Compiled by Michael Chang, Yechiel Engelhard, Lisa Frist and Gabrielle Tiven (CARE Rural Health Mission)
1. Health Indicators & Disease Prevalence
2. Healthcare System
3. Health Inequality
4. Impact of public health & the health system on enterprises’ roles in delivering health care
Given social and economic inequality in India, it is not surprising that public health issues vary widely. The country faces simultaneous problems arising from poverty, such as malnourishment and malaria, as well as wealth, such as obesity and diabetes. Government spending on healthcare is quite small, so private enterprise plays a very large role in all sectors of the Indian healthcare system.
1. Health Indicators & Disease Prevalence
Life expectancy & mortality
Life expectancy is 64.1 years for men and 65.8 years for women (2005). Because of differenes in literacy, income and socioeconomic conditions among communities there are large differences in life expectancy across geographic regions of the country.
The infant mortality rate in 2005-06 is 57 per 1000 live births, an improvement from 70 deaths per 1000 live births in 1999. The mortality rate for children under five is 85 per 1000 live births (2002) and is highest for the poor and rural. The maternal mortality rate is 301 deaths per 100,000 live births (2001-03). The main causes of a high maternal mortality rate include low socioeconomic status of women, inadequate pre-natal care, a low proportion of deliveries in hospitals and the limited availability of skilled birth attendants.
As of 1999, the main causes of mortality in India were non-communicable diseases (48 percent), communicable diseases (42 percent) and injuries (10 percent).
- The dominant communicable diseases are infectious and parasitic diseases, respiratory diseases, maternal conditions, perinatal conditions and nutritional deficiencies.
- The dominant non-communicable diseases are malignant neoplasm, diabetes mellitus, neuropsychiatric disorders, sense organ disorders, cardiovascular diseases, respiratory diseases, digestive diseases, musculo-skeletal diseases, congenital anomalies and oral diseases.
Recently diseases such as dengue fever, viral hepatitis, tuberculosis, malaria and pneumonia have reappeared with drug resistance. This is attributed to poor housing, insufficient clean water and sanitation, a weak public health and an increase in air travel.
Economic growth is driving up rates of life style diseases such as obesity, hypertension, cancer, and diabetes. Over the next 5-10 years, lifestyle diseases are expected to grow at a faster rate than infectious diseases in India.
It is estimated that over 40 million Indians have diabetes, and that more than 73 million will have the disease in 2025. Diabetes disproportionately affects affluent urban areas compared to rural villages. The disease is more prevalent in the south than in the north, particularly in Chennai and Hyderabad, where 16% of the population has diabetes. Because of a strong genetic vulnerability to diabetes, Indians tend to contract the disease earlier than other populations.
In India today approximately 2.5 million people are HIV positive, an incidence rate of 0.36% of the population. The incidence rate in Andhra Pradesh is 0.97% of the population. While the HIV rate is stable or declining among pregnant women, the rate is high or increasing among sex workers, drug users and men who have sex with men.
Up to 14 million people in India are blind and 3.2 are hearing imparied. More than 16 million people have physical disabilities impairing motor skills, and 3% of the nation’s children are mentally retarded. The main cause of blindness is cataracts.
2. Healthcare System
Total healthcare spending in India was $30.5 billion in 2003. The government funded only 18% of that spending, with state governments covering 80% of the public share and the federal government another 15% through national healthcare programs. The federal government launched an initiative in 2005 to focus on improving rural healthcare, particularly in states with low health indicators. Existing public hospitals are underfunded and provide only basic care.
Private enterprise covers 82% of healthcare spending in the country, compared with averages of 27% for the G7 countries and 59% for BRIC countries overall. Much of the inpatient and outpatient care provided in India is done by the private sector.
Approximately 90% of Indians do not have any kind of health insurance, so families usually have to pay for health expenditures out of pocket. This is especially onerous for the poor, who can be sent into significant debt by a large medical bill.
Two-thirds of India’s hospitals and clinics are in urban areas and only 3% of specialist doctors live in rural areas. The rural population often relies on non-Western medical traditions, such as ayurvedic medicine and acupuncture. Overall, only a quarter of the population has access to Western medicine (i.e., allopathic, in which the treatment is opposite the symptom, as opposed to homeopathic, in which the treatment is a minute trace of a substance than would normally cause disease in a healthy person).
3. Health Inequity in India
Health inequity is high in India both in terms of health access and health outcomes. The sharpest differences can be seen in the division between the wealthy and poor and secondarily between urban and rural populations. Access to health services is by far the best for the wealthy. In general, health services are more accessible in urban areas, however, the urban poor face the worst barriers due to the high cost of urban health services. In comparison, subsidized or free government health care is more readily available in rural areas, though still quite limited.
Widespread lack of sanitation facilities, sewers and clean drinking water negatively impact health outcomes. Data from the World Health Organization shows that the percentage of the population using improved drinking-water sources and improved sanitation facilities has been increasing, however, rural areas still fall far behind urban areas despite a shrinking gap. Also births are much more likely to be accompanied by skilled health personnel among urban and wealthy populations.
4. What is the impact of public health and health system issues on enterprises’ roles in delivering health care?
Private enterprise currently plays a very large role in the health system in India, and its potential role continues to grow. At roughly 6%, Indian health care spending as a percentage of GDP is low relative to other large countries but perhaps even more distinct is that the private sector is responsible for greater than 80% of the total healthcare spending. The private nature of the health care system in India, unencumbered by hefty government intervention, allows the system to be more responsive to the needs of patients, and more innovative and frugal in its approach.
Looking forward, enterprises can play a key role in serving the health care needs of the Indian poor by: a) expanding the health care infrastructure to broaden its catchment area; b) providing financial solutions to help the poor pay for care; and c) driving down cost of care through innovative medical procedures, pharmaceutical R&D and manufacturing, and good resource management.
a. Expanding the Health Care Infrastructure
As of 2007, India had 860 hospital beds per million people, far below the world average of 3,960 per million. With limited public plans to finance the building of medical centers, there is a large opportunity for the private sector to invest, particularly in smaller cities. Already, private enterprises like Apollo Hospitals and Columbia Asia are taking advantage of generous government subsidies and have begun to build new hospitals in small- and medium-sized cities. Many are also employing telemedicine to even more effectively reach the poor and leverage the existing infrastructure.
b. Provision of Health Insurance
Access to care can also be increased through financial innovation and provision of insurance. The government has spearheaded Rashtriya Swasthya Bima Yojana, a public-private national health insurance plan, where premiums to private insurance companies are paid for by the government. Despite the program’s early successes (over 15 million families enrolled), the vast majority of the population remains uninsured. There is a clear opportunity for private health care providers and private insurance providers to help finance access to health care for the poor.
c. Driving Down Cost of Care
Private enterprises in India are already world leaders in providing low-cost healthcare. Apollo Hospitals charges $2,300 for a heart bypass surgery. LifeSpring Hospitals has reduced the price of child delivery to $40 for natural birth and $140 for a caesarean-section. Indian entrepreneurs, working in a largely private, nimble, and profit-driven health system, are incentivized to innovate medical procedures to capture more of the middle- and lower-class market. Innovation is not limited to just medical procedures though. Already established in pharmaceutical manufacturing (India manufactures 80% of the world’s supply of generic drugs), there is now an opportunity for Indian companies to play a larger role in pharmaceutical research and development. Finally, India is at the forefront of health information-technology (HIT) implementation, with an estimated 60% of hospitals using HIT, compared just 20% in the United States, allowing Indian hospitals to run lower overhead expenses. By continuing to push HIT and other methods to increase efficiency, private enterprises in India can further reduce costs, leading to greater access to care for the poor.
1. “Country Health System Profile: India.” World Health Organization, Regional Office for South-East Asia. Retrieved 14 February 2011 from http://www.searo.who.int/en/Section313/Section1519_10855.htm
2. The Economist. Health Care in India – Lessons From a Frugal Innovator. 16 April 2009. Retrieved 12 February 2011 from www.economist.com: www.economist.com/node/13496367/print
3. “HIV Epidemic in India.” Joint United Nations Program on HIV/AIDS. Retrieved 16 February 2011 from http://www.unaids.org.in/displaymore.asp?itemid=322&chkey=109&subchkey=0&chname=HIV%20Epidemic%20in%20India
4. “India: health profile.” World Health Organization. Retrieved from http://www.who.int/gho/countries/ind.pdf
5. India Knowledge@Wharton. Innovating Around India’s Health Care Challenges: India Knowledge@Wharton. 29 July 2010. Retrieved 12 February 12 from Knowledge@Wharton: http://knowledge.wharton.upenn.edu/india/article.cfm?articleid=4501
6. Joe, William et al. “Health Inequality in India: Evidence from NFHS 3.” Economic and Political Weekly. 2 August 2008. Retrieved from http://www.hss.iitm.ac.in/rt-ppp/Urban%20Health/Journal%20Articles/Health%20Inequality%20in%20India-%20Results%20of%20NFHS%203.pdf
7. PricewaterhouseCoopers. “Healthcare in India: Emerging Market Report 2007.” 2007. PricewaterhouseCoopers. http://www.pwc.com/en_GX/gx/healthcare/pdf/emerging-market-report-hc-in-india.pdf
8. Robinson, Simon. “India’s Medical Emergency.” Time magazine. 01 May 2008. Retrieved 13 February 2011 from http://www.time.com/time/magazine/article/0,9171,1736516,00.html
9. UNDP Press Release. “2010 Human Development Report: Asian Countries lead development progress over 40 years.” 4 November 2010. Retrieved 14 February 2011 from http://hdr.undp.org/en/media/PR6-HDR10-RegRBAP-E-rev5-sm.pdf