a tribute to the ongoing relevance of this ancient system of medicine. By the twenty-first century there were 98 colleges of ? yurvedic medicine in India.

Three other systems—Unani, homeopathy, and Tibetan medicine—are from non-Indian sources. Unani is Greek in origin, founded on Galenic concepts of good health being dependent on the balance of four humors (blood, phlegm, yellow bile, and black bile). Seventeen colleges operate in India. Its practitioners are known as hakims. Homeopathy originated in Germany. Treatment is based on empiric observations that highly diluted matter often relieves symptoms caused by that very substance in its concentrated form. For instance, repeated small bites by poisonous snakes protect snake charmers from death following a severe bite. Education is imparted by 132 colleges. With more than 182,000 practitioners, homeopathy is the second-largest system in India. Tibetan medicine resembles ?yurveda. It was established in India in 1961 after the Dalai Lama fled from Tibet to India.

Medical Services as an International Industry

India reportedly attracts approximately 100,000 patients from abroad every year, as certain hospitals provide international standards of care at affordable prices. The Apollo group, India's largest chain (38 hospitals) pioneered the concept by establishing state-of-the-art medical facilities in India's metropolitan centers and other large towns like Pune, Kochi, and Ahmedabad. Most hospitals are also linked to good hotels and shopping centers, which cater to the families of patients. By A 2003 the Confederation of Indian Industry, sensing commercial opportunities, became actively involved, offering Indian facilities to Britain's beleaguered National Health Service as a low cost, expeditious alternative for British patients.

The prices of Indian health care are quite low. For instance, heart surgery costs U.S.$8,000 in India, compared to $30,000 in the United States; liver transplantation, which is $300,000 in the United States, is $45,000 in India; similarly, orthopedic surgery is generally available for a tenth to a third of its price in the West.

Both the Indian government and the private sector are active in the growing global telemedical services. Telemedicine was initially available in radiology, cardiology, and pathology. Advances in technology have added electronic stethoscopy, ophthalmoscopy, and spirometry.

Rajesh Kadian

See also? yurveda ; Health Care for Tourists

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