There are two major issues, which usually vie for attention in understanding problems of health and health care in India. First issue is about giving preventive health priority over the medical care or curative care. It is correctly argued that improvement of preventive health and the social and economic condition would improve health status of people. There are clinching evidences available to prove that, much before the scientific medicine discovered drugs to cure many common diseases, these diseases were brought under control in the developed countries by public health measures and by improving general living standards of people. Indeed, the contribution of curative medical care in improving people’s health status is very little. This perspective thus correctly identifies preventive health and socio-economic intervention and strategy as the primary need for tackling our health problems. Rudolf Virchow came to this conclusion one and a quarter century back when he coined the slogan, “Medicine is a social science, and politics nothing but medicine on a grand scale” (Rather, 1983: xiii).
The second issue is an expressed or underlying assumption of many discussions that, health care services in India are underdeveloped. This assumption flows from the understanding that since India is an underdeveloped country and there are millions of people having no physical access to health care; the health care, therefore, must be underdeveloped. Thus, the attention is more on the stated policies of the government, the number of Primary Health Centres, public sector hospitals and beds etc.; and the operational problems therein. Much of the debate on decentralisation of health care under the panchayati raj system is also about the health care in the government sector.
Although these two issues appear to be unconnected, we feel that it need not be so. In this paper, an attempt is made to explain the inadequacy of the narrow public health perspective, for it fails to take into account the medical power structure existing and acting as a great bulwark against the public health reforms. It attempts to show that the health care services in India are not as underdeveloped as assumed, for the major part of the health care does not exist in the public sector but in the private sector. The health care services in private sector are almost exclusively curative. The power acquired by the private sector in curative health care is so great that unless strategy for public health reforms are combined with the reforms in entire curative medical care sector (both government and private), we may not be able to achieve desired results.
The health care delivery sector in general, and the private sector in health in particular, is virtually not regulated in India. There is hardly any license-permit raj in the health care delivery. Given the great inequity in distribution of and the chaos in health care, it is relatively easy to make a case for regulations on the private sector. However, as it is argued in this paper, kind of strategy adopted and its social objectives are of crucial importance.
Social objectives of health care services
What are the social objectives of health care services and to what extent our present health care services fulfilling them? Undoubtedly, the exercise in listing social objectives would generate some differences, particularly because it would primarily reflect one’s expectation and perspective. If we start with the basic that we narrated in the very first paragraph of this essay, one could safely say that the health care, in so far as it is within the medical care paradigm, could at best aid in achieving desired health status. Achievement of health is thus a result of complex interplay of socio-economic, political and medical care developments.
Having said this, the specific objectives of services or medical care becomes obvious, that is aiding in the achievement of health by making available basic health care services (curative, preventive and promotive) to all who need it. Just as universal access to basic resources of the society for achieving health to all is the objective of socio-economic and political development, the universal access to health care is the chief objective of health services or health care development. In essence, health care is a part of the broad development process and therefore, shaped by it. From here, one can fine-tune the argument. It is not simply the universal access to any health care services, but to the services that could actually aid in achieving health. Thus, the services made available must be appropriate, adequate and rational in order to be effective. Besides, the services must be in the dynamic state of development in order to meet the changing epidemiological needs.
In order to understand the extent, to which the existing health care is geared to achieving the social goal, we need to look at the size and distribution of health care services, and the system within which it is operating.
Health Care Service Sector in India
In several papers in the past, we have shown that the total size of health care services in India is large enough to make the health care universally accessible to all people in our country (Jesani and Anantharam, 1993; Jesani and Nandraj, 1994; Jesani, 1998). We have pointed out, again and again, that the actual size of private health sector is kept hidden by the policy makers who have hardly made any attempt to study it. Similarly, the official health data reporting agencies like CBHI (Central Bureau of Health Intelligence) have grossly under-reported the information on private sector as they have no means to collect data in the absence of proper registration laws for the private hospitals. However, from the findings of various field studies conducted in last 15 years, it has become now clear that the private health sector has an overwhelming presence in the health care services.
Tables 1, 2 and 3 show the size of health care sector in India. The data presented are taken from the official government agency, CBHI, New Delhi and Census reports. Along with that, we have also provided our estimates based on findings of various surveys and reports. Clearly, the government has shown great amount of political will in developing or allowing unfettered development of curative health care sector in India, and that much of it is due to the expansion of the private sector.
As against official attempts to provide a community based non-professional health worker for the 1000 rural population, we find that we already have one formally qualified and registered doctor for 889 people. Similarly, according to our estimates, we have one hospital for 11,744 persons and one hospital bed for 693 people. Availability of such abundant health human power and infrastructure does not give a picture of genuine under-development of health care services in India. Indeed, the real shortage shown by the data is of nurses, and not of doctors, hospitals and hospital beds. Since nurses cannot do “independent” or private market based practice in the manner and to the extent as doctors, they have been paid scanty attention. This has precluded the market driven expansion of nursing education. The medical education, on the other hand, is increasingly driven by the market demand, and thus we have one fourth of allopathic and two third of non-allopathic medical colleges in the private sector. As a consequence, and contrary to the genuine need of people, the doctor nurse ratio in our country is in favour of doctors. We have 1.4 doctors for 1 nurse when we should have two or three nurses for one doctor.
While in absolute terms the size of health care sector appears to be “good enough”; its distribution is very lopsided. As shown in tables, there is overwhelming dominance of private sector in all categories. In fact, when we examine data of 1961, 1971 and 1981 census, we find that there is a progressive “de-ruralisation” in the location of doctors. In 1961, 49.65% of all doctors were in rural areas, but in 1981, only 41.2% were located there. As a consequence, for urban areas, we have better doctor population ratio (1 urban doctor for 387 urban persons) than many of the developed countries. The ratio for rural areas (1 rural doctor for 1611 rural persons), is bad, but the worst is the ratio of doctors at the PHCs (1 PHC doctor for 24,938 rural persons), is the worst. Thus, the real underdevelopment is related to the government services and not for the whole health care sector.
Similar issues emerge while examining data on the hospital infrastructure. The quality of data on human power are better simply because there are laws for the registration of doctors from various systems of medicine. However, in the absence of uniform laws for the registration of hospitals, the data provided by the official agencies are great underestimation. We have tried to correct the underestimation by using the findings of the survey done in Andhra Pradesh. This survey of 1993 (Census of all hospitals) by the Director of Health Services (Andhra Pradesh) and the Andhra Vaidya Vidhan Parishad, found 2802 hospitals and 42,192 hospital beds in the private sector. As against only 266 hospitals and 11,103 beds officially reported by the CBHI in that year (Nandraj and Duggal, 1997, pg. 23). Thus, the Official (CBHI) data under-reported the private hospitals by 10.5 times and beds by 3.8 times. We had a similar experience in Maharashtra. In 1991, as a result of the High Court order in the Public Interest Litigation filed by the Medico Friend Circle, the Bombay Municipal Corporation did rigorous listing and registration of private hospitals in he city. They found 907 hospitals and nursing homes. However, CBHI (1992) data for that year provided a total of only 1174 private hospitals and nursing homes for the entire state of Maharashtra, thus showing the gross underestimation of the private sector in official data (Nandraj and Duggal, 1997, pg. 23). Indeed, there are problems in our estimates, which are based on the reported underestimation in Andhra Pradesh. However, even if one applies finer statistical correction to the data, that would reduce the size of private sector only by few percentage points. In any case, the health sector needs attention of competent statistician and economist to put its data system in order. While conceding the possibility that our estimates might be counting some more number of hospitals and beds in private sector, it is indisputable that private sector has dominant presence in the hospital sector.
Interestingly, official data show that there is one urban hospital bed for 457 urban persons in urban areas. If we are able to make our own estimation, undoubtedly we will find that actually we have one hospital bed for less than 300 persons in the urban areas.
Lastly, similar trends are visible when we look at the data on health care financing. While government was spending, in 1995, only Rs. 85.10 per capita per annum from its revenue expenditure on health, people were spending from their own pockets over Rs. 600 per capita per annum in 1997. Over the years, the private spending on health care has increased while the increase in government spending has slowed down. In the situation of extreme poverty of a large proportion of population, this only makes the health care inaccessible to large mass of people.
It is easy to conclude from this account that in terms of absolute numbers, we have a very large health care sector. This size is also largely due to dominant presence of the private sector. Further, the growth of private sector is unplanned. It is not promoted as a part of a larger system of national health services. It is allowed or is encouraged to grow within the unfettered market forces in the health care. As a consequence, the private sector domination has thoroughly commodified the health care services. This has created a strong medical business class, which is acting in league with companies manufacturing drug, instrument, equipment and other essential items for the health care services. Not only that, the unfettered market in health care delivery has attracted powerful corporate business groups. This trend in the corporatisation of health care is growing very fast, and as soon as the health sector is opened up to the private insurance companies, the power of medical business classes would get only stronger. Thus, the large size of health sector and the private sector dominance has created a powerful social force which needs to be taken into account in any planning for the public health and in achieving social objective of making health care universally accessible.
Regulations over health care services
As stated earlier, health care is one sector where the neo-liberal criticism of license and permit raj is the least applicable. This is simply because the health care laws and regulations are prominent due to their absence and not due to their preponderance.
It is interesting to note that the much of the government health sector under the ministry of health and family planning is created through the policy pronouncement, without translating such policies into any law. While the Bhore Committee made a recommendation for enacting a uniform and comprehensive Public Health Act to streamline and promote efficient administration (Bhore Committee, 1946, p.502-7), it was not followed up. As a consequence, unlike Canada and many Western European developed countries, there is no comprehensive framework or system created for the health care delivery system in India. Thus, the Primary Health Centres (PHCs) catering to the health care needs of rural masses have been established without enacting any comprehensive law for them. While the laws for local government bodies such as panchayati raj institutions, municipalities and municipal corporations stipulate that they should be involved in provision of health care, they do not specify any basic minimum provision as their responsibility. As a consequence, we have a large public sector in health care with minimum of legislative framework. In the absence of law making it mandatory not only to create service, but also provide stipulated minimum health care, the citizens are not able to exercise any right over quantity and quality of health care provided. The only options available to citizens are either not to use service or find a political solution by supporting one set of politician against others. While they are doing the former by gradually abandoning the government services, the latter is not as yet a major political issue as health care is still not a priority political issue for people. This has helped in the proliferation of medical market and irrational care.
While the government health care services are not established and run under any comprehensive law, they being government services are highly bureaucratised. One aspect of bureaucracy is existence of too many procedures, regulations and orders. These regulations and orders do specify, at least on paper, the standards for basic minimum infrastructure and services, though they do not provide justiciable right to minimum quantity of health care. These regulatory standards are often used to create public outcry and to show that the services are failing. As a result, the government health care services usually come under closer public scrutiny.
It is even more interesting to note that in 50 years since independence, not a single committee has looked at the role and functioning of the private sector in health care. The government has also not undertaken or commissioned any national level study of the private sector. It is normally assumed that since people are using the private sector, the services provided by it must be of good quality and the providers must be behaving rationally and ethically. It is also assumed that the market itself is good regulator for both quality of care as well as ethical behaviour of the providers. To what extent are these assumptions true?
While market mechanism in general has its own problems, its operation in the health care is the greatest problematic that even the most market-friendly societies have failed to solve. There are severe limitations to the notion of the sovereign, rational and informed consumer in health care. In health care, the provider decides on behalf of the consumer what the consumer should buy. As a result, the consumer autonomy is greatly limited. When there is a fusion of consumer and supplier in the health care professional and institution, the market failure becomes an inevitable reality. Any regulatory mechanism devised for market regulation, therefore, sooner than later, become counter productive as the provider finds newer ways to take decisions on behalf of the consumer. There is a sizeable body of literature in health economics to show that when number of health care providers increase, there is neither a drop in the quantity of care supplied nor the average income of the providers come down. On the contrary, the trends show that with the increase in number of providers, the total quantity of services provided increase with the concomitant increase in the health care expenditure and the income of providers (Auster and Oaxaca, 1981, Fuchs, 1978). The “supplier induced demand” is the most commonly encountered phenomenon in health care. The expansion of health care market also depends upon people’s perception or how such perception is shaped, about the health and illness. The market thus commodifies every thing, including the body and its parts in order to expand its operation. The normality is in no time converted into a perceived ill health and the body is objectified. What the services provide in response to such demand is also not always rational and good for the body. There is sufficient evidence to show that market expansion in health is often related to increase in irrational and harmful medication, investigations and surgeries.
The assumption that competing providers and the existence of rational consumer lead to provision of better quality of health care has also been proved incorrect. On the contrary, one observes increasing supply and consumption of irrational care, which is both of low quality and high price. (Ivan Illich, 1975, Uplekar and Rokle, 1987, Phadke et.el. 1995). As we showed earlier, there is high concentration of private health care in the urban areas. So much so that in some respect the urban health service indicators as good as in any developed country. However, the fast accumulating evidence from India suggests that a situation contrary to such assumption exist. The glitter that goes with the private hospital’s attempts to attract more patients hides the fact that the medical quality of care provided in those institutions is not as good as it is made out to be. The patient satisfaction is a very vague operational concept for the real medical quality of care. In most of the studies of poor patient in public hospitals it is found that the patient satisfaction is of high order. A simple reason for this is not always due to high quality of medical care, but largely due to the facilities provided are much better than what such poor patients actually have at their own homes. The same is often true for the patients using five star hospitals. Here too, they get facilities which as good as or better than what they normally have.
However, when all these institutions are studied by using the objective minimum criteria for standards of medical quality, different results come out. In a district level study of private hospitals and clinic, it was found that a big majority of private hospitals did not confirm to the minimum standards of medical care (Nandraj Sunil, Duggal Ravi, 1997). Not only they had low quality; some of the measures taken to circumvent quality standards were dangerous for the safety and well being of patients. A committee appointed by the Mumbai High Court in 1993 to assess situation in the private nursing homes and hospitals in Mumbai City encountered similar situation. Thus, neither in rural areas, nor in over supplied urban areas, the market on its own created condition for improving quality of health care in the private sector.
Where are our health laws?
In the absence of any comprehensive planning and law governing the entire health care services, the health care in India can hardly be called a system. In this regard, India resembles the health care services in the USA. Scholars have shown great reluctance to call the US health care services a system because it is fragmented, overlapping, unplanned and the delivery pattern are very diverse (Morgan Capron, 1989, pg. 503). All these characteristics are present in India, too. However, there is a crucial difference. That is, the market based private supplier dominated health care in the USA has the highest number of laws and regulations governing it. In India, the laws and regulations are prominent for their absence and for their preponderance.
In the USA, numerous laws and regulations are integral part of the market friendly health care. There is neither a comprehensive law to plan and systematise health care, nor there is a fundamental constitutional right to health care in the USA. Instead, she has numerous laws and regulations to reduce market failure, to regulate expenditure and financing, to ensure better quality of health care, to make available information so that patients could become more informed, to confer confidentiality of medical information and so on. Interestingly, all serious efforts to deregulate the US health care system have always failed and led to enactment of new regulations. A classical example of this phenomenon was observed during the long rule of Ronald Reagan. His administration, in its zeal to deregulate health care, made serious attempts. But much before his term got over, he was forced to put in place even more number of newer forms of regulations (Kinzer David, 1988). In essence, the US example shows that the market friendly health care inevitably leads to plethora of laws and regulations. For without them, it is neither possible to sustain market friendliness nor people’s political support for the market in health care.
As against this, in India, we have hardly any laws and regulations in the field of health. The only law that could be called somewhat complete is related to the education, registration and monitoring of doctors. The laws which have created three medical councils (Allopathic, Indian System and Homeopathic), the Indian and State Medical Council Acts, lay down some standards for education, registration and disciplining of unethical medical practices. Despite these laws being the best among the health laws, they are grossly deficient. There is absolutely no standard for continuing medical education and competency of medical practitioners. The medical councils are virtually defunct and normally biased on the question of disciplining the unethical medical practitioners.
Scenario is absolutely dismal with regard to hospitals. There are only two states in India (Maharashtra and Delhi) where long-standing hospital and nursing home registration laws exist. In the rest of the states, only very recently some efforts are being made to enact registration laws. As far as we know, only three more states have succeeded in enacting such law in recent times, while in the rest no such effort is being made or if it is being made, the same have been frustrated by the powerful medical vested interests. We are still not sure about those three states whether the laws have been notified and thus implemented.
Besides, the registration laws enacted are merely for registration, they do not contain even basic rules defining the minimum physical and medical quality standards for the establishment of hospitals and nursing homes. The Maharashtra Act, the oldest one passed in 1949 and the Delhi Act of 1952, do not specify standards, not the newer laws have paid any attention to this aspect. The only law on hospitals which not only specified concrete standards but also put certain ceiling on the cost of each aspect of hospital care was passed as an ordinance in Karnataka during emergency. But it was never ratified as a law and thus lapsed, and nobody seems to ever remember it simply because it happened to be a part of the bitter memory of emergency.
The last but most talked about law is the Consumer Protection Act of 1986. This law, which covers doctors and hospitals, does nothing but simplifies the operation of tort laws as applicable in the civil courts and cuts down the waiting time for the case to be decided. While many high profile cases of negligence tried under the Consumer Protection Act have been reported in the media, the fact remains that malpractice litigation are neither as common nor as pernicious as found in the USA or other developed countries. In a country with nearly million doctors, the number of malpractice litigation are still counted in hundreds, showing that patients in India are not so litigation oriented and that the legal forums created for them are not functioning as efficiently as made out to be. Besides, the compensations awarded are not so spectacular to make people to make great use of such legal provisions. While one can always discuss pros and cons of malpractice litigation, it must be kept in mind that such litigation have very limited role to play in regulating the market and providers. For as is witnessed in recent times, much before many cases get filed, the providers over-react and try to create their own defences. This behaviour of providers only perpetuates the existing market mechanism, with only one proviso that if you charge, be prepared to pay when you go wrong.
Once we have covered these laws, the rest of the laws and regulations are only for listing what is not existing.
What strategy for regulation?
We need not stress any more the need for regulating market and the providers in health care sector. There is enough evidence to prove that without basic laws and regulations, the market neither succeeds in fulfilling its own promises, nor does it ever succeed in fulfilling social objective of making health care universally accessible.
What is more important to understand in Indian context is about the kind of regulations needed and how these regulations would be a part of the larger strategy for health sector reforms.
If the issue is tackled as merely regulations for the private sector, one inevitably gets pushed on the path taken by the USA. More so when the structure of health care is very much like that is existing in the USA. In that case, we need only to enumerate various areas of health care in which new laws and regulations are needed. There is no doubt that one needs to regulate market, safeguard interests of consumers and provide them with information, but all of them still do not add up to make health care universally accessible to the masses of poor people in our country. Thus, while those things are absolutely essential in any system, if the structure of health care is kept intact they would only perpetuate market that is one of the basic cause in health care for reducing access for the poor. There is no historical example in any country showing that the market with some or more regulatory laws would on its own solves the social problem of access. The USA is again a classical example. Despite the highest number of laws and regulations for the market and for controlling the behaviour of providers, the highest amount of resources spent of health care, and over 40% of health care financed by the Government; the USA has miserably failed in providing health care to all her citizens. There are still 40 to 50 million US citizens who are neither covered under the government health schemes (Medicare and Medicaid) nor have resources to buy private health insurance. Interestingly, a simple study of the US laws on health would show that only Criminals and Psychiatric patients involuntarily institutionalised have basic right to health care from the government. For the rest, there is no such right available (Curran and Shapiro, 1982, Morgan Capron, 1989, Fuenzalida-Puelma and Scholl, 1989), The situation in India is identical, the only difference being that even our prisons and mental asylums do not offer right to basic health care services. Thus, enacting new laws and regulations, though necessary, are not going to be adequate in creating a radically different situation.
Thus, the point is not just regulating the private sector, but to go beyond it. The regulation of private sector needs to be articulated within the fundamental reforms aimed at making health care universally accessible. This has been achieved in many developed capitalist and democratic countries. Most parts of the Western Europe and Canada are classical examples of such reforms within the market economies. This path raises different set of questions. What are the overall aims of regulations and reforms? Is the aim universal access to basic health care? Is it to keep the cost of health care at affordable level? Is it to put the system under the democratic and participatory control of people? In this context it should be remembered that the failure of community health movement in India had a lot to do with the fact that it existed within the market set up, and it did not raise the political demand for creating universal access by reforming the entire health sector. The same fate awaits all efforts to bring health care under the control of panchayati raj system. This is not because the concept of putting health care in people’s hand is incorrect. But because unless the panchayats are also given right to reorganise both public and private health care; and unless both of them are brought under one umbrella of plan and regulation for meeting social objectives of health care, such decentralisation would fail to achieve universal access. In worst cases, the situation would only help the state to reduce its expenditure and the private sector and health care market, to expand.
The structural and planned reforms with a basic aim of making health care universally accessible is indicated for the simple reason that only such a strategy would bring under control the powerful medical business interests in health care provision. The medical interests in the state system as well as in the private health care are not only powerful, but they also work in tandem in defeating any organised public health reforms. At this stage of the history of health care development in India (more so when medical care sector is so vast), the public health movement cannot think in terms of bypassing the medical power. The basic reorganisation of medical care would create greater space for both the public health as well as community health movement to succeed.
Table: 1: Health Human Power
Doctors | CBHI, 1994 | Total Number (1992) | 9,49,722 |
. | . | Population Per Doctor | 889 |
. | Our Estimates | %age of all Doctors in Private Sector | 85 |
. | . | Population Per Private Doctor | 1,048 |
. | . | Population Per Govt. Doctor | 5,924 |
. | CBHI (1993) | Number of Doctors at the PHCs | 23,490 |
. | . | Doctor Per PHC | 1.12 |
. | . | Rural Population Per PHC Doctor | 24,938 |
. | Census (1981) | %age of Doctors in rural Areas (1981) | 41 |
. | Our Estimates | Urban Population Per Urban Doctor | 387 |
. | . | Rural Population Per Rural Doctor | 1,611 |
Dentists | . | Total Number (1993) | 19,523 |
. | . | Population Per Dentist | 43,228 |
Nurses | . | Total Number (1993) | 6,74,946 |
. | . | Population Per Nurse | 1,250 |
. | . | Doctors Per Nurse | 1.4 |
Sources: (1) CBHI (Central Bureau of Health Intelligence), “Health Information of India” 1991, 1992, 1993, 1994 (2) Census (1981).
Notes: (1) Our estimation of proportion of doctors in private sector is an underestimation.
(2) In order to calculate Doctor-Population ratio for rural and urban areas, the proportion found in Census, 1981 has been applied, as the 1991 Census data on this are still not available. (3) 1991 Census population (rural, urban, total) figures are used for calculating ratios.
Table: 2: Health Care Institutions (Hospitals, Beds, PHCs)
Hospitals | CBHI, 1994 | Total Number (1993) | 13,692 |
. | . | Population Per Hospital | 61,637 |
. | . | %age of Hospitals in Private Sector | 67 |
. | . | Population Per Private Hospital | 92,607 |
. | . | Population Per Govt. Hospital | 1,84,305 |
. | Our Estimates | Total Number | 71,860 |
. | . | Population Per Hospital | 11,744 |
. | . | %age of Hospitals in Private Sector | 93 |
. | . | Population Per Private Hospital | 12,628 |
Hospital Beds | CBHI, 1994 | Total Number (1993) | 5,96,203 |
. | . | Population Per Hospital Bed | 1,416 |
. | . | %age of Beds in Rural Areas | 21 |
. | . | Rural Population Per Rural Bed | 5,136 |
. | . | Urban Population Per Urban Bed | 457 |
. | . | %age of Beds in Private Sector | 35 |
. | . | Population Per Private Bed | 4,000 |
. | . | Population Per Govt. Bed | 2,191 |
. | Our Estimates | Total Number | 12,17,427 |
. | . | Population Per Bed | 693 |
. | . | %age of Beds in Private Sector | 64 |
. | . | Population Per Private Bed | 1,083 |
. | . | Population Per Govt. Bed | 1,926 |
PHCs | CBHI (1996) | Total Number | 21,854 |
. | . | Rural Population Per PHC | 28,768 |
Source: CBHI, "Health Information of India”. 1994, 1996.
Note: (1) Our estimations of number of hospitals and beds are based on the extent of under-estimation in government (CBHI) data found in Andhra Pradesh in 1993 Survey (Census of all hospitals) by the Director of Health Services (Andhra Pradesh) and the Andhra Vaidya Vidhan Parishad. They found 2802 hospitals and 42,192 hospital beds in the private sector in Andhra Pradesh as against only 266 hospitals and 11,103 beds officially reported by the CBHI in that year (Nandraj and Duggal, 1997). Thus, the Official (CBHI) data under-reported the private hospitals by 10.5 times and beds by 3.8 times. This indeed is very rough and inaccurate estimation. However, the intention is only to show the trend. (2) 1991 Census population (rural, urban, total) figures are used for calculating ratios.
Table: 3: Health Expenditure, Public and Private:
Expenditure | Estimates | Total Health Expenditure as %age of GNP | 5 to 7 |
. | Govt. (1995) | Health as % of total revenue expenditure | 2.63 |
. | Govt. (1995) | Per Capita revenue expenditure on health | 85.1 |
. | CEHAT (1997) | Per capita household expenditure on health | 624 |
. | Our estimates | Private expenditure as % of total health expenditure | 88 |
Source: (1) Duggal Ravi, Nandraj Sunil, Vadair Asha (1995), “Health expenditure across states” (Part I & II), in Economic and Political Weekly, April 15, 1995 and April 22, 1995, Pages: 834 to 844 and 901 to 908. (2) CEHAT (1998), Health Sector Database, CEHAT, Mumbai. (3) Madhiwalla Neha, et. el. (2000), “Health, households and women’s lives: A study of illness and child-bearing among women in Nashik district, Maharashtra, Mumbai: CEHAT.
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Nandraj Sunil, Duggal Ravi, “Physical Standards in the Private Health Sector”, Mumbai: CEHAT, 1997, pg. 23, quotes the data of 1993 Survey (Census of all hospitals) by the Director of Health Services (Andhra Pradesh) and the Andhra Vaidya Vidhan Parishad, supplied to them by those agencies.
Phadke Anant, Fernandes Audrey, Sharda L, Mane Pratibha, Jesani Amar (1995), A study of supply and use of pharmaceuticals in Satara district, Mumbai: FRCH, June, pp. 152.
Rather L.J. (1983), “Forward to the English Edition” in Virchow Rudolf, “Collected Essays on Public Health and Epidemiology”, New Delhi: Amerind Publishing Co.
Uplekar Mukund, Rokle Madhu (1987), “Aren’t we being dangerously overdrugged” in FRCH Newsletter, Vol. I, No. 4, May-June 1987:2.