Why Have We Failed? – An Analysis of the Origin of India’s Maternal & General Healthcare Problems

Many articles have been written on the topic of India’s pathetic and failing healthcare system. While each publication gave its own sets of views and advice, leaning on either the patient’s side or towards the doctor’s side, none whatsoever have addressed the issue of its origin. This article tries to look at the origin of the poor healthcare system and tries to find points which can be corrected and those that have gone beyond our control.

The reason that doctors form such an important part of any country (developed or otherwise) is that they serve a very basic purpose of treating mankind’s illnesses, a necessity which comes immediately after basic needs like food and water. Another reason is the number of doctors needs to be directly proportional to the population of that country as a single doctor can treat only a certain number of patients per day. Unfortunately doctors cannot be mass reproduced like computer software and downloaded online by anybody with a smart phone. So basically an explosive population growth in itself can lead to acute shortage of doctors. Let’s analyze India’s population growth over the last century.

a. Stable population period (1891-1921)

According to Kingslay Davis, “India’s population remained almost stationary since 1800 at around 125 million for about 50 years. The population recorded at the time of 1881 census exceeded the figure for 1921 by 1.47 crores. While we can wrongly deduce that the Indians at that time were wiser, the real reason for stable population during these times was high death rate due to famines, influenza, cholera etc.

b. Fast growth of population (1921-1951)

The rate of growth of population was moderate and irregular till 1921. The year of 1921 is known as the year of Great Divide. The rate of population growth fluctuated between 1.0 and 1.35 per cent per annum. These were the better years as population grew most probably due to falling death rates.

Population explosion: 1951 onwards

The year of 1951 is also termed as population explosion year. During the period of ten years, population increased by 781 lakhs. The growth rate of population was 21.5% in the decade of 1951- 61 compared to the previous ones. During 1961-71, the population increased by 1090 lakhs. The growth rate of population was 24.8%. During the period 1971-81, population increased by 1376 lakhs. The growth rate of population was witnessed to be 25%. According to the latest population census of 2001, the population of India increased to 102.70 crores in 2001. Growth rate of population during this period was 1.9 percent per year. The main factor responsible for this tremendous rise in population in the last 50 years was fall in death rate due to improvement in medical facilities but no fall in birth rate [1] and this upward trend is going to continue at least till 2050 (Figure 1). Now coming to number of doctors in India, there is one government allopathic doctor for every 10,189 people. You don’t need an epidemic, however predictable, for the public health system to collapse. It is a matter of routine that patients share beds and doctors are overworked [1] (Figure 2).

Figure 1: Upward trend is going to continue at least till 2050.

So as you can see that the total number of allopathic doctors (as others are incapable of providing critical primary health care) in India are little above 10 lakhs. Is this a poor number? Actually when we compare it with United States (one of the most developed, significantly populated and geographically large countries) the exact number of doctors of medicine was 1,045,910 there (approx 10 lakhs) as of 2013 [2] which is similar to ours. If we compare it with UK (total number of doctors as of 2017 is just 232,708) [3], we have actually produced many more doctors than our British rulers in the last 50 years! So actually if you look at the statistics we have done far better in churning out doctors than our western developed counter parts!

Figure 2: Total number of doctors in India.

So the problem prima facie does not seem to be number of doctors as there are limits to the amount a country, which is just 71 years old, can spend on producing doctors. Still it has done better than UK and has almost similar number of doctors as USA. Nevertheless India has one of the worst doctor patient ratios in the world. Why?

The answer is obvious, an uncontrolled population explosion. But then the question arises that what happened in 1961 that we suddenly exploded into baby boom. Actually the question should be “What failed to happen that caused the baby boom?” By 1961 India had more than a decade of Independence and the government through its various struggling but yet partially successful programmers like Malaria eradication, Immunization, etc had slowly brought down the mortality rate. However due to high birth rate the population started growing exponentially. Acknowledging this fact the government started the compulsory sterilization spearheaded by a politician in particular. According to media reports [4], people were forced to have sterilization, which eventually had a role in the downfall of that government in subsequent elections. Surprisingly this particular politician’s wife now has a major opposition to forced sterilization of unruly street dogs! [5]. The idea though was good and essential, its implementation was improper in a democratic country. However if the government of any democracy has responsibilities to its citizens then its citizens also have many duties which it needs to follow. This is exactly where the Indian poor have just purposefully and selfishly to the point of stupidity have failed this country and its government, the results of which it faces everyday now. Had the poor of that decade been responsible enough to get sterilization (voluntarily) they would not have produced so many poor. For it is known that a poor couple, for reasons a plenty, will most likely bring up children who will remain poor. Apart from few anecdotal reports of a poor man’s son or daughter becoming a Doctor, Engineers, or anything middle class most of them continue to be below the poverty line. Blaming successive governments (whether correctly or incorrectly) does not bring any relief to that particular poor family. Playing with statistics, the Indian reports state that the percentage of people living below poverty line has drastically reduced from approximately 50% to 25%. A significant deed indeed but when you look deeper into statistics you realize that the actual number of poor (which matters most, as you have to give subsidy to an actual number rather than to a percentage) has increased compared to the 1950s! (Figure 3).

Figure 3: The game of tables, 26.1% of today’s population is much more than 54.9% in 1973-1974.

How poverty is a big business

Growing up, most of us would remember the Government Ads promoting population control and the famous but now forgotten slogan of “Hum Do Hamare Do”. Why did the government suddenly stop promoting population control? One, because it lost badly a round of elections making the politicians afraid to implement sterilization policies, which were correct but did not find favor with the vested interests of the poor. Secondly, the politicians soon realized that, more the people, more the constituencies and eventually more parliamentary seats. More the seats, more the chance of becoming an MP. The 1st Lok Sabha (1951) had 489 constituencies; the current Lok Sabha (2014) has 545. (An increase of 56 seats in 63 years, almost one seat per year). So instead India burden is now projected as “Youth with power”, “Working class” and other decoratory but futile terminologies.

How the poor are holding democracy at ransom

But even the poor in India cannot be considered just innocent party to this game. Democracy for the last 7 decades have made them realize their power in numbers and many times they have misused their voting majority to get short term gains which eventually do no good either to them or to the country. Legalizing slums, hawkers, and absolutely free healthcare and education (without any desire to reproduce less) are some of the prime examples. True is the counter argument that education and money would have prevented them from producing more kids but a country so short of resources cannot educate and improve every citizen’s life and then expect them to respond voluntarily and at their leisure. Some amount of citizen duties should be expected from them, at least in the area of population control. But they have rather used their very numbers to vote leaders who belong to their similar mindset and increased their numbers. Instead of voting an educated leader from the middle class they have voted either dynasties or their own. This vicious cycle needs to end and some lesions in this regard can be learnt from China.

Politicians & corruption- the much beaten reason

Corrupt and lazy politicians have been the rot of this country and have an equal role in the mismanaged healthcare. Funds are regularly diverted from government health programmes to party or personal coffers. These politicians come from either dynasty who have no touch with ground realities or come from the poor class and have only short term goals. The middle class is never elected but just is the punching bag of both these classes. Remember the founding fathers of this nation were at least middle class or well educated and even foreign trained ( Gandhi, Dr BR Ambedkar, Subhash Chandra Bose, Nehru etc), unlike today’s leaders.

Most of the schools and colleges in India are understaffed and even if they have staffs they lack any quality education themselves to impart anything further. Also students learn only to pass exams and not for the joy of learning. Libraries have closed and time is spent on YouTube and social media. Thus how will quality doctors be produced as medicine is a very academic subject unlike business? Short term patch ups like ‘bridge course’ are farcical at best as you can give anybody a degree but how will you give them the brains?

Indians have no sense of planning, clearly seen if anyone takes a ride in any city, town or village. Houses are just boxes with rods jutting out of them. They can be colored, partially or totally ugly and sometimes naked as they are. Drains built by the British have never been upgraded. Roads and fly-over are made based on political desires and not realistic needs. Government hospitals are dirty, stinking with stray dogs and kittens feeding on placenta and dead bodies. There is total lack of any personal or at least humane touch to any construction done by rogue contractors and builders. Also there is no referral system which is followed by the patients. Every patient with chest pain wants to go to the cardiologist without consulting his GP unlike the NHS system in the UK.

Though the entire country wants development but no one is punctual about it. Timelines are regularly flouted and so is the scenario in hospital development. Though every Indians wants work to happen fast when it comes to himself his vested interests stop him or her from completing the task given.

Hygiene and cleanliness are overlooked in entire India as if they have an epidemic blindness to it. This might also arise from the primary religious beliefs here where cleaning garbage and toilets is considered a lowly job for the marginalized of the society belonging to lower castes. Whatever be the reason Indians are inherently dirty and do not seem to have any problem with it either. Also most people do not exercise or lose weight by cutting calories as obesity in this flood and famine stricken country is considered a symbol of wealth and opulence. Diabetes and hypertension related complications are thus common place. Complaining about cost of angioplasty stents is thus of no use, when it could have been prevented by very cheap and actually money saving methods of low diet and regular exercise.

A country where people have not yet learned where to urinate and defecate not much can be expected. People forget to stand in queue taught in their primary school and gather in ICUs and doctors like monkeys waiting for bananas. What is astonishing is the very acceptance of this behaviour by the majority of the so called civilians of this country. Every problem is fought with chaos creating more problems. Labor rooms with 3 women delivering on the same bed at the same time naked is ghastly not only to see but to even imagine, and still this is a common scenario in many tertiary government medical colleges in the country.

This is the biggest reason that India can NEVER cure its healthcare problems. Vested Interests, when people do what they don’t speak and speak what they don’t do. Laziness, lack of punctuality, lack of transparency, corruption runs endemic in the poor, middle and rich, man and women, Muslim or Hindu, Brahmin or Baniya. Every one of them speaks need of change but be part of it. When a child sees his father or mother follow vested interests, non punctuality, dirtiness, how can he follow or preach otherwise even after becoming a doctor.

So the biggest roadblock towards correcting India’s Healthcare or for that matter anything else in this country are its own people. It’s not just politicians (as they come from the same people), or the British (who left sufficiently long back and actually exposed the country to modernity) or illiteracy (as illiterates in other countries like Thailand at least have civic sense which even the graduates of this country don’t have) or poverty (the slums in Bangkok are cottages which are very clean). No, the answer is India’s 1.2 Billion uncorrectable civilians. As wise men have said “India will forever be the NEXT greatest country” [6].

1. https://www.hindustantimes.com/india-news/public-healthsystem-in-crisis-too-many-patients-not-enough-doctors/story-39XAtFSWGfO0e4qRKcd8fO.html
2. https://www.statista.com/statistics/186260/total-doctors-ofmedicine- in-the-us-since-1949/
3. https://www.gmc-uk.org/doctors/register/search_stats.asp
4. https://www.indiatoday.in/magazine/guest-column/story/19780215-how-did-the-emergency-get-mixed-up-withsterilization-822855-2014-11-07
5. http://indianexpress.com/article/india/india-others/patiala-ngo-toldto- suspend-dogs-sterilisation-after-manekas-letter/
6. http://www.economicsdiscussion.net/population/growth-ofpopulation- in-india-timeline-and-statistics/4487