First, the government has an opportunity to issue a clarion call for universal health

insurance (UHI). UHI will free the current out-of-pocket spending and channel funds toward
far more productive uses.
While strengthening the public health-care system, the government could concurrently adopt a
few bold, high-impact interventions within three years to improve health care. In India, around
1.5 million children continue to die before their fifth birthday, mostly due to conditions that are
avoidable. Thus, a second priority should be to include a rapid scale-up of the introduction of
new vaccines against diarrhoea and pneumonia among children.
Smoking kills about 1 million Indians every year. All cigarettes must be taxed on their tobacco
content and not length. The Asian Development Bank has found that tripling the tax rate can save
about 8 million lives.
Preventing vascular deaths
Controlling malaria
TB
Finally, a major effort should be made to improve health reporting. The Census should be
strengthened, expanded and paired with the economic census and other surveys. This new
central information hub will help track and report on development and progress.
GOVT SPENDING MORE ON TERTIARY HEALTH CARE THAN ON PRIMARY. IS IT
JUSTIFIED?
1. The ministry of health is reportedly planning to open 10 more AIIMS-like institutes

as well as cancer centres in different states. Creating new cancer centres is

desirable, given the burden of the disease and the inadequate number of
treatment centres. Today, cancer is one of the main causes of premature
mortality in our country, and the 25 regional cancer centres are not being able to
cope with the high load of patients. Additional cancer centres would definitely be
meeting a badly felt need.
2. However, it is not clear why the government is planning to establish more AIIMS-

like hospitals. The health ministry may wrongly believe that India needs more
such centres of excellence to train doctors as well as to provide high quality
healthcare services to people.
3. However, such a move has serious implications for the rest of the health system.

The government spends about 1.3 per cent of the GDP on healthcare among
the lowest in the world. As per the ministrys own report, the government spent
less than Rs 1,000 per Indian in 2012-13. Of this, more than 10 per cent already

goes towards medical education. If more scarce resources are diverted to tertiary
care and medical colleges, the allocation for primary and secondary healthcare
may be reduced.
State of Primary health care centres in India
4. Primary healthcare is the centre of any health system be it in India or in the

United Kingdom. Currently, in most states, primary health centres (PHCs) and
referral hospitals are severely understaffed and under-equipped. One PHC with a
single doctor is responsible for the health of 30,000 people. In Brazil, a
comparable centre has four doctors for every 10,000 people.
5. The government spends just about Rs 5 per person on medicines. This is so

inadequate that most PHCs do not have medicines beyond the first few months
of a year.
6. Patients are asked to purchase medicine from private pharmacies, incur out-of-

pocket expenses at a time of illness. This creates a significant financial barrier

and prevents patients from accessing healthcare at the PHC.
7.

If the money that would be spent on these AIIMS-like centres were used to
increase the budgetary allocation for PHCs, there could be more staff and
medicines at these centres. Patients trust in government facilities would be
enhanced and there would be a corresponding increase in their utilisation. It
would be a step in the right direction if we were able to achieve universal health
coverage in the near future.

Negative effects on spending more on tertiary health care sectors

8. Apart from the economics of building more AIIMS-like centres, such institutions

have other effects. They will attract specialists from existing health centres,
thereby further depleting the human resource pool for district and referral
hospitals.
9. Also, because of their iconic stature, patients may bypass the existing facilities to

seek care directly at the AIIMS-like centres. This is evident in the original AIIMS,
New Delhi, where patients come from neighbouring states and crowd the
outpatient and inpatient services. This compromises the quality and effectiveness
of the centre.

10. On the other hand, if PHCs and referral hospitals are strengthened, patients can

be provided good quality care closer to their residence. This is beneficial both for
the patient and for the health services.
11. And finally, it has been hypothesised that these centres will create more doctors

who can then work for the country. However, existing evidence proves otherwise.
In 2009, AIIMS, New Delhi, was spending Rs 98 lakh on a single medical
graduate. More than 50 per cent of these graduates went on to serve in rural
areas in the US and UK. It is a fallacy to expect all graduates from these centres
of excellence to work for our country.
12. On the other hand, investment in the three-year BSc in rural health course would

increase the probability of having clinical staff at the PHC level. Chhattisgarh has
shown the way and we can definitely learn from it.
So what sould be our priority
Today, for every 1,000 live births, more infants die in India than in countries like
Nepal and Bangladesh.
We need to catch up with these countries, and the main way to do this is to increase
investment in preventive services like routine immunisation, good quality antenatal
care, screening for cancers and promoting healthy lifestyles. Our country needs to
provide quality outpatient services and round-the-clock emergency services at
facilities that are close to the people, not only at district headquarters. If India is to
ensure that all people have access to quality healthcare, we need to provide
quality primary and secondary healthcare for all, rather than tertiary healthcare
for a few.