INTRODUCTION

Hospitals and health care centers are our life lines; they are temples of life, giving hope to the hopeless, life to the lifeless and as a matter of fact have become indispen- sable. During the last couple of decades with the advent of technology, the face of these life savers has changed dramatically and in developed western countries, most

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*Corresponding Author: shaima.s.ali@gmail.com Received 20th July, 2015

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of them have acquired new dimensions providing best of treatments to those who can afford them or their gov- ernance which can make them affordable, through sus- tained efforts. Humanity has always been dealing with its inner con#icts, while other conjectures are combating with changing moral codes and parameters set by soci- ety, our life styles are undergoing drastic changes and although there seems to be a health revolution, going

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on, with health care taking at a fast speed, developing nations like India, and the below level ones which are leaping ahead economically still are not moving towards a state of balanced health.

Despite good intentions, health systems across devel- oping nations are unable to deliver high-quality, afford- able services to all. Thousands of children die each day needlessly of preventable diseases, as quality of care is extremely substandard. Sick patients—if they can get to a clinic and afford treatment—face long excruciable waits. Critical health information is buried in thick medical !les, and facilities are plagued with severe shortages of those who can heal. Inequities in the provision of health care are one of the greatest challenges we currently face as global citizens—and these demands are only ampli!ed in the developing world, (Health Information, 2010 and Shaima Miraj 2014 and 2015).

SOME OF THE EXISTING PROBLEMS IN HEALTH CARE SYSTEM

Spending on health care in India was an estimated !ve percent of gross domestic product (GDP) in 2013 and is expected to remain at that level through 2016. Total health care spending in local-currency terms is projected to rise at an annual rate of over 12 percent, from an esti- mated $96.3 billion in 2013 to $195.7 billion in 2018. While this rapid growth rate will re#ect high in#ation, it will also be driven by increasing public and private expenditures on health, (Industry Report, Health Care India, 2014 and Deloitte India 2015).

India’s public health care system is patchy, with underfunded and overcrowded hospitals and clinics, and inadequate rural coverage. Reduced funding by the Indian Government has been attributed to historic fail- ures on the part of the Ministry of Health and Family Welfare (MHFW) to spend its allocated budget fully. This is despite increasing demand, due, in part, to growing incidence of age- and lifestyle-related chronic diseases resulting from urbanization, sedentary lifestyles, chang- ing diets, rising obesity levels, and widespread avail- ability of tobacco products. India’s health care sector witnesses close to 50 percent spend on in-patient beds for lifestyle diseases, especially in urban and semi-urban pockets. In addition, India has one the world’s highest numbers of diabetes sufferers, at more than 65 million individuals. This trend has resulted in the mushroom- ing of super specialty hospitals to combat lifestyle dis- eases. The government’s low spending on health care places much of the burden on patients and their fami- lies, as evidenced by the country’s out-of-pocket (OOP) spending rate, one of the world’s highest. According to the World Health Organization (WHO), just 33 percent

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of Indian health care expenditures in 2012 came from government sources. Of the remaining private spend- ing, around 86 percent was OOP, (Indian Medical Tour- ism http://articles.economic times.indiatimes.com., IBEF Healthcare March 2014, Healthcare spending, http:// www.livemint.com).

If in a country like India with the government spend- ing thousands of crores annually on health coupled with International aids in billions of dollars, the condition of hospitals, health care centers and health providers is in tatters; one can imagine their conditions in countries like Pakistan and Bangladesh. A study on sickness revealed that around 40 to 50 million people are under medical supervision for major ailments at any given point of time and about 200 million man days are lost annually on account of sickness. The country spends about 6 per cent of its GDP on healthcare while private healthcare expend- iture is about 4.25 per cent of GDP, which has grown at the rate of 12 per cent per annum over the last few years.

Perusal of the National Health Policy, (2008-09) shows that the total allocation for health sector in the !nancial year (2008-09) was Rs 165,340 million, an increase of 15 percent over last year. Out of this, National Rural Health Mission (NRHM) has been allocated Rs 120,500 million. The National AIDS Control Program (NACO) got Rs 9,930 million in comparison to Rs 9,690 million last year .Center has allocated Rs 2,050 million for a new health insurance scheme named Rashtriya Swasthya Bima Yojana to provide a health cover of Rs 30,000 for every worker in the unorganized sector falling below poverty line (BPL) and his/her family. A National Pro- gram for the elderly with a plan outlay of Rs 4,000 mil- lion has been proposed and two National Institutes of Ageing, eight regional centers, and a department for geriatric medical care in one medical college/tertiary level hospital in each State, have been proposed. But what ails the health care system in the country despite all this?

Hospitals run by the government in developing nations almost function as white elephants and except for the below poverty lines, people do not have any faith in them as they seldom get proper treatment. It is not that there are improper facilities, quali!ed person- nel and doctors with specializations, it is rather poor state of administration, management and implementa- tion of policies and schemes, which are in plenty. The state of healthcare delivery in India is well summarized by the World Bank that reported: “a detailed survey of the knowledge of medical practitioners for treating !ve common conditions in Delhi found that the average doc- tor in a public primary health center has around a 50-50 chance of recommending a harmful treatment”. If that is the condition of the doctors, what then is the likely con- dition of the patients? (World Bank Report, 2005)

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On the contrary a visit to any multi specialty hos- pital in India managed by private sector, one will get an impression that it is the power of money which can buy you any health package starting from economy to deluxe, whether it is from your own pocket or from your insurer. The effective services which these private mega hospitals provide, leaves one in awe, their huge success in a short span of time is a testimony to their professional business like approach in managing them using the cutting state of the art technologies for unlim- ited pro!ts. One group soon successfully expands and a chain of hospitals is formed, with multinationals and economic giants tying up for this fast growing business. Medical tourism is on a rise, as foreigners from Middle East, Africa, Pakistan, Bangladesh , in increasing num- bers are now coming to India for private health care for complex pediatric cardiac surgery or liver transplants— procedures that are not done in their home countries. They also come from the United Kingdom, Europe, and North America for quick, ef!cient, and cheap coronary bypasses or orthopedic procedures. A shoulder operation in the UK would cost £10 000 done privately or entail several months’ wait under the NHS. In India, the same operation can be done for £1700 and within 10 days of a !rst email contact.

The recent remarkable growth of the private health sector in India has come at a time when public spending on health care at 0.9% of gross domestic product (GDP) is among the lowest in the world and ahead of only !ve countries—Burundi, Myanmar, Pakistan, Sudan, and Cambodia. Despite good intentions, health systems across the globe are unable to deliver high-quality, affordable services to all. Thirty thousand children die each day needlessly of preventable disease. Quality of care is substandard. Sick patients—if they can get to a clinic and afford treatment—face long waits. Criti- cal health information is buried in thick medical !les, and facilities are plagued with severe shortages of those who can heal. Inequities in the provision of health care are one of the greatest challenges we currently face as global citizens—and these demands are only ampli!ed in the developing world (Rockefeller Report, 2010).Yet India ranks among the top 20 of the world’s countries in its private spending, at 4.2% of GDP. Employers pay for 9% of spending on private care, health insurance 5-10%, and 82% is from personal funds. As a result, more than 40% of all patients admitted to hospital have to bor- row money or sell assets, including inherited property and farmland, to cover expenses, and 25% of farmers are driven below the poverty line by the costs of their medical care.

In India and the subcontinent, mega health projects by big names like Max, Fortis, Glaxo, Artemis, Apollo, Reliance, Birla, Mallaya and many others are on the rise.

Almost all metro and major cities have a very healthy competition in this newly growing health care indus- try. On the other hand most of the government hos- pitals whether in urban or rural areas have the same malady, corruption in magnanimous proportions. This single factor which has adhered to our life as an insepa- rable attribute, is taking our progress to where we had started. Whether we take the case of India, Pakistan or Bangladesh or any underdeveloped country thriving on aids from international quarters, perhaps the story is the same. It is this weak governance coupled with loss of character, morals, honesty and commitment that is giving way to alternatives which though are costly, but very effective.

Most people do not compromise on matters of life and death and are subscribing to the philosophy to pay more to get best of the services, though the costly ones are also not immune to default and may be of harrowing experience to some despite paying heftily. Private health care in India is expensive for Indian patients: 28-30% of the project cost of a 100 bed hospital and upwards relates to recurrent expenditure on medical equipment. Maintenance costs and import duties for such equipment are high. The saying in private hospitals is: “Spend in US dollars and earn in Indian rupees.” Private health care is there for those who can afford it. Berating private health care for not assuming the government’s role in provid- ing health care to its citizens is not the solution.

In general, the extra ordinary success of private health care sector is inversely proportional to the failure of government one. It is not that the paucity of funds which is causing the failure of these public hospitals in some places, but it is non governance, lack of aware- ness, education and non activism on our part that is responsible for the sorry state of affairs in one of the most important areas of our life. Even in India if one goes little down south, one can scale up the progress of this very upcoming sector. But in places where there is demonocracy instead of democracy , then a very huge chunk of public money, government funds via taxes, coupled with a lot of international aid goes in the drain.

There are several instances where billions of hard earned public exchequer has been criminally wasted at the cost of national health. Recently a national news- paper Dainik Bhaskar highlighted a big scam of crores of rupees in the National Rural Health Mission schemes in the state of Madhya Pradesh, where from an annual budget of Rs.765.65 crores , Rs 50 to 75 crores have been spent on seminars and workshops in which family members of health of!cials also enjoyed at 5 star hotels on public money. In a two day seminar 2 million rupees were spent in Khajuraho a tourist attraction in MP as per the report of the number one newspaper of the state and central India. Similarly 50 crores are being spent

annually on advertisements alone rather than on quality work to improve the health of the people!

Rest of money perhaps goes to other channels includ- ing the #ourishing NGOs which without accountabil- ity on percentage basis provide services which are well known. The paper has reported that as a result of such wasteful expenditures, the real issues of infant mortal- ity, health of women and children, the aged and hapless remain neglected despite huge fund at hands. (Dainik Bhaskar, 2008) This is example of one state, one can imagine what several developing nations which have a weak governance and accountability with a labyrinthine legal system do with large aids in the name of humanity. It seems that there is mostly a competition to advertise what is being done only on paper, it is happening right from the central government to the states, (Perappadan, 2005).

WHAT CAN BE DONE TO IMPROVE THE CONDITIONS OF OUR HEALTH CARE SYSTEM

It is time to restructure radically the governance for a prosperous civilization; hopefully the young generation takes the mantle in the right direction. Time has come now to repay the country what we have taken from it, let us stick to our traditions and morals which have their own values. In this context general awareness, honest and sincere media activism with private public partner- ships playing important role has to take a lead now in order to take control of the depilated conditions of our health institutions.

The existing set up of government hospitals needs total revamping with managers taking up the management and administration of hospitals rather than the physicians and doctors, who should be allowed to concentrate on their !elds and do justice to their specializations , experience and expertise other than running a hospital or health care unit. Regulation of !nances must become more stringent, as wastefulness is one of the major drawbacks of proper health management. A regulatory body at the national level must come enforce to manage the !nances of the government hospitals with central and state sharing the problems and their solutions.

We have enough of government controlled councils who have almost bled the public to death. Private admin- istrative controlling professional bodies on the lines of Western countries, have to be brought in now with transparent working. There are several doctors, physi- cians, academicians, entrepreneurs and health manag- ers of repute who can contribute to develop a work- ing model of government hospitals run without hassles. These are already working excellently in some of the smaller southern states of our country. Micro-Insurance,

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micro -!nancing, crowd credit !nancing and many more viable economic modules of healthy governance of the health sector are the need of the hour. Trusts of mul- tinational companies, big corporate house have already started to work in this direction, there is no dearth of !nances but certainly we do need its proper manage- ment, which in the present circumstances is not dif!cult at all with state of the art economic models available, (Widge and Cleland, 2009).

In the Times of India, India’s leading news paper on the occasion of 61st Independence Day editorial, governance has been ranked as perhaps the single most important issue that needs immediate attention, (TOI, 2008). It is not merely about building institutions; it is about ensuing that these institutions are accountable to the people, while they uphold the rule of the law. Our public hospitals also need a strong accountable govern- ance with a strict vigil by honest of the honest armed with acts like right to information, speedy trials in fast track courts of special nature, a viable and just media

,otherwise the future of individuals and the nation as well will be at risk.

There is an urgent need of sweeping reforms in insur- ance !nanced programs at the national, regional, and health facility levels, with either the government !nanc- ing health programs wholly or with a strategy which will increase access to care in partnerships. The Min- istry of Health should emphasize cost sharing, with an expanded role for the private sector and health insur- ance, in this context private NGOs can play a key role in improving access to health insurance schemes through the piloting and scaling up of community-based health insurance(CBHI) schemes appropriate for the rural poor, (Wilson, 2009).

Experts vary in opinion about potential size of Health Insurance market. To attain world average of Health expenditure, India needs 80 billion USD of health allo- cation. Assuming 20% of the expenditure is the poten- tial allocation for ex-ante preparedness through insur- ance route, Indian Health Insurance volume measured in terms of premium should be targeted at INR 64000 crores.

But there is need for substantial structural changes to achieve this desirable magnitude of performance. Esti- mation suggests only 1% of the market has been tapped so far. In the medium term of three years, even with present effort the market may reach INR 15000 crores. In the past, growth of health insurance has been very slug- gish, right from its formal introduction in the eighties. But in the last few years the cumulative average growth rate attained has been 37%.

Micro-insurance in health sector should be best done as a provider-centred model, but the current attempt is full service model, which is not cost effective and highly

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fraught with moral hazard. Micro-insurance has not assumed any signi!cant volume at present but going by IRDA norms, the companies should have a short term target of INR 300 crores and medium term target of INR 2500 crores by scaling up rapidly in next three years.

Transparent health regulatory bodies or councils should be set up at the national, state and district levels to manage the ailing health care system of the public hospitals with both the central, state and health insur- ance companies sharing the problems and their solu- tions. In the place of already existing government health departments, private administration controlling profes- sional bodies on the lines of western countries has to be brought in now with transparent working. There are several doctors, physicians, academicians, entrepreneurs and health managers of repute who can contribute to developing, working models of government hospitals that can run without hassles, making the reach of free or economic health packages to the needy.

One way to increase India’s health care funding and access is through innovative public-private partnerships. While an appropriate model for partnerships at the pri- mary, secondary, and tertiary levels still remains a dis- tant dream, participation by the government and private sector will help create a blueprint for such partnerships to create an infrastructure for the future. One such example in India is SRL (Diagnostic), which has partnered with the Himachal Pradesh State Government to set up and operate 24 labs in the large state-run hospitals in vari- ous districts, thereby bringing superior diagnostics serv- ices to the doorstep of people in remote areas. Among other suggestions to improve care, companies should leverage information technology (IT) to create patient- centric healthcare systems that can improve response times, reduce human error, save costs, and impact the quality of life. At the same time, the government should focus on establishing more medical colleges and train- ing institutes to provide the requisite doctors, dentists, nurses and paramedics. The government also should invest in preventive and social medicine by promoting health education and preventive health-care concepts, ( Shaima Miraj 2014, Deloitte, 2015)

These are already working well in some of the smaller southern states of India, like that of Kerala and Kar- nataka. Micro-insurance, micro-!nancing, crowd credit !nancing and many more viable economic modules of better governance of the health sector are the need of the hour. Trusts of multinational companies and big corporate houses have already started working in this direction with excellent results. There is no dearth of !nance, but certainly we do need to manage it prop- erly. Recently, several workers in healthcare have given invaluable suggestions, e.g. public–private partnerships

need more encouragement, with an increasing role for government as the !nancier of healthcare rather than the provider, protecting the generic drug industry, reducing the healthcare taxes, training of more com- munity health workers and free access of healthcare to all, (Golcha,2014, Narayan, 2011, and Shaima Miraj 2014 and 2015).

Finally it can be concluded that the government has to share the burden of health care. Lack of government interest in health care in a democracy! Possible only in developing nations. Let it not be that!

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Wilson, C. (2009). Dis-embedding Health Care: Marketisation and the Rising Cost of Medicine in Kerala, South India. Journal of South Asian Development 4: 83-101.

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