India's
recent mission to Mars seems to have provoked questions mainly from non-Indians
on the need to prioritise development in other areas such as healthcare. Most
Indians seem to be proud of the Mars mission and live on hope that the great
successes seen in space exploration may somehow be replicated one day in other
areas. Many non-Indian commentators and overarching international organisations
have asked for India to raise healthcare spending.
The
numbers seem to be all over the place. For the purpose of this blog discussion
we will assume the following for Indian healthcare expenditure:
Percentage
of GDP spent on healthcare 4%
Percentage
of government expenditure on healthcare 8%
Per
capita spending on healthcare $60 (if you believe wikipedia its $124)
Out of
pocket expenses is around 60%
This is
when the arm chair commentators, the ones who have never been bitten by a mosquito
in an area where malaria is prevalent, should get out of the discussion and get
a dose of reality.
What can
you get in western healthcare for $60? Not a lot.
This $60
per person per year spent on Indian healthcare is mostly accounted for by the
20% of people who represent the middle class and above. Many of the middle
class get much more than $60 spent on them leaving in theory and in practice, a
large proportion of the population to have nothing spent on their healthcare $0
per year. A friend recently had a colonoscopy in a frightfully expensive
hospital in India and spent Rs 70000 ($1111) this may mean this friend has used
up 17 other Indians' annual healthcare spend. You get the picture.
70% of
the Indian people live less than $2 per day (33% of people are below the
official poverty definition of $1.25 per day). You get the bigger picture.
By how
much should India raise its healthcare expenditure? Doubling it to $120? What
would that get? Nothing in reality. Doubling that to $240? You would not even
scratch the surface. If the entire per capita income of an Indian which
averages $1100 is spent on healthcare India will still have a healthcare
expenditure less than Lithuania. Even at that level no one can predict if
healthcare benefits will be equitably distributed across the population. It may
well be possible that the rich will get healthier and the rest may get
unhealthier.
The US
example is relevant here where 18% of GDP is spent on healthcare at nearly
$9000 per person yet 40 million US citizens do not have healthcare cover and US
has poor outcomes for many chronic conditions. Throwing money at problems does
not necessarily solve problems.
Ask for a
better system. Ask for a different system. If that system costs a little more,
then the money follows, do not ask for more money to be spent on the existing
system - it just goes down the drain.
Copying
the current western systems of the 21st century for healthcare delivery in
India straightaway is expensive. This
means the benefits of any copied western systems will reach the small proportion
of the wealthy population. Well worth remembering the Jaguar in India costs the
same as in England and obviously the only wealthy get to use it.
Alternative
medical systems (ayurveda, siddha, homeopathy, etc) are still unable to provide
comprehensive answers at a population level.
So what
is missing? What are the potential avenues to explore?
Cannot Escape Evolution
There can
be no doubt health improvement at population level has evolved gradually over
time from the early 1900s. Interestingly the earliest foundations of population
level health improvement happened not by direct personal medical based
interventions but by infrastructure based social living conditions improvement.
I am talking about covering the drains, separating animals from human beings,
providing clean drinking water and so on. Direct intervention based healthcare
followed much later.
In India
in 2013 there are still many areas even within all the cities greater
boundaries where there are open sewers. In 2013 in one of the poshest areas of
a very major city there are contaminated water supplies. The healthcare budget
cannot not solve this; yet solving it will improve the health of the people.
A healthy
population is the greatest boost to an economy but the population cannot be
made healthy by primary, secondary or tertiary care based direct personal
medical interventions - i.e. doctors, clinics, hospitals. Populations can be
made healthy only by political will and civil engineers. That is the trick
India is missing. Building more primary and secondary care centres with open
drains around them is the opposite of a decent healthcare solution. India
cannot hope to improve the health of the population by avoiding a well
established evolutionary pathway.
It seems
India and its well wishers may be looking for the magic injection that will
solve major health problems. There may be magic injections for diseases but we will
do well to remember that there are no magic injections for health.
Under the
given current conditions, doctors cannot solve the healthcare problem of India.
Get the engineers out there. Get them to cover the drain, clear the puddle, provide
clean drinking water and keep the roads clean. You will find the population
becomes healthier contributes effectively to the economy. Then and only then we
can spend more on healthcare and expect to benefit from it.
©M HEMADRI
Follow me on twitter @HemadriTweets
I have blogged previously about great areas of Indian healthcare which you may want to check out.
Dr Bang's remarkable achievement in rural India which gets the same results as cities http://successinhealthcare.blogspot.in/2013/01/swadeshi-healthcare.html
My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture http://successinhealthcare.blogspot.in/2013/04/my-conversation-with-dr-ravindran.html
