At a time when Universal Health Coverage has become the new buzzword of healthcare in India since Ayushman Bharat, the National Health Profile 2019 throws up sobering figures. Between 2009-10 and 2018-19, India’s public health spend as a percentage of GDP went up by just 0.16 percentage points from 1.12% to 1.28% of GDP, and remains a far cry from the 2.5% GDP health spend that has been India’s target for some years now.
The National Health Profile (NHP) is an annual stocktaking exercise on the health of the health sector.
The current situation
“The cost of treatment has been on rise in India and it has led to inequity in access to health care services. India spends only 1.28% of its GDP (2017-18 BE) as public expenditure on health. Per capita public expenditure on health in nominal terms has gone up from Rs 621 in 2009-10 to Rs 1,657 in 2017-18,” NHP 2019 says.
Compare this with the average total medical expenditure per childbirth in a public hospital: Rs 1,587 in a rural area and Rs 2,117 in an urban area. Based on Health Survey (71st round) conducted by NSSO, average medical expenditure incurred during hospital stay during January 2013-June 2014 was Rs 14,935 for rural and Rs 24,436 in urban India.
In his Independence Day address in 2011, then PM Manmohan Singh had declared that financing of health would be upped to 2.5% of GDP, during the 12th Five Year Plan (a concept since discontinued). In 2018, Prime Minister Narendra Modi said at the Partners’ Forum meeting in Delhi: “We are committed to increasing India’s health spending to 2.5% of GDP by 2025, reaching to more than $100 billion. This will mean an actual increase of 345 per cent over the current share, in just eight years.”
Blueprint for meeting targets
In 2011, the High Level Expert Group of the erstwhile Planning Commission submitted its seminal report on the roll-out of Universal Health Coverage (UHC) in India. Recommendation 3.1.1 reads: “Government (central government and states combined) should increase public expenditures on health from the current level of 1.2% of GDP to at least 2.5% by the end of the 12th plan and to at least 3% of GDP by 2022.”
The report adds: “Financing the proposed UHC system will require public expenditures on health to be stepped up from around 1.2% of GDP today to at least 2.5% by 2017 and to 3% of GDP by 2022. The proposed increase is consistent with the estimates by government as well as our preliminary assessment of financial resources required to finance the NHP. Even if we assume that the combined public and private spending on health remains at the current level of around 4.5% of GDP, this will result in a five-fold increase in real per capita health expenditures by the government (from around Rs 650-700 in 2011-12 to Rs 3,400-3,500 by 2021- 22). There will also be a corresponding decline in real private out-of-pocket expenditures from around Rs 1,800-1,850 in 2011-12 to Rs 1,700-1,750 by 2021-22.”
Universal Health Coverage, according to the World Health Organization, means that “all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.” The three objectives are: equity in access to health services; quality of health services should be good enough to improve the health of those receiving them; people should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
There are wide disparities in the health spend of states, the NHP points out. The Northeastern states had the highest and the Empowered Action Group (EAG) states plus Assam had the lowest average per capita public expenditure on health in 2015-16. EAG states are the eight socio-economically backward states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand and Uttar Pradesh. Among the big states (erstwhile) Jammu and Kashmir leads with a 2.46% GSDP spend on healthcare – nearest to the ideal spend. Among the NE states, the leaders in health spend were Mizoram with 4.20% GSDP spend and Arunachal Pradesh with 3.29%.
Even states seen as better performers on health parameters, such as Tamil Nadu and Kerala, fare poorly on the health finance index. Tamil Nadu spent 0.74% of its GSDP and Kerala 0.93% of its GSDP on healthcare.
India and world
The NHP does some very telling calculations on India’s per capita health spend and how it stacks up against countries who are on the UHC path. In 2016, India’s Domestic general government health expenditure stood at $16 per capita. This is lower than Norway ($6,366), Canada ($3,274), Japan ($3,538), Republic of Korea ($1,209) and Brunei Darussalam ($599). Among the 23 countries including India that the Central Bureau of Health Intelligence chose for that comparison, the highest per capita spender is the United States at $8078. The American system, though, is considered neither ideal nor economical. This data has been sourced from the Global Health Expenditure Database of the World Health Organisation.
The NHP also notes the change in disease profile of the country with a shift towards the non-communicable disease from communicable ones – a fact that has been minutely documented by the State Level Disease Burden Study that was released some years ago and the subsequent analyses of that data periodically published in various medical journals. “ It has been observed that the non-communicable diseases dominate over communicable in the total disease burden of the country. In a recent report of India Council of Medical Research, titled India: Health of the Nation’s States: The India State-Level Disease Burden Initiative (2017), it is observed that the disease burden due to communicable, maternal, neonatal, and nutritional diseases, as measured using disability-adjusted life years (DALYs), dropped from 61 per cent to 33 per cent between 1990 and 2016. In the same period, disease burden from non-communicable diseases increased from 30 per cent to 55 per cent. The epidemiological transition, however, varies widely among Indian states: 48% to 75% for non-communicable diseases, 14% to 43% for infectious and associated diseases, and 9% to 14% for injuries,” the NHP notes. DALYs are an international standard of disease burden that measures how much of a normal life span of an individual is taken away by a disease related morbidity of mortality.
The NHP has also noted that medical education infrastructure has shown rapid growth over the past few years. “The country has 529 medical colleges, 313 Dental Colleges for BDS & 253 Dental Colleges for MDS. The total number of admissions for academic year 2018-19 in Medical Colleges is 58756. The Dental Colleges saw an admission of 26960 in BDS and 6288 in MDS in the academic year 2018-19,” it says.
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