Challenges to Healthcare in India - The Five A's

The Indian healthcare scenario presents a spectrum of contrasting landscapes. At one end of the spectrum are the glitzy steel and glass structures delivering high tech medicare to the well-heeled, mostly urban Indian. At the other end are the ramshackle outposts in the remote reaches of the “other India” trying desperately to live up to their identity as health subcenters, waiting to be transformed to shrines of health and wellness, a story which we will wait to see unfold. With the rapid pace of change currently being witnessed, this spectrum is likely to widen further, presenting even more complexity in the future.

Our country began with a glorious tradition of public health, as seen in the references to the descriptions of the Indus valley civilization (5500–1300 BCE) which mention “Arogya” as reflecting “holistic well-being.”[1] The Chinese traveler Fa-Hien (tr.AD 399–414) takes this further, commenting on the excellent facilities for curative care at the time.[2] Today, we are a country of 1,296,667,068 people (estimated as of this writing) who present an enormous diversity, and therefore, an enormous challenge to the healthcare delivery system.[3] This brings into sharp focus the WHO theme of 2018, which calls for “Universal Health Coverage-Everyone, Everywhere.”

What are the challenges in delivering healthcare to the “everyone” which must include the socially disadvantaged, the economically challenged, and the systemically marginalized? What keeps us from reaching the “everywhere,” which must include the remote areas in our Himalayan region for instance, where until recently, essentials were airlifted by air force helicopters?.[4]

While there are many challenges, I present five “A's” for our consideration:

1. Awareness or the lack of it: How aware is the Indian population about important issues regarding their own health? Studies on awareness are many and diverse, but lacunae in awareness appear to cut across the lifespan in our country. Adequate knowledge regarding breastfeeding practice was found in only one-third of the antenatal mothers in two studies.[5,6] Moving ahead in the lifecycle, a study in urban Haryana found that only 11.3% of the adolescent girls studied knew correctly about key reproductive health issues.[7] A review article on geriatric morbidity found that 20.3% of participants were aware of common causes of prevalent illness and their prevention.[8]

   Why is the level of health awareness low in the Indian population? The answers may lie in low educational status, poor functional literacy, low accent on education within the healthcare system, and low priority for health in the population, among others.

   What is encouraging is that efforts to enhance awareness levels have generally shown promising results. For instance, a study in Bihar and Jharkhand demonstrated improved levels of awareness and perceptions about abortion following a behavioral change intervention.[9] A review on the effectiveness of interventions on adolescent reproductive health showed a considerable increase in the awareness levels of girls with regard to knowledge of health problems, environmental health, nutritional awareness, and reproductive and child health following intervention.[10]

   The message is clear – we must strive to raise awareness in those whom we work with and must encourage the younger generation to believe in the power of education for behavior change.

2. Access or the lack of it: Access (to healthcare) is defined by the Oxford dictionary as “The right or opportunity to use or benefit from (healthcare)”[11] Again, when we look beyond the somewhat well-connected urban populations to the urban underprivileged, and to their rural counterparts, the question “What is the level of access of our population to healthcare of good quality?” is an extremely relevant one. A 2002 paper speaks of access being a complex concept and speaks of aspects of availability, supply, and utilization of healthcare services as being factors in determining access. Barriers to access in the financial, organizational, social, and cultural domains can limit the utilization of services, even in places where they are “available.”[12]

   Physical reach is one of the basic determinants of access, defined as “ the ability to enter a healthcare facility within 5 km from the place of residence or work”[13] Using this definition, a study in India in 2012 found that in rural areas, only 37% of people were able to access IP facilities within a 5 km distance, and 68% were able to access out-patient facilities[14] Krishna and Ananthapur, in their 2012 paper, postulate that in general, the more rustic (rural) one's existence – the further one lives from towns – the greater are the odds of disease, malnourishment, weakness, and premature death.[15]

   Even if a healthcare facility is physically accessible, what is the quality of care that it offers? Is that care continuously available? While the National (Rural) Health Mission has done much to improve the infrastructure in the Indian Government healthcare system, a 2012 study of six states in India revealed that many of the primary health centers (PHCs) lacked basic infrastructural facilities such as beds, wards, toilets, drinking water facility, clean labor rooms for delivery, and regular electricity.[14]

   As thinkers in the disciplines of community medicine and public health, we must encourage discussion on the determinants of access to healthcare. We should identify and analyze possible barriers to access in the financial, geographic, social, and system-related domains, and do our best to get our students and peers thinking about the problem of access to good quality healthcare.

3. Absence or the humanpower crisis in healthcare: Any discussion on healthcare delivery should include arguably the most central of the characters involved – the human workforce. Do we have adequate numbers of personnel, are they appropriately trained, are they equitably deployed and is their morale in delivering the service reasonably high?

   A 2011 study estimated that 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 9%.[16] This workforce is not distributed optimally, with most preferring to work in areas where infrastructure and facilities for family life and growth are higher. In general, the poorer areas of Northern and Central India have lower densities of health workers compared to the Southern states.[17]

   While the private sector accounts for most of the health expenditures in the country, the state-run health sector still is the only option for much of the rural and peri-urban areas of the country. The lack of a qualified person at the point of delivery when a person has traveled a fair distance to reach is a big discouragement to the health-seeking behavior of the population. According to the rural health statistics of the Government of India (2015), about 10.4% of the sanctioned posts of auxiliary nurse midwives are vacant, which rises to 40.7% of the posts of male health workers. Twenty-seven percentage of doctor posts at PHCs were vacant, which is more than a quarter of the sanctioned posts.[18]

   Considering that the private sector is the major player in healthcare service delivery, there have been many programs aiming to harness private expertise to provide public healthcare services. The latest is the new nationwide scheme proposed which accredits private providers to deliver services reimbursable by the Government. In an ideal world, this should result in the improvement of coverage levels, but does it represent a transfer of responsibility and an acknowledgment of the deficiencies of the public health system?

   As trainers and educators in public health, how are we equipping our trainees to deliver a health service in the manner required, at the place where it is needed and at the time when it is essential? It is time for a policy on health human power to be articulated, which must outline measures to ensure that the last Indian is taken care of by a sensitive, trained, and competent healthcare worker.

4. Affordability or the cost of healthcare: Quite simply, how costly is healthcare in India, and more importantly, how many can afford the cost of healthcare?

   It is common knowledge that the private sector is the dominant player in the healthcare arena in India. Almost 75% of healthcare expenditure comes from the pockets of households, and catastrophic healthcare cost is an important cause of impoverishment.[19] Added to the problem is the lack of regulation in the private sector and the consequent variation in quality and costs of services.

   The public sector offers healthcare at low or no cost but is perceived as being unreliable, of indifferent quality and generally is not the first choice, unless one cannot afford private care.

   The solutions to the problem of affordability of healthcare lie in local and national initiatives. Nationally, the Government expenditure on health must urgently be scaled up, from <2% currently to at least 5%–6% of the gross domestic product in the short term.[20] This will translate into the much-needed infrastructure boost in the rural and marginalized areas and hopefully to better availability of healthcare– services, infrastructure, and personnel. The much-awaited national health insurance program should be carefully rolled out, ensuring that the smallest member of the target population is enrolled and understands what exactly the scheme means to her.

   Locally, a consciousness of cost needs to be built into the healthcare sector, from the smallest to the highest level. Wasteful expenditure, options which demand high spending, unnecessary use of tests, and procedures should be avoided. The average medical student is not exposed to issues of cost of care during the course. Exposing young minds to issues of economics of healthcare will hopefully bring in a realization of the enormity of the situation, and the need to address it in whatever way possible.

5. Accountability or the lack of it: Being accountable has been defined as the procedures and processes by which one party justifies and takes responsibility for its activities.[21]

In the healthcare profession, it may be argued that we are responsible for a variety of people and constituencies. We are responsible to our clients primarily in delivering the service that is their due. Our employers presume that the standard of service that is expected will be delivered. Our peers and colleagues expect a code of conduct from us that will enable the profession to grow in harmony. Our family and friends have their own expectations of us, while our government and country have an expectation of us that we will contribute to the general good. A spiritual or religious dimension may also be considered, where we are accountable to the principles of our faith.

In the turbulent times that we live in, the relationships with all the constituents listed above have come under stress, with the client-provider axis being the most prominently affected. While unreasonable expectations may be at the bottom of much of the stress, it is time for the profession to recognize that the first step on the way forward is the recognition of the problem and its possible underlying causes. Ethics in healthcare should be a hotly discussed issue, within the profession, rather than outside it.

Communication is a key skill to be inculcated among the young professionals who will be the leaders of the profession tomorrow. As leaders in community medicine and public health, we may be the best placed to put this high up in the list of skills to be imparted. A good communicator is better placed to deal with the pressures of the relationships with client, employer, peer, colleague, family, friend, and government.

The five as presented above present challenges to the health of the public in our glorious country. As we get ready to face a future which is full of possibility and uncertainty in equal measure, let us recognize these and other challenges and prepare to meet them, remembering that the fight against ill health is the fight against all that is harmful to humanity.