Health infrastructure is an important indicator for understanding the health care policy and welfare mechanism in a country. It signifies the investment priority with regard to the creation of health care facilities. Infrastructure has been described as the basic support for the delivery of public health activities. India has systematically improved health conditions. Life expectancy has doubled from 32 years in 1947 to 66.8 years at present; Infant Mortality Rate (IMR) has fallen to 50 per thousand live births. Further, it is estimated that public funding accounts for only 22 per cent of the expenses on healthcare in India. Most of the remaining 78 per cent of private expenditure is out-of-pocket expense. The share of the richest 20 per cent of the population in total public sector subsidies is nearly 31 per cent, almost three times the share of the poorest 20 per cent of the population.
Healthcare System and Structure
Healthcare has become one of India’s largest sectors both in terms of revenue and employment. Healthcare comprises hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medical equipment. The Indian healthcare sector is growing at a brisk pace due to its strengthening coverage, services and increasing expenditure by public as well private players.
Indian healthcare delivery system is categorized into two major components public and private. The Government i.e. public healthcare system comprises limited secondary and tertiary care institutions in key cities and focuses on providing basic healthcare facilities in the form of Primary Healthcare centres (PHCs) in rural areas. The private sector provides majority of secondary, tertiary and quaternary care institutions with a major concentration in metros, tier I and tier II cities. India’s competitive advantage lies in its large pool of well trained medical professionals. India is also cost competitive compared to its peers in Asia and Western countries. The cost of surgery in India is about one-tenth of that in the US or Western Europe.
Medical education infrastructure in India has shown rapid growth during the last 20 years. The country has 476 medical colleges, 313 colleges for BDS courses and 249 colleges which conduct MDS courses. There has been a total admission of 52,646 Medical Colleges and 27060 in BDS and 6233 in MDS during 2017-18.
There are 3215 Institutions for General Nurse Midwives with admission capacity of 129,926 and 777 colleges for Pharmacy (Diploma) with an intake capacity of 46,795 as on 31st October, 2017. There are 23,582 government hospitals having 710,761 beds in the country. 19,810 hospitals are in rural area with 279,588 beds and 3,772 hospitals are in urban area with 431,173 beds. 70 per cent of population of India lives in rural areas and to cater to their need there are 156,231 Sub Centres (SCs), 25,650 Primary Health Centres (PHC) and 5,624 Community Health Centres (CHC) in India as on 31st March 2017.
Towards Universal Access to Health Care
Universal access to health care is a well-articulated goal for both global institutions and national government. India’s national Health Policy, 2017 envisions the goal of attaining highest possible level of health and well-being for all at all ages through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without financial hardship to the citizens. Under health related Sustainable Development Goal (SDG) no. 3 (Good Health and Well-Being), a commitment towards global effort to eradicate disease, strengthen treatment and healthcare, and address new and emerging health issues has been pronounced. The gains of India in many health related indicators helped the country to make progress in achieving MDGs. Ayushman Bharat Mission, world’s largest health scheme announced in the Union Budget 2018-19, is the latest initiative for expanding the health insurance net and targets 10 crore poor and deprived rural families. There has been a concerted effort to improve the health care infrastructure as well as delivery mechanism in the last couple of years. Several schemes, programmes and initiatives have been undertaken to bridge the gap to make the quantity as well as quality of the health services available to the last mile.
Major Government Initiatives
Government of India has taken some major initiatives to promote Indian healthcare industry. On September 23, 2018, Government of India launched Pradhan Mantri Jan Arogya Yojana (PMJAY), to provide health insurance worth Rs 500,000 (US$ 7,124.54) to over 100 million families every year. In August 2018, the Government of India has approved Ayushman Bharat National Health Protection Mission as a centrally Sponsored Scheme contributed by both Centre and State governments at a ratio of 60:40 for all States and 90:10 for hilly North Eastern States and 60:40 for Union Territories with legislature. The Centre will contribute 100 per cent for Union Territories without legislature.
Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)
The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) has the objectives of correcting regional imbalances in the availability of affordable/ reliable tertiary healthcare services and also to augment facilities for quality medical education in the country.
PMSSY has two components:
- Setting up of AIIMS like institutions
- Upgradation of Government Medical College Institutions.
Six AIIMS-like institutions, one each in the States of Bihar (Patna), Chhattisgarh (Raipur), Madhya Pradesh (Bhopal), Orissa (Bhubaneswar), Rajasthan (Jodhpur) and Uttaranchal (Rishikesh) have been set-up under the PMSSY scheme. Approved cost of each new AIIMS in first phase was Rs. 820 crores, Rs. 620 crores towards cost of construction and Rs. 200 crores for procurement of Medical Equipment and modular Operation Theatres.
PMSSY also envisaged up-gradation of several existing medical institutions in different states in the country. Initially the estimated outlay for up-gradation was revised to Rs. 150 crores per institution (From initial estimate of Rs. 120 crore), with Rs. 125 crore as the share of Central Government.
Ayushman Bharat, Pradhan Mantri jan Arogya Yojana (PMJAY)
One of the most ambitious health insurance programmes in the world today, the Pradhan mantra Jan Arogya Yojana (PMJAY). Ayushman Bharat, gives India the chance to transform its healthcare infrastructure. Launched in September 2018, PMJAY aims to address the healthcare needs of India’s poorest 100 million households. The path to success, however, is strewn with several challenges. If these hurdles are overcome and if PMJAY succeeds. India’s largest health insurance scheme would also become its most effective healthcare initiative.
PMJAY has the potential to institute reforms to the country’s healthcare and health insurance systems at a lower cost to the exchequer. If streamlined, health information and monitoring systems can arrest the possibility of over-provisioning and cost-inflation. The idea to shift away from a decaying system of government-funded hospitals and people, towards a mix of private and government health care, governed by common principles and financed by low-cost health insurance–is a step in the right direction.
The Swachh Bharat Abhiyan launched by the Prime Minister on 2nd October 2014, focuses on promoting cleanliness in public spaces. Public health care facilit4eis are a major mechanism of social protection to meet the health care needs of large segments of the population. Cleanliness and hygiene in hospitals are critical to preventing infections and also provide patients and visitors with a positive experience and encourages moulding behaviour related to clean environment. As the first principle of healthcare is “to do no harm” it is essential to have our health care facilities clean and to ensure adherence to infection control practices. Swachhta Guidelines for Public Health Facilities have been issued separately. To complement this effort, the Ministry of Health & Family Welfare, Government of India has launched a National Initiative to give Awards to those public health facilities that demonstrate high level of cleanliness, hygiene and infection control. “Kayakalp” is an initiative to promote sanitation and hygiene in public healthcare institutions. Facilities which outshine and exceed the set measures are awarded and incentivized under Kayakalp.
Till date, “Kayakelp’ initiative has been able to encourage public health facilities in the country to work towards attainment of excellence in cleanliness and hygiene. “Kayakalp” is becoming instrumental in building confidence of the users in public health facilities.
The Government of India has launched Mission Indradhanush with the aim of improving coverage of immunization in the country. It aims to achieve at least 90 per cent immunization coverage by December 2018 which will cover unvaccinated and partially vaccinated children in rural and urban areas of India.
Private sector in Health Care
The Supreme Court in a recent judgment directed government hospitals in Delhi to refer poor patients to private hospitals. This decision has been described as a pro-poor decision which aims at bringing the poor rural patients at par with the urban rich patients who till now had been the sole beneficiaries of such private institutions. The court directed that the private institutions would provide medical care free of cost the poor, pending preparation of a scheme which would involve private players in treating the poor. The appeal was filed against an earlier decision of the Delhi High Court whereby, the High court had directed certain private hospitals to ensure free treatment to 10 percent in-patients and 25 percent outpatients, this mandatory ruling was given on the ground that the land’ for construction was given on an undertaking which bound the private players to provide free health care to people who belong to economically weaker sections of the society. The apex court directed that the Delhi Government and Private Health institutions should come together and draw up a plan for serving the poor. This decision would go a long way in strengthening the public health system. The issues of access to quality health care may be addressed by collaboration between State Governments and private players.
The healthcare market can increase three fold to Rs 8.6 trillion (US$ 133.44 billion) by 2022. India is experiencing 22-25 per cent growth in medical tourism and the industry is expected to double its size for present (April 2017) US$ 3 million to US$ 6 billion by 2018.
There is a significant scope for enhancing healthcare services considering that healthcare spending as a percentage of Gross Domestic Product (GDP) is rising. The government’s expenditure on the health sector has grown to 1.4 per cent in FY18E from 1.2 per cent in FY14. The Government of Indian is planning to increase public health spending to 2.5 per cent of the country’s GDP by 2025.
The hospital and diagnostic centers attracted Foreign Direct Investment (FDI) worth US$ 5.25 billion between April 2000 and June 2018, according to data released by the Department of Industrial Policy and Promotion (DIPP).
In 2017, the Government of India approved National Nutrition Mission (NNM), a joint effort of Ministry of Health and Family Welfare (MoHFW) and the Ministry of Women and Child Development (WCD) towards a lifecycle approach for interrupting the intergenerational cycle of under nutrition.
As of September 23, 2018, the world’s largest government funded healthcare scheme, Ayushman Bharat was launched.
As of November 15, 2017, 4.45 million patients were benefitted from Affordable Medicines and Reasonable Implants for Treatment (AMRIT) Pharmacies.
As of December 15, 2017, the Government of India approved the National Medical Commission Bill 2017. It aims to promote medical education reform.
Road Ahead: Healthcare infrastructure and services
India’s healthcare industry is one of the fastest growing sectors and it is expected to reach $280 billion by 2020. The country has also become one of the leading destinations for high-end diagnostic services with tremendous capital investment for advanced diagnostic facilities, thus catering to a greater proportion of population. Besides, Indian medical service consumers have become more conscious towards their healthcare upkeep.
Indian healthcare sector is much diversified and is full of opportunities in every segment which includes providers, payers and medical technology. With the increase in the competition, businesses are looking to explore for the latest dynamics and trends which will have positive impact on their business. The hospital industry in India is forecasted to increase to Rs 8.6 trillion (US$ 132.84 billion) by FY22 from Rs 4 trillion (US$13 61.79 billion) in FY17 at a CAGR of 16-17 per cent.
India’s competitive advantage also lies in the increased success rate of Indian companies in getting Abbreviated New Drug Application (ANDA) approvals. India also offers vast opportunities in R&D as well as medical tourism. To sum up, there are vast opportunities for investment in healthcare infrastructure in both urban and rural India.
Garg (2018) suggests that public healthcare service should ensure three “Es-Expand -Equity – Excellence”. Access to adequate health care would need expansion of tertiary care facilities. Tertiary care should be equitably distributed to different segments of population. The setting tip of new facilities will have to address imbalances at three levels-regional, specialties, and ratio of medical doctors to nurses and other healthcare professionals.
India is well poised to a better public healthcare infrastructure, facilities and services and hopefully with all the well intentioned initiatives we shall see health taking a top priority agenda in the coming years and delivering on the promises that the new and bold initiatives in the health sector.