Why Are Our Tertiary Care Hospitals Always Crowded?
Short answer to the title question is that our ‘Public Health Care System’ is grossly inadequate and whatever is in place is also not working to its optimum capacity. Let me look at some facts.
The World Health Organisation (WHO) recommends ‘3 hospital beds per 1000 population’. Affluent countries like Germany and Austria have seven to eight! To meet the guideline, we need about 42 lakh hospital beds. As per information available, in 2021, we had a total of 8.25 lakh beds – that translates to nearly 0.6 beds/1000 persons – which is indeed woefully short. Before I proceed further, let me mention that ‘Public Health & Hospitals’ in India is a ‘state subject’ and state authorities often do not post information on time and accurately. Therefore, this figure of 8.25 lakh beds may not be correct and there might have been improvements. Even then we could’ve inched up to 0.8 or one bed/1000 population – long way to reach the 42 lakh total in all government and private hospitals!
Our public health system – which is charged with the objective of ‘preventing disease, prolonging life, improving health and efficiency of the people’ – has of course, seen vast upgradations but still needs much more. A remarkable scheme, introduced by the government – ‘Ayushman Bharat’ – deserves special mention and is expected to provide significant succour to the poor. Our spend on healthcare has moved ever so slowly from 1.12 per cent of GDP in FY 2010 to 1.35 per cent in FY2020. A recent ET edit mentioned that Central & State governments’ budgeted expenditure on health, for FY 2023, is 2.1 per cent of GDP and the NHP plans to increase it to 2.5 per cent in FY2025. Curiously, total expenditure on health (public + private) that was 4.5 per cent of GDP in 2004-05 dropped to 3.8 per cent in 2016-17. Incidentally, the United States spends an eye popping 16.8 per cent of its GDP on healthcare! For the United Kingdom and Japan this figure is about 10-11 per cent. Our 2.1 per cent of GDP – spent in FY2023 was the lowest amongst BRICS nations.
It is also worth mentioning here that the distribution of healthcare expenditure in India, between public (38 per cent) and private (62 per cent) is highly skewed. I think the rub lies in the fact that out of the Rs 5.8 lakh crore total spent in 2016-17, only 1.9 lakh crore was on capital expenditure which was just 1.2 per cent of GDP. So there’s very little ‘capacity building’ – addition of new hospitals!
To be fair, there are huge improvements on the ‘mother & child health’ front. For example, MMR (maternal mortality rate) came down from 556 per lakh population in 1990 to 122 in 2014-16 and further to 103 during the period 2017-19. ‘Institutional deliveries’ have reached nearly 90 per cent and that perhaps explains the fall in MMR. Secondly, the United Nations has set a target of bringing down MMR globally to under 70/one lakh by 2030 as a sustainable development goal (SDG) and, happily in India, after start of NHP 2017, eight states have already achieved that. State wise figures – Kerala (19), Maharashtra (33) Telangana (43) Andhra (45), Tamil Nadu (54) Jharkhand (56) Gujarat (57) and Karnataka (69) – with the exception of Jharkhand – relate well with the status of education and thus awareness. I only hope the Jharkhand figures are not cooked up!
Incidentally India’s target at ‘under 100/lakh by 2020’ was nearly achieved with 97 during 2018-20. Here again schemes like the PM Suraksha Matritva Abhiyan, Anushasan Poshan Abhiyan and Anemia Mukt Bharat, implemented through direct cash benefit (DBT) to pregnant women’s bank accounts have helped hugely to ensure basic nutrition. Similarly, Infant Mortality Rate (IMR) which stood at a catastrophic 190/1000 live births in 1950, came down to 27.7 in 2022 and is expected to reach a figure of 5/1000 by the year 2100. Also, on the immunisation front, a 2019-20 report, by the Ministry of Health & Family Welfare, disclosed that 62 per cent of all children between the age of 12 and 23 months had been fully vaccinated under NHFS-4 in 2015-16 as against only 44 per cent that underwent this exercise during 2005-6 under NHFS-3.
The death rate in the country, which stood at 7.27/1000 people in 2011 improved consistently to reach 6.71 in 2019 only to spike to 7.35 in 2020 and the peak of 9.45 in 2021 due to Covid, but thankfully came down to 7.38 in the following year. For some reason the UN projects it at 7.7 in 2024. Anyway it is a far cry from the ghastly 25/1000 in 1950 and about 9/1000 in 2000. Deaths due to communicable diseases (CDs) have been controlled pretty well @ about 27.5 per cent of all deaths but those due to Non Communicable Diseases (NCDs) have risen from 37.9 per cent to an astonishing 61.8 per cent over the last couple of decades. The biggest killer are the Cardio Vascular Diseases, followed by cancers, diabetes and chronic respiratory diseases.
We do have an elaborate public healthcare system through a network of about 30,000 primary health centres (PHCs), 5,600 community health centres, 1,250 sub district hospitals, 1,000 district hospitals, with a total of about 7.4 lakh beds available in public facilities. Then there are CGHS and ESIC hospitals. The defence services and the Railways have their own set-ups of efficient hospitals and even a highly ranked ‘Armed Forces Medical College’ at Pune. Defence authorities are also quite liberal about issuing NOCs for those (including veterans and their families) seeking treatment at private hospitals and bills are settled by the defence establishment. Notwithstanding the multi-tiered government set-up – besides the fact that the total number of beds is too small for the needs – it is sadly very inefficient. Many of the PHCs often do not have doctors. There’s some sort of a mandatory ‘rural service’ tenure for all those graduating from government colleges but almost everyone tries to avoid that by fabricated excuses. Not to put the entire blame on these young doctors, it is a fact that living conditions in the villages are just too poor to attract these bright men and women. So, bottom line, patients’ load moves on to tertiary care hospitals concentrated in big cities and metros.
In a country of our size and complexities, we need a much more robust government healthcare system at the primary and secondary levels rather than to push everything to the overcrowded and super expensive tertiary hospitals; most of these owned by the private sector corporates and located in metro cities. We have to find ways and means of significantly increasing the number of beds in PHCs and district hospitals and make sure that these are all well-staffed and run efficiently.
We can’t wait for the Supreme Court to issue directives to the government – as indeed they have done recently in response to a PIL – to clamp down on very well run private hospitals to put a ceiling on their charges which will only bring in more malpractices and reduce the quality of care and may even persuade our highly qualified and experienced doctors to move out to the West. We have to invest heavily in public facilities even in the tertiary sectors and let market forces bring in greater efficiency and, hopefully, even costs. Clearly, we also need many more medical colleges to add thousands of doctors in the country. More colleges – especially by the government – will also ease the ‘nefarious practice of capitation fees’ charged by private colleges which have mostly become money making businesses.
To end this column, let me quote Dr Basant Garg, additional CEO, National Health Authority (BW Healthcare – February ’24) “Empowerment, not just treatment, defines the future of Indian Healthcare”. He goes on to add a ray of hope when he says “ABDM (Ayushman Bharat Digital Mission) is helping India leapfrog technologically in its healthcare sector to provide a seamless, interoperable and efficient digital healthcare infrastructure”. He feels this will make the system citizen-centric rather than disease-centric and it will empower citizens to access information related to their health, healthcare professionals, facilities and insurance claims. He envisions that under ABHA (Ayushman Bharat Health Account) citizens will have access to their health records digitally and won’t have to worry about carrying their records physically. I hope and pray he succeeds in his mission.
The author is member, Managing Committee of the Indian Cancer Society, Delhi and was member of the Governing Council of the Rajiv Gandhi Cancer Institute and Research Centre. He is past president of AIMA and former member, Board of Governors, IIMC
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