Recent government expenditures to improve access to effective health care in Delhi, India, have been insufficient to overcome the impact of poverty and inequalities, leading to a rise in deaths from preventable illness such as septicemia and tuberculosis in the capital city, according to a study led by Rutgers School of Public Health researcher Michael K. Gusmano.
In a paper recently published in the journal Public Health, Gusmano and researchers from New York University and Columbia University found that compared to similar large middle-income nations, India has failed to achieve minimal sanitation and public health standards, resulting in a climbing rate of amenable mortality (premature deaths due to causes which are treatable).
Delhi's rates of amenable mortality - selected for the study because Delhi's statistics are medically certified and more complete than those of India as a whole - were compared against those of Moscow, São Paulo and Shanghai, mega cities in similar large, middle-income countries with booming economies that likewise have been striving toward a goal of universal health coverage.
The researchers found that between 2004 and 2013 - when the economy of India was growing rapidly ¬- amenable mortality increased by about 25 percent in Delhi, while the comparison cities experienced a decrease in amenable mortality of at least 25 percent.
"Despite having the world's largest generic drug industry, thriving medical tourism, significant innovations in the delivery, financing and manufacturing of health care services and products, there is a basic failure to assure minimal standards of sanitation and public health," says Gusmano.
Though a part of the country's wealthiest territory, half of Delhi's 16 million inhabitants live in slums and other substandard housing. With more than half of India's households lacking toilets and more than 200 million people with no access to safe drinking water, the World Health Organization estimates that 900,000 Indians die annually from drinking contaminated water and breathing polluted air.
"The living conditions contribute to the higher rates of illness, while the relatively low rates of investment in the primary care infrastructure and drug availability and affordability make it harder to treat people once they become sick," says Gusmano. "There are problems at both ends of the spectrum."
Using data that could be routinely and reliably monitored over time to assess amenable mortality - population estimates and vital statistics, including medically certified death records and hospital records for people ages one to 69 - the researchers found a disparity in care.
"There is very high quality of care, which the wealthy receive. The vast majority of the people living in poverty or just above the poverty line do not have access to that system, but to public and private systems that are inadequate to meet the population's health care needs and deliver care of dubious quality," says Gusmano.
On average, two medical officers are responsible for providing care to as many as 400 patients a day in public facilities, and with the exception of a few specialty hospitals, most public hospitals and other clinical facilities are in poor condition.
"The inadequate public infrastructure means there's a heavy reliance on the private sector for delivery, but there are deep concerns about the private sector in terms of both quality and cost," says Gusmano. "The facilities range from world-class institutions to virtually unregulated private facilities that leave patients at the
mercy of unscrupulous practitioners. Patients pay out-of-pocket, which limits access and puts those with lower incomes at risk of financial distress."
During the years included in the study, Delhi's health care expenditures increased from 7 to 12 percent of its budget, the availability of hospital beds nearly doubled and new primary care clinics were built to alleviate pressure on the public and private systems. "However, the increasing number of residents who die prematurely each year due to preventable conditions point to the fact that more needs to be done," says Gusmano. "Delhi needs to substantially increase public health spending, monitor health system performance and implement programs that address the causes of extreme deprivation."
The study shone a spotlight on the need for India to improve its data collection from health care institutions so that the government can realize where it is falling short. "It's hard to know how to fix the situation if you do not know what is going on. We should know the type of workforce at these facilities and their training, the maintenance of the facilities and the outcomes of the patients," Gusmano says. "Compared to other cities in India, Delhi kept the best records, so it's possible the deaths from amenable mortality in other areas are significantly greater. Delhi can be looked at as a best-case scenario, which isn't very good."
Gusmano notes there were signs that progress is being made, such as a decline in maternal death and an initiative to found neighborhood clinics to help alleviate overcrowding in public clinics and expand access to care for the poor and middle class. "By pushing resources down to the community level, practitioners can be more responsive to the needs of residents on the most local level," he says. "This makes us optimistic."