State public health expenditure is just 1 per cent of GDP. The time to invest in healthcare is nowE Kumar Sharma   

Covid-19 has put the focus squarely on the healthcare sector. “If there is one clear message, it is the spotlight on healthcare. India’s per capita public expenditure on health is just $83, compared to $500 in China and $9,400 in the US. We need to increase it to at least $200-300 per capita,” says B.S. Ajaikumar, Chairman and CEO, HealthCare Global, a chain of cancer hospitals. The numbers are after accounting for purchasing power parity or PPP. In absolute terms also, it is a low $25 per capita, or `1,765. The government spends just about 1.09 per cent of GDP on public health. The National Health Policy aims to increase it to 2.5 per cent of GDP by 2025.

The Centre recently announced setting up of infectious disease wards in district hospitals and public health laboratories at block levels to increase testing facilities, in a move to combat the virus outbreak.

Invest More for Better Outcomes

“There are a number of states which spend substantially more than the national average. Kerala, Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Mizoram, Sikkim and Puducherry with some of them spending as much as between `3,500 and `10,000 per capita on health, over twice the national average. The health outcomes of these states are the best in the country. It’s no surprise that these states are the least affected by Covid-19,” Ravi Duggal, an independent researcher, has said in a detailed study of healthcare spending by states. “Compare them with lowest spenders like Bihar, Uttar Pradesh, Jharkhand, Madhya Pradesh, Odisha, West Bengal, Karnataka, Maharashtra and Punjab, which shows in their weak primary healthcare system,” he adds.

This can be seen globally as well, says Dr Devi Prasad Shetty, cardiac surgeon, and Chairman and Managing Director of Narayana Health. “Germany, which did better than many other European countries in fighting Covid-19, has 29 intensive care units per 1 lakh population, compared to 12 in Italy, seven in the UK and just one or two in India,” he adds.

The First Point of Contact

Reforms in the sector need to focus on some key areas. One is strengthening district hospitals and primary health centres (PHCs), the first points of contact for most Indians. The second is building a cadre of healthcare professionals. Leveraging nursing capabilities in rural areas, and creating more medical seats, can go a long way in strengthening the system.

Former Health Secretary Keshav Desiraju says: “Every district hospital (there are about 750 across the country) should be fully equipped to handle epidemics, sudden increase in number of patients, etc. A district hospital is where a person goes, or ought to be able to go, with any complaint.” It needs surgeons, anaesthetists and a functioning blood bank backed by qualified nursing staff.

Bridging the Specialist Shortfall

However, creating a team of medical staff and specialists is not easy. “Arunachal, Mizoram, Himachal Pradesh, Jammu & Kashmir, Sikkim, Goa and Puducherry do very well with 20-40 government doctors per lakh people and less than 25,000 people per PHC. With adequate number of doctors, district hospitals and teaching hospitals in these states also function better. Bihar, Uttar Pradesh, Maharashtra, Karnataka and West Bengal have the lowest access to such facilities. They have more than 30,000 people per PHC and less than the national average of nine government doctors per lakh population,” says Duggal. “We need to know how many specialists – anaesthetists, cardiologists, gynaecologists and paediatricians – are there, and only then can we draw up plans on how many we need,” says Dr Shetty.

One way to bridge the talent gap, says Dr Shetty, is doubling the number of medical seats from 70,000 to close to 1.5 lakh, mainly in the government sector. The quickest way to achieve this, he says, is by asking each government college to set up another college, taking in 100 students every year. “Given that most of them have sprawling campuses, the initial part of medicine study – the pre-clinical areas of anatomy, physiology and biochemistry – can be done in the same campus of the older college, and for clinical learning, newer colleges could tie up with district hospitals.”

Building a Cadre

Crucial to this ramp-up in the number of doctors is the issue of building a cadre of healthcare professionals in the country. Says Desiraju, “An ideal public health cadre will have three tiers – a Director of Public Health at the state level on a par with the Director Health & Family Welfare, a District Public Health Officer, on a par with the Chief Medical Officer or civil surgeon, and field-level workers, including auxiliary nurse midwifes (ANMs), ASHAs, Anganwadi and male multipurpose workers. The duties and responsibilities of each of them should be clear apart from the training and qualification required.”

The Centre can give guidance, but states have to execute those. Dr Shetty feels one of the important changes that the policy must look at is to “ensure that all nurse practioners, trained in primary care and serving in rural areas should be allowed to prescribe 47 basic drugs.”

Better Grip on Vaccines, Devices

One important gap in the healthcare system that coronavirus has brought to the fore is the dependence of the government on outside entities for dealing with the crisis. After having shut all public sector manufacturing of vaccines by 2008, it was left with no option but to wait for Indian private vaccine makers to tie up with international bodies or with Indian entities such as the National Institute of Virology (NIV) to develop a vaccine.

“There is a reason for the government to invest in vaccine manufacturing. It is very risky for the government to be dependent only on private sources. All of India’s measles vaccines come from the Serum Institute, Pune. It is an excellent institution and India’s best chances of developing and commercially manufacturing a Covid-19 vaccine are in the Serum Institute. However, if for any reason there is a crisis and a shortfall in production, the country’s immunisation programme will collapse. We cannot afford to let this happen,” says Desiraju. “There are other elements in the medical manufacturing space where the government does not necessarily need captive units like medical equipment, ancillaries, disposables, hospital equipment, highly sophisticated equipment such as those used for cancer care, etc. But vaccines are not one of them,” he adds.

Dr Shetty, however, is in favour of making medical equipment, devices, implants and consumables in India, either by private companies or by multinationals. This will prevent dependence on other countries, like China in the recent case, for crucial supplies, he feels.