I’m writing this post from Jamshedpur – an industrial town in the state of Jharkhand in north-east India. It is better known as the home of Tata Steel, the flagship company of Tata Group which has more recently made its mark in the global business world by acquiring Jaguar, LandRover and Corus; and manufactures the world’s cheapest car.
But I digress. I have flown here from London to visit my elderly and infirm parents, both of whom were recently ill with Chikungunya fever. A viral fever spread by mosquitoes, the illness has anecdotally reached epidemic proportions in the town with local hospitals having run out of beds and doctors having fallen ill themselves. The epidemic is hardly surprising, given that it’s the monsoon season and discarded plastic bags may have blocked the drainage system. But, sadly, what is also not surprising is the complete lack of public education by the authorities that the illness is preventable. No one I have spoken to so far seems to be aware that the illness is spread by mosquitoes. Where public health in India is concerned, not a lot seems to have changed since I was medical student in Kolkata in the 1980s.
India’s healthcare system is one of sharp contrasts. In a country of 1.2 billion people, the top 10 – 20% who can afford private health insurance, either through their employer or with cash from their own pockets, has access to some of the best quality healthcare in state-of-the art private hospitals located in India’s big cities. These corporate hospitals also attract a lot of wealthy patients from the West in the form of medical tourists as well as publicity and attention in the media. The rest of the population, largely poor and rural, has to get by on India’s underfunded, understaffed and overcrowded government hospitals, often paying expenses for medications themselves. Illness is a common reason for falling into poverty in India with 21% of households reporting that out-of-pocket health spending accounts for over 15% of their non-food expenditure .To say that India’s healthcare system is dysfunctional would be an understatement; to say that it is inequitable would be stating the obvious.
Currently, India spends 1% of its GDP on healthcare . The central government, headquartered in New Delhi, allocates these funds to each of India’s 28 states. Accountability for implementing various healthcare initiatives with these funds lies with state governments. This decentralised model has further worsened the problem of inequity as the different states have varying levels of efficiency and effectiveness when it comes to providing healthcare for its residents. A person living in the state of Uttar Pradesh,in north India, would be less likely to have access to an ambulance as 620 of the 779 ambulances purchased by the state were found lying idle at a warehouse by a team of central government investigators . On the other hand, a poor labourer in the state of Andhra Pradesh, in south India, can access a novel government-sponsored health insurance programme that can potentially reduce financial hardship and raise the quality of care in hospitals . In other words, there is a PIN code lottery analogous to the postcode lottery often described in the UK National Health Service i.e. the quality of healthcare a patient receives depends simply on where he or she lives.
Not that the Indian authorities aren’t trying to improve the healthcare system for its citizens. Government officials acknowledge that too little is spent on healthcare and that, India is likely to double its spend on healthcare from 1% to 2% of its GDP during the next five-year plan starting in 2012 . But simply increasing the healthcare budget isn’t the answer as many of the problems are systemic and related to poor infrastructure; an inadequate doctor-to-patient ratio; and a reported lack of governance and accountability. Some recent government initiatives, like the National Rural Health Mission have, indeed, made a difference. For example, cash incentives to health visitors and pregnant women to deliver their babies in hospital have improved both maternal and infant mortality rates in India since 2005. However, at 230 maternal deaths per 100,000 births in 2008 and 50 infant deaths per 1000 births in 2009, India is still well behind many other emerging economies, especially China .
India faces what is described as a ‘triple burden of disease’ – battling developing world health problems such as high infant and maternal mortality, malaria and tuberculosis in the mostly rural population side-by-side with developed world illnesses such as diabetes and heart disease in the urban, more affluent areas. This dual burden is made more complex by the high number of injuries and road deaths as an unintended consequence of the rapid urbanisation resulting from the economic boom . In 2009, the WHO ranked India as the global frontrunner in road deaths, with approximately 13 deaths every hour on India’s roads!  That shocking statistic roughly equates to a jumbo jet crashing every day, killing everyone on board. But unless presented in that fashion, the numbers are unlikely to have any impact on behaviour of road users.
There is anecdotal evidence of the use of technology to improve public health in rural India. The country’s Minister for Health recently announced that the state was collecting and maintaining a database of mobile phone numbers of pregnant women in order to send SMS reminders to track immunisation of their new born babies . With 9 million home births in 2010, these new mothers are often unaware of the risks of infectious diseases their babies face, with many dying of neonatal tetanus. With a bit of foresight from the state, similar mass communication of preventive measures to counteract mosquito-borne diseases can be undertaken through mobile SMS too. India, after all, is a famously well-connected country with 812 million mobile phone subscribers who have built a social network through SMS, not the web . The rural poor cannot afford Facebook and Twitter on smartphones and laptops; neither do they have enough electricity supplies to charge these unaffordable gadgets. But a significant percentage of them have basic mobile phones that are used innovatively for microcredit, money transfers and comparing the price for fresh fish between villages. So why not use mobile text messaging for health communication too?
India’s authorities are no doubt planning and making some progress with public health issues. The Public Health Foundation of India, a public-private partnership, is putting together a financing plan to create a broad-based health insurance system that is affordable to a large percentage of the population . However, as India celebrates 64 years of independence from British colonial rule this week, I guess the only people in the countrywho can influence the masses positively with public health campaigns are Bollywood stars and cricket heroes. Endorsing Coke, Pepsi , Adidas and Hyundai doesn’t save lives. What about an advert of Sachin Tendulkar requesting motorists not to use their mobile phones while driving on India’s chaotic roads? Being left disabled after a serious head injury is not cool.
- Health system innovation in India Part I: India’s health system challenges: Blog hosted by the Chief Economist of the World Bank
- Health system innovation in India Part II: Aarogyarsi: Blog hosted by the Chief Economist of the World Bank
- India’s public health crisis: The government responds: The Wall Street Journal – India Real Time
- Transcript: The Wall Street Journal answers questions on India’s health crisis: from 1st August 2011
- India leads world in road deaths: WHO 2009
- India turns to mobile phones in a bid to improve vaccination rate: The Wall Street Journal – India Real Time
- Mobile phones in India: A webless social network: The Economist
[photograph courtesy of Zsolt Zatrok]