INTRODUCTION:

Health care system is the organization of people, institutions, and resources that deliver health care services to meet the health needs of the targeted population. There are a wide range of health systems, across the world with different histories and organizational structures. According to the World Health Organization (WHO), a well-functioning health care system requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained health facilities and logistics to provide quality medicines and technologies (WHO, 2013). Implicitly, each nation plans and develops its own health systems in accordance with the needs and the resources at hand, although the common element in all health systems is primary health care and public health care measures (White F, 2015).

Data and sources of Data:

The study used World Bank Data for assessing the position of India in the world health system, Sample Registration System (SRS) data for Infant Mortality Rate, Maternal Mortality Rate, Total Fertility Rate and other health indicators of the different states in India.

Health Care System in Different Countries:

The role of health care systems is to improve the quality of life and to promote the social wellbeing of the people, which is well recognized. Countries having different health systems have different policies. According to Common Wealth Fund’s International Comparison Report (2016), France is one among the countries which is having the best health care system in the world. Private and public funding together caters to the health needs of all the residents’ in that country. Italy and UK also ranked within ten in the comparison. Italy provides basic health care to its citizens, covering all necessary treatments free of cost. The UK has the National Health Service (NHS) since late 1940s. The country is running the primary health care units through a decentralized thrust by paying the doctors and running the hospitals. The British NHS is also included among the most successful health care systems in the world. Access to health care and the cost of the services are the two factors that provide the country’s system the top ranking. Universal health insurance coverage is available in UK and the country is the leader when it comes to the treatment and management of chronic diseases. Almost all treatments are free (Shah, 2011). In China, the Central Government has overall responsibility for national health legislation, policy, and administration. It is guided by the principle that every citizen is entitled to receive basic health care services, with local governments- provinces, prefectures, cities, counties, and towns responsible for providing them according to local circumstances. China’s 2003 National Health Service Survey shows that 55.9 percent of urban residents and 21.4 percent of rural residents have insurance coverage. China has kept public ownership over most health facilities, making public provision of care the central mode for the majority of services. Specifically, China has established the New Cooperative Medical Scheme (NCMS) a government-run, voluntary insurance program that insures rural residents against catastrophic health expenses (Yip and Mahal, 2008).

Sri Lanka has a unique health care system where one can go directly to the hospital (government or private), to the family doctors or directly to a specialist with no reference from a third party. Sri Lanka’s model of primary health care, available free through a government health system with island wide availability, forms a sound basis for providing universal health coverage. Sri Lanka provides free universal healthcare. This is a country which has low investment for the health sector but giving wonderful rich dividends in the health care system. It is one of the most cost-effective health care systems in the world. Cuba’s health care system is the best model for poor countries in rendering health care for the poorer sections of the society. This was made possible as the country’s leadership recognized the importance of public health care system with focus on preventive services. A distinct feature of this system is the community based polyclinics. The most revolutionary idea is that, doctors stay in the neighborhoods so as to enable them to serve the patients at the earliest possible time. Singapore is having a successful and admirable health care system in the world in terms of efficiency in financing (Tucci, 2004). The primary health care is mainly supervised under the control of Singapore Government Ministry of Health. The country implements a universal health care system with efficiency. In Switzerland, each citizen has to purchase health insurance. The universal coverage is a constitutionally guaranteed right and there are no out-of-pocket expenses. Netherland’s health care system is considered to be one of the best health care systems, in the European Union (EU). In the country, patients have a lot of freedom when it comes to choosing the healthcare provider. Patients with long-term health issues need not worry about finance; as the State Insurance Schemes take care of the needs of its citizens. In Ethiopia the health extension program delivers cost-effective basic services that enhance equity and provide care to millions of women, men and children. In India, National Health Insurance Program is designed to provide baseline universal health care. Unfortunately, the scope of the service is too small to provide service to a significant proportion of the population. Only about 25 percent of the Indian population is supposed to have access to the services of the National Health Program, the majority of these people being in urban centres. Those living in rural India suffer from lack of access to public health care services; and lack of money to afford private health clinics. Recognizing this problem in 2005, the Government of India launched the National Rural Health Mission (NRHM) a flagship scheme of the Union Government which seeks to provide effective health care to rural population throughout the country. Only one in ten citizens of India has any form of health insurance.

India in the Global Scenario:

The health standards in India have considerably improved since independence. The concerted efforts of the governments and other agencies have contributed to the expansion of the health care system. There are noteworthy improvements in the life expectancy, Infant Mortality Rate and Maternal Mortality Rate. A large number of health care services across the country such as extensive health campaigns, sanitation drives, government and private hospitals, immunizations drive, and health literacy amongst people helped to improve India’s health status. Janani Shishu Suraksha Karyakarm (JSSK), Janani Suraksha Yojana (JSY), Reproductive, Maternal, New–born, Child and Adolescent Health Services; and National Health Programmes in restricting theincidences of diseases such as Polio, HIV, TB, leprosy etc have all played a pivotal role in improving India’s health indicators. However allotment of more funds is needed to enhance the health services in the country.

Countries from the different categories:

A comparison of different countries in this regards elected randomly from each category of the World Bank classification using World Bank Atlas method (2017) gives a picture of the diversity of nations in different category.

In 2014, world spending on health care was about 8 per cent of the total global income. Out of this, nearly 60 per cent was spent by government sector. Though the role of government varies from country to country, every government plays an important role (Mohantyand Ashima, 2015). Health expenditure of government and health indicators of the selected countries are given in table.

Table 1: Health Expenditure of Government and Health Indicators of Selected Countries-2014

COUNTRIES	Health expenditure, public(% of GDP)	Health expenditure total(% of GDP	Out-of-pocket expenditure (% of private expenditure on health	Infant Mortality Rate 2014	Life expectancy at birth 2014	Maternal Mortality Rate 2014
LOW INCOME COUNTRIES
Ethiopia	2.9	4.9	78.1	41	64	353
Nepal	2.3	5.8	79.9	29	70	258
Uganda	1.8	7.2	54.6	62.47	58	343
LOWER MIDDLE INCOME COUNTRIES
Bangladesh	0.8	2.8	92.9	31	72	176
Egypt	2.2	5.6	90.1	20	71	33
India	1.4	4.7	89.2	40.5	68.3	174
Pakistan	0.9	2.6	86.8	66	66	178
Srilanka	2.0	3.5	95.8	8	75	30
UPPER MIDDLE INCOME COUNTRIES
Brazil	3.8	8.3	47.2.	15	74	44
China	3.1	5.5	72.3	9	76	27
Costa Rica	6.8	9.3	91.0	9	79	25
Cuba	10.6	11.1	100	4	79	39
Malaysia	2.3	4.2	78.8	6	74	40
HIGH INCOME COUNTRIES
Australia	6.3	9.4	57.1	3	82	6
Canada	7.6	10.4	46.8	4	82	7
France	9.0	11.5	29.1	4	82	8
Germany	8.7	11.3	57.3	3	81	6
Ireland	5.1	7.8	52.0	3	81	8
Italy	7.1	9.2	86.9	3	83	4
Japan	8.5	10.2	84.8	2	84	5
Singapore	2.1	4.9	94.1	2	83	10
Spain	6.4	9.0	82.4	4	83	5
Switzerland	7.7	11.7	78.8	3	83	5
U.K	7.6	9.1	57.7	4	81	9
U.S	8.3	17.1	21.4	6	79	14

Source: World Bank Data, 2015

Note: For Low income countries, the Gross National Income per capita is of US$1,025 or less. For Lower middle-income countries, the Gross National Income per capita between US$1,026 andUS$4,035.For Upper middle-income countries, the Gross National Income per capita is between US$4,036 and US$12,475.For High-income countries, the Gross National Income per capita is above US$12,476.

Globally, countries spend an average of 5.4 percent of Gross Domestic Product (GDP) on health. Low-income countries spend an average of4 percent of GDP towards health expenditure and the lower middle-income groups of countries spend an average of 5 percent of GDP on health. On the contrary, high-income group of countries spend an average of 10 percent of GDP. It is estimated that India spends only 4.7 percent of its GDP on health against 17.1 percent by United States, 11.3 percent by Germany and 11.5 percent by France. However, on the basis of the index measuring country performance on the health related Sustainable Development Goal (SDG) indicators, India ranks at 143 out of 188 countries. The public health expenditure, in percentage of GDP in India is low compared to other countries of the world with an exception to the lower income countries. Low public expenditure on health system in India results in inadequate infrastructure that brings poor health outcomes. It is very much evident that, low level of public spending on health is an important cause for India‘s poor health status, which is one of the lowest in the world. India remains one among the five countries with the lowest levels of public health expenditure in the world. It is to be noted that Cuba or Costa Rica have achieved universal health care due to the support of the government in providing massive investment for public health care facilities in rural areas.

In India, as the facilities in the public health system are very inadequate, people are left with no option but to seek services from private health care services which contribute an adverse impact on out-of-pocket expenditure. The burden of households’ out-of-pocket expenditure is accounted to 89.2 percent in India. While public spending on health care is lesser, the out- of-pocket expenditure on households has been found to be larger and its end result could be financially ruinous.

Infant Mortality Rate is an indicator of the health status in a country. All the upper middle income and high income countries are performing better than India. Japan, Singapore, Germany, U.K, Italy, Australia and Ireland have Infant Mortality Rate less than five, whereas India is having Infant Mortality Rate of 40.5 which is evenworse than the other lower middle income countries and the neighboring countries like Srilanka having eight, Bangladesh having 31, and Nepal with 29. According to the World Bank (2015), India ranks 146^th position among the countries of the world.

Life expectancy at birth is also a yardstick of the overall quality of life in a country. All the high income countries and a few upper middle income countries have a life expectancy above 75. Among the lower middle income countries, Srilanka, Nepal and Bangladesh which are India’s neighbouring countries have better life expectancy than India’s 68. According to World Health Organization (2015), India ranks 126^th position in life expectancy.

High income countries are having Maternal Mortality Rate less than 10. Among the lower middle income countries, where India is included, Srilanka is having Maternal Mortality Rate 30, whereas that of India is 174. Countries like Pakistan and Bangladesh are having more or less the same rate as that of India. India ranks 162^thposition among other countries of the world (World Bank, 2015). While comparing with other countries of the world, the high income and upper middle income group of countries are performing far better than India. Among the lower middle income countries, India’s position is not appreciable. Srilanka, is performing better than India even if the total health expenditure spent by Srilanka is less than that of India. This can be compared to a similar study by Rawat Deepa, Kalpna Aggarwal and Manish Dev (2006) according to which the countries like China, Sri Lanka and Bangladesh have better health indices than that of India. A comparison of the health expenditure and health indicators of India with other countries of the world reveals the real position and condition of the health of the Indian population.

Figure 1: Health Expenditure and Out-of-pocket Expenditures of Selected Countries

Source: Table 1

The figure 1 and 2 portray the position of India with other countries of the world. Though India has improved a lot in the area of health, the overall health scenario, is not commendable

Figure 2: Infant Mortality Rate, Life Expectancy and Maternal Mortality Rate of Selected Countries

Source: Table 1

State wise Human Development Index in India:

Public health is one of the factors that constitute Human Development Index (HDI). Life expectancy at birth, which is influenced by maternal care, antenatal care and child and infant care, is considered for calculating HDI. The index shows that there has been significant progress in the State in the areas of educational, health and basic social infrastructure. Among the 29 states of India seven states were selected from the high income category and eight states from low income category.

Table 2: Trend in Human Development Index of the Selected States of India

States/Country	1991		2001		2015
States/Country	Value	Rank	Value	Rank	Value	Rank
A.P	0.377	9	0.416	10	0.616	9
Assam	0.348	10	0.386	14	0.555	15
Bihar	0.308	15	0.367	15	0.536	17
Gujarat	0.431	6	0.479	6	0.616	10
Haryana	0.443	5	0.509	5	0.661	6
Karnataka	0.412	7	0.478	7	0.617	8
Kerala	0.591	1	0.638	1	0.711	1
M.P	0.328	13	0.394	12	0.556	14
Maharashtra	0.452	4	0.523	4	0.665	4
Orissa	0.345	12	0.404	11	0.556	13
Punjab	0.475	2	0.537	2	0.661	5
Rajasthan	0.347	11	0.424	9	0.576	12
Tamil Nadu	0.466	3	0.531	3	0.666	3
U.P	0.314	14	0.388	13	0.541	16
W.B	0.404	8	0.472	8	0.604	11
All India	0.381	-	0.472	-	0.608	-

Source: Human Development Report 2005 and 2015.

The table 2 describes the trends in HDI of selected states during the period 1991-2015.The interstate variations in the HDI shows that Kerala stood first consecutively in all the three periods. In all the three periods, Kerala is having a value greater than the average value of the country taking the state high on HDI. A striking point to be noted in terms of HDI is that, Kerala with 0.71 performs even near to the developed nations of the world

like USA, Canada, and Australia.

State wise Distribution of Health Indicators in India

A comparison with other states of India in respect of various health indicators is shown in table 3

Table 3: Health Indicators of Selected States of India-2013

States	Health expenditure as a percentage of total state expenditure	Infant mortality Rate	Maternal Mortality Rate	Total Fertility Rate	Institutional deliveries	Children 12-23 months received full vaccination
Andra Pradesh	6.06	39	92	1.8	88.5	60.2
Assam	4.78	49	300	2.3	65.9	64.4
Bihar	3.88	42	208	3.4	55.4	69.9
Gujarat	5.09	35	112	2.3	56.4	54.8
Haryana	3.88	36	127	2.2	77	52.1
Karnataka	4.35	29	133	1.9	89.1	77.6
Kerala	5.48	12	61	1.8	99.6	82.5
MP	4.18	52	221	2.9	82.6	66.4
Maharashtra	4.08	22	68	1.8	92	66.2
Orissa	4.11	49	221	2.1	82.7	68.8
Punjab	4.92	24	141	1.7	78	68.4
Rajasthan	5.15	46	244	2.8	82.7	74.2
TN	4.71	20	79	1.7	94.1	56.2
UP	5.31	48	285	3.1	56.7	52.7
West Bengal	4.67	28	113	1.6	74.6	79.5
All India	4.66	38	174	2.3	61	53.5

Source: Sample Registration System, 2012-13 and DLHS, 2012-13.

Note: Full vaccination includes BCG, measles, 3 doses of DPT and Polio

Expenditure on health care is an important determinant of health outcome. The table 3 depicts that Andra Pradesh, Uttar Pradesh, Gujarat, Kerala and Rajasthan has been spending relatively higher share of its total revenue expenditure on health care services compared to other states of India. In the matter of health indicators like Infant Mortality Rate, Maternal Mortality Rate, institutional deliveries and full vaccination received by children between 12 to 23 months, Kerala performs much better than all other states in India and better than the country’s average. While comparing with the other states of India, Kerala registers lowest Maternal Mortality Rate in the country along with two other states; Tamilnadu and Maharashtra that could achieve the Millenium Development Goals (Reducing Maternal Mortality Rate to less than 109 death per 100000 live births a Millennium Development Goals for 2005). Kerala’s Infant Mortality Rate of 12 is the lowest along with Goa which is far better than the country’s average of 38. The State stands first in the service of institutional deliveries in the presence of health professionals and with the required medical facility, and it is the only state in India where almost all births now take place in a health centre. The immunization rate is 82.5 percent which is far above the country’s average of 53.5 percent. In the case of Total Fertility Rate, West Bengal ranks first with 1.6, followed by Punjab and Tamil Nadu with 1.7 and Andra Pradesh, Maharashtra, Kerala at 1.8. The state wise comparison shows that Kerala is ahead of all other states and even better than the country’s average in most of the health indicators.

CONCLUDING OBSERVATIONS:

The comparison of India health indicators in the Global context shows that, the Infant Mortality Rate and Maternal Mortality Rate are better for high income and middle income countries than India. India is having low level of public spending on health which leads to poor health status compared to other nations of the world. Countries like China, Srilanka and even Bangladesh have better health indices than India. Data on different States in India with respect to health care shows that Kerala achieved better position on the health sector and the HDI of Kerala is even near to that of the developed countries of the world. Kerala is one of the best performing states in terms of Infant Mortality Rate, Maternal Mortality Rate, Total Fertility Rate, institutional deliveries and immunization.

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Received on 16.06.2018 Modified on 18.07.2018

Res. J. Humanities and Social Sciences. 2018; 9(3): 575-579.

DOI: 10.5958/2321-5828.2018.00096.7

Health Care System of India–A Comparison with health indicators