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Wednesday, May 22, 2019

Infographic: India's health delivery infrastructure

This article is part 2 of a 4-part series which is my attempt at a capsule course on India’s healthcare system. For part 1 – “Timeline of events”, please click here.

A quick look at India’s healthcare system might remind you of one of those restaurants with 40-page menus – infinite options, something for everyone, no one will go home disappointed. But as you look closer and start making choices, well. Turns out the salad 231 you want isn’t available because ingredients are missing. This other salad - the new chef doesn’t know the recipe, sorry. Yes they have soup 494, and it’s the best, but you’ll have pay 3 times what they said in the menu. Or they could make you this other soup which costs less, but they need you to wait for 8 hours for it and to go buy some of the spices yourself. And so on. Like most things in our capitalist universe, the impressive menu turns out to be an ambitious facade that serves only those who have the power and money to navigate the system.

Ok rant over. So how does India access healthcare? We have an extensive public health system that delivers free care, which seems logical because a fifth of our total population makes less than 50 rupees a day. And yet, 70% of India’s total spending on health is via out-of-pocket payments (OOPs) to a private healthcare system, which also extensive.  

Let’s look at the public health system first. It is a well-planned system – structured into three tiers increasing order of complexity from primary to tertiary care, supported by over 3 million frontline health workers who work in at community levels.

The more I look at it, the more brilliant it seems. It seems well-thought out, deeply in tune with the country’s realities. The network is denser in rural areas where 70% of India lives. There are about 150,000 subcentres (SCs), 25, 000 primary healthcare centers (PHCs) and 5,510 community healthcare centers (CHCs) – the three main levels of care with increasing variety of services offered, and increasing number of people served. At the ground level, there is an army of 3 million plus community health workers (CHWs), each of whom is responsible for about 500 people. The go door to door, provide education on health and nutrition, counselling, and referrals so that diseases get diagnosed and treated early.

But. This amazing system is supported by less that 1.4% of India’s total GDP. And so, the infographic above, which I painstakingly put together from policy documents, does not tell the entire story. The story, more like a tragic Premchand novella, would have the following chapters:
  • Demotivated and missing community workersAsha workers do not receive fixed salaries, and their contractual payments or honorariums can range from rupees 500 to 3000 per month. These honorariums often get delayed or missed. The anganwadi workers’ salaries have recently been raised to rupees 10,000, but non-payment is common. These workers work for over 8 hours each day in anganwadi centers and their workloads are massive. Half of all subcentres (SC) have CHW staff shortages
  • Physician shortages: About 10% of the PHCs do not have doctors, which doesn’t seem too bad. Especially since CHCs face far worse shortfalls of specialists (surgeons, obstetricians,  gynecologists, physicians, and pediatricians); these shortfalls exceed – wait for it – 80%.
  • Quality issues: Less than 20% of the functioning sub-centres, PHCs and CHCs meet Indian Public Health Standards (IPHS).

These and multiple other issues mean that Indians, whether they live in rural and urban India must look to the private sector for getting the care they need. What does that look like? This private world of healthcare is even more complex – care seekers can choose from the friendly neighbourhood practitioner to swanky hospital chains.

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