‘Where is the public health sector?’: Public and private sector healthcare provision in Madhya Pradesh, India
Introduction
The economic reforms adopted in India since 1991 have set a foundation for strong economic growth. Annual economic growth increased from an average of 4% in the four decades before reform to 8.1%. Foreign direct investment has grown from $100 million in the early 1990s to about $5.5 billion. There has been the growth of a world-class information technology sector, an evolving biotechnology sector, a competitive automobile industry, and a large service sector. But there is need to temper these successes with an honest look at the overall reality. India is a country of stark contradictions; 220 million people live below poverty line [1] for whom the economic growth of the last decade has meant little.
The economic achievements have been encouraging successes, but in themselves are insufficient to bring broader economic and social progress to the vast majority. Despite the economic optimism, there is growing concern that the basic institutions, organizations, and structures for public sector action are failing, especially for those at the bottom. Besides areas like education and infrastructure, the state of public health has been dismal. Notwithstanding some improvements in health indicators and some control over infectious diseases, India's public health system is ailing, under-funded and non-responsive. This vacuum in healthcare provision has been filled by a large, heterogeneous, private health sector that operates on a fee for service basis. This sector has now emerged as a dominant constituent of the health system with 77.4% of all health expenditure being made here [2]. It represents a resource widely used even by low-income groups.
This paper is based on a survey of all healthcare providers (HCP) among the 60.4 million people [3] in the central Indian province of Madhya Pradesh (MP). The survey was conducted as part of the development of a health management information system in the province by the provincial ministry of health under a bilateral donor assistance program. A heterogeneous group of HCPs with varying levels of qualification, work in different set-ups in its 52117 villages and 394 towns. There are no existing comprehensive records (official or otherwise) of all HCPs in the province. Some fragmented and often outdated information (limited to qualified doctors) is available with professional bodies and drug suppliers. Thus, a primary survey in the province was necessary.
The paper demonstrates empirically the public and (dominant) private sector health care provision in rural and urban MP. It discusses the growth of a heterogeneous flourishing private health sector that has expanded to cover area left by a receding public health sector, and the need for strong public private partnerships to achieve public health ends.
Section snippets
Methods
MP, India is a large relatively socio-economically backward province (60.4 million in 48 administrative districts). Three quarters of the population (73%) is rural [3] and 37.4% live below poverty line [4]. Though the province has some of India's poorest health indicators, there has been a steady improvement in these indicators over the last twenty-five years. (Recent official figures report infant mortality rate in the province at 79 and maternal mortality ratio at 498 [5].)
This survey, which
Human resources
Of the 24,807 qualified doctors mapped in the survey, 18757 (75.6%) work in the private sector. Eighty percent (15142) of these private physicians work in urban areas. Of all qualified paramedical staff 72.1% (67793) work in the private sector, though only a quarter of these worked in urban areas.
Table 1 shows that 77% of all qualified doctors worked in urban areas (26% of the population is urban). This works out to be 1 physician per 834 urban population and 1 per 7870 rural population.
Most
Discussion
India has been known to have an extremely heterogeneous health system, with different systems of medicine being practiced by varyingly qualified providers in different kinds of practice set-ups in the public and private sectors in rural and urban areas. Though the dominance of the private health sector in India is known, the survey provides an empirical confirmation at provincial level, and more specifically describes the nature of the constituents of the private sector.
Conclusion
Given that there is such a large established private sector in the province, it has been advocated that the state needs to move towards constructive oversight [24], the public sector needs to find a balance between direct provision of services where necessary and new roles in coordination and regulation (of the entire health sector—public and private). The state needs to take a lead with good governance, and forge viable partnerships with the dominant private sector to ensure equitable health
Acknowledgements
Danida supported MP Basic Health Services Program, Department of Health and Family Welfare, Bhopal, India. Swedish International Development Assistance, Stockholm.
Contributors: Both authors contributed to the fieldwork, analysis and write-up of the paper.
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The rural private practitioner
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