UP: As population rises, healthcare system collapses

In Uttar Pradesh, the number of public health centres (PHCs), the frontline of the government's healthcare system, decreased 8 per cent over the last 15 years to 2015, a period when the state's population increased by more than 25 per cent. Smaller sub-centres, the first point of public contact, increased by no more than 2 per cent over the 25 years to 2015, a period when the population grew by more than 51 per cent.

These data, from the 2015 Rural Health Statistics (RHS), indicate how successive UP governments have neglected affordable, accessible and quality healthcare for the 200 million people — only five countries have larger populations — of India's most populous state, home to nearly a fifth of all Indians.

The result of this neglect is manifest in the major indicators of UP's health deprivation, according to various government data sets that we studied:

* A new-born in UP is expected to live four years fewer than in the neighbouring state of Bihar, five years fewer than in Haryana and seven years fewer than in Himachal Pradesh.
* UP contributed to the largest share of almost all communicable and non-communicable disease deaths, including: 48 per cent of all typhoid deaths (2014); 17 per cent of cancer deaths and 18 per cent of tuberculosis deaths (2015).
* After Assam, UP has India's second-highest maternal mortality rate (MMR); 285 maternal deaths for every 100,000 live births (2013), with 62 per cent of pregnant women unable to access minimum ante-natal care.
* The inaccessibility of institutional care is evident from the fact that around 42 per cent pregnant women, more than 1.5 million, deliver babies at home.
* About two thirds (61 percent) of home deliveries in UP are unsafe.
* UP has the highest child mortality indicators, from the neonatal mortality rate (NNMR) to the under-five mortality rate. Of 64 children who die per 1,000 live births before five years of age, 35 die within a month of birth, and 50 do not complete a year of life.
*Universal immunisation plays a key role in decreasing child mortality: About half of UP's children are not vaccinated (2013).
*Of those who survive, more than half of children (50.4 per cent) younger than five have recorded stunted growth (national average: 38.7 per cent), the highest stunting rate in India.
* Between 2006 and 2014, on average, the proportion of stunted children below five in India fell from 48 per cent to 38.7 per cent. The comparable data for UP was 56.8 per cent to 50.4 per cent.
Over the last decade, several surveys, reporting and independent studies have revealed wide healthcare disparities across India and the situation in social-economically backward states, such as UP, which is not alone. It is one of eight states that comprise the empowered action group (EAG) of backward states (formerly called the BIMARU states) – UP, Madhya Pradesh, Odisha, Jharkhand, Bihar, Rajasthan, Chhattisgarh and Uttarakhand – identified in 2005 for special attention.
But over the last decade, that attention has not resulted in any significant progress in UP, one of the poorest-performing of the eight EAG states.

Why a decade of progress across India escaped UP

Healthcare has been low on the priorities of successive UP governments. The per capita expenditure on health in UP increased from Rs 260 to Rs 372 over four years to 2010, according to a 2012 National Institute of Public Finance and Policy report, compared to Rs 356 to Rs 580 in Kerala and from Rs 299 to Rs 579 in Tamil Nadu over the same same period.

Among the major states of India, UP, Assam, Madhya Pradesh and Odisha account for the lowest life expectancy at birth, in contrast to the decade-long progress evident in most southern, western and eastern states.

What are the reasons for UP's poor healthcare record? A combination of several factors, such as a shortage of healthcare professionals, increasing cost of healthcare, the mushrooming of private healthcare and a lack of planning.

A third of the rural population in UP has been deprived of primary healthcare infrastructure, according to the norms of the Indian Public Health Standards (IPHS).

The state requires 31,037 sub centres, 5,172 PHCs and 1,293 community health centres (CHCs) to meet the healthcare demands of its population. But UP is 33 per cent short of sub-centres and PHCs and 40 per cent short of CHCs, according to RHS-2015 data.

This further impacts the implementation of centrally-sponsored health programmes, which in turn require an effective network of public health institutions.
There has also been no expansion of public healthcare institutions over the last 15 years. Thus, low-quality private healthcare services thrive in UP.

In India, the private healthcare system now provides two-thirds of medical treatment, according to this April 2016 Health in India report from the ministry of statistics.

In UP, private health providers – including unrecognised doctors and quacks – meet 85 per cent of medical needs, according to the report.
It appears that the people of UP have two choices: an inadequate, inefficient public healthcare system and a private healthcare system offering low quality and expensive services.

UP patients incur highest medical costs among poor states, double national average
With few other options, UP's people must frequent the private healthcare system, where the average per person cost of treatment of one ailment is highest amongst most poor (EAG) states.

The average cost of treatment at sub-centres and PHCs in UP is Rs 660 per person, more than double the national average of Rs 312 per person, according to the ministry of statistics report.

Currently, UP relies on a public healthcare infrastructure that is two decades old. A fifth of the population deprived of healthcare cannot contribute to the social or economic growth of the country.