Viral fever and dengue patients at the Noida District Hospital in India
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To illustrate the changing spectrum of healthcare needs using China as a model, currently 6% of her population is diabetic, 20% hypertensive and 25% overweight. Topping this, 30% of the population continue to smoke (WHO). A population cohort with the above problems will require several multi-disciplinarian visits over the next 20 years, dealing with the problem in itself and other clinical offshoots. For example, being a diabetic increases a person's risk for cardiac and renal disease over a period of time, thus placing a strain on other branches of the
health system. Combine this need for chronic care with a vastly undermanned system and things do not look too good. South Asia also offers similar challenges, with chronic diseases a priority in urban centers while infectious diseases remain a scourge and the main killer in the rural hinterland.
"Confounding the obvious state of under-preparedness the sector faces, is the financial model countries in the region employ to pay for healthcare. The Middle Eastern countries employ a mix of public (funded by petrodollars, heavily subsidized) and private sector hospitals (paid for by insurance or direct fees) to take care of their health systems. Other nations like Singapore, South Korea mandate universal insurance cover for everyone, paid for by varying degrees by the individual, the employer and the rest subsidized by the government (40-60% depending on country). The government also has healthcare safety nets for those who cannot afford insurance.
Looking at South Asia and India in particular, the scenario suddenly turns very bleak. India currently spends 4% of her GDP on healthcare of which government spending accounts for a measly 19%. Compare this to France where 11% of her GDP is on healthcare, of which government spending is 79% (World Bank data). France of course has the highest satisfaction rates for her health system. In some areas of India, especially the rural sector, health spending can form a disproportionate figure of up-to 18% of income. In addition there is a huge manpower crisis in the existing network of primary care facilities with 15.1% shortfall in doctors and up-to 56.8 per cent in Multi health workers (Bulletin on Rural Health Statistics 2008). This of course is not including the large rates of absenteeism and the already existing shortfall in required number of primary health centers.
China to start with had an excellent network of rural practitioners (barefoot doctors) and a centralized healthcare system which made tremendous gains in life expectancy, by a series of public health measures including sanitation, immunization and control of disease vectors. With Deng Xiaoping's revolution in the early 80s, the apparently successful model of health was dismantled overnight without an adequate replacement. This happened through a reduction in funding from the central government for hospitals, in which the onus was placed on the province. There was also a change in pricing policy which enabled hospitals to make huge profits on new procedures and drugs. The commune system which had served most of rural China was also dismantled overnight and the public health system was decentralized, partially privatized (Blumenthal NEJM 2005).
All this contributed to creating a system that was ranked 188 among 191 nations by the WHO in the year 2000. Subsequently, however, massive government spending ($125 billion from 2009 to 2011) promises to alleviate the situation with an aim to cover 90% of the population with insurance by 2011 and universal health care by 2020. This of course does not address the basic problem of high drug costs and lack of accessibility of quality care for all.
Therein lies the next problem. An increasingly affluent population has come to expect the same level of service in healthcare as they would in other sectors. The inadequacy of the system to match up to expectations of service levels and an unrealistic expectations of a quick cure leads to great levels of dissatisfaction. Match this with a belief (true in many cases) that doctors indulge in a system where expensive investigations and drugs help line their pockets through a 'cut' system and suddenly the sector seems to be in turmoil. Recent reports of increasing levels of violence against healthcare workers in China and India illustrates this problem."
To summarize, the two big engines of economic growth in Asia (South Asia and China, mainland SE China) have healthcare systems that are fragmented, suffer huge deficits of manpower and facilities and a potential flashpoint of anger to a young population that is increasingly demanding the best possible care. Further complicating the scenario is the presence of traditional systems of medicine which often operate in unregulated areas without proper checks and controls.
This brings us back to the root question: why didn't anyone think about this ten years ago? Simple: quick returns. Build a road or an airport, investment flows into the region and in a few years, the whole region gets transformed. Healthcare however with its long training periods (6-12 years for a doctor and 4-8 years for allied professionals), takes a much longer period to show any tangible benefits, often up to a generation.