URBAN HEALTHCARE - ISSUES AND CHALLENGES Ravi Duggal INTRODUCTION Health care access and availability in India has a peculiar rural-urban and a public- private mix that generates a political economy, which makes the health sector both discriminatory and purchasing-power-dependant. This is a contradiction given the fact that the larger majority in both rural and urban areas do not have a purchasing power even to sustain adequate nutritional requirements. In a country where nearly half the population struggles under severe poverty conditions and another one-half of the remaining manages at the subsistence level it is a sad state of affairs that social needs like health and education have to be more often than not bought in the market place. With a new government installed which talks about reforms with a human face we perhaps have an opportunity to seek positive changes. Today there are over 15,000 hospitals (68% private) with about 900,000 hospital beds (45% private) and about 25,000 Primary Health Centres in the country, and a total of over 1,200,000 qualified practitioners (89% private) of all systems of medicine. The skewed rural/urban availability of public health services is well known - 70% hospitals and 85% of hospital beds under public domain are located in urban/metropolitan areas when 70% of the population lives in the rural and backward areas of the country. The pattern of distribution of the private health sector is not very different, they too tending to concentrate in urban/metropolitan areas - 60% hospitals, 75% of hospital beds and 70% of allopathic doctors are found in urban areas. 1 However, the private health sector is not confined to just the allopathic qualified practitioners. There are nearly twice as many practitioners qualified in various Indian systems of medicine and homoeopathy, and a larger proportion of them (60%) are located in the rural and backward areas, 90% of them also practicing modern medicine. This scenario reflects that the character of healthcare in rural and urban India is very different, especially in terms of access and quality. The private sector definitely has a better penetration in areas where the majority live. Further, because of a complete lack of regulation and control there is another large chunk of practitioners, estimated at about half as many as the qualified, who practice modern medicine without having any qualifications in any system of medicine - again a larger majority of them are in rural and backward areas. This entire private health sector operates on a for-profit basis within the context of a supply-induced-demand economy. And estimates based on various studies show that the private health sector is as much as 4 to 6% of the GDP, in sharp contrast to less than one percent of the GDP which the governments spend. 2 1 Given the large size of the private health sector data becomes a major problem. While public sector data is available, though with a lag of 3-4 years, private sector data is difficult to come by except through surveys etc.. The author has made estimates here based on data from the Ministry of Health, State medical councils, the Census of India and utilisation surveys done by various institutions like the NSSO, NCAER and others 2 There are now a number of studies which have documented private health expenditures. Some of the important ones are: NCAER, 1992: Household Survey of Medical Care, New Delhi; Kanan, KP, et.al., 1991: Health and Development in Rural Kerala, KSSP, Thiruvananthapuram; Duggal R et.al., 1989: Cost of Health Care- Survey of an Indian District, FRCH, Bombay; NSSO,1989 and 1998: Morbidity and Utilisation of medical Services – 42 nd Round and 52 nd Round, GOI, New Delhi