Healthcare – China spends 10x and the developed world 100x of India

It is a pity that India spends so little on healthcare for its citizens.

For a country that ranks a low 130 on HDI but with superpower ambitions, it is a shame that we can’t spend enough to improve the healthcare available to our people.

The central government health budget is about ₹50K crores and the states three times that. The total healthcare spend by the centre and states put together is ₹200K crores, which is about 28 billion US dollars.  This translates to 21 US dollars per capita.

Another telling statistic is that most of the healthcare expense in India is in the private sector. Government spend of $21 is only 30 percent of the spend. Both rural and urban India depend primarily on the private sector for medical care.

As a comparison, spend by government in the US on healthcare is over 100 times more, at 2500 US dollars per capita. While total healthcare spends in the US are actually higher than 8000 dollars per capita, the share of government spend is about 2500 dollars.

In the UK, while total spend on healthcare per capita is lower than the US, the government spend on NHS is even higher than the US at above 3000 dollars per capita.

The Chinese government too, spends ten times as much as India does on healthcare per capita.

I am simply unable to understand India’s poor focus on healthcare.

True, the current government has come up with an ambitious healthcare policy but the proof of the pudding is in the budgets. What is the point of announcing a policy that needs ₹800K crores of funding but only ₹200K crores has been budgeted? Where is the balance money going to come from?

Is this then a policy or just a statement of desire?

I think it is clear and everybody understands now that our real capital is our human capital. But without prioritising health and education, the human capital will not be of good quality. Then of what use will that human capital be? Surely not capable of the productivity gains we need, if we are to become a middle income country in the next 15 years.

Criminal or Needs Help? How Do We Know?

Someone told me the other day that the reason why we send people to jail is not to punish them. That’s not the reason at all.

The reason is protection. And it works both ways. Protecting society from criminals and protecting criminals from vigilante justice. One keeps society safe and the second keeps it sane.

That brings me to the topic of mental illness. It is possible to argue in the following manner :  Almost all criminal behaviour is deviant from what we consider “normal”.  Criminal behaviour born of thought patterns that are deviant from the normal is what we may call mental illness. And so a person who has exhibited criminal behaviour is to be treated as a victim of mental illness.

In the last century, we have recognised and accepted some forms of deviant behaviour as born of mental illnesses and recognised that some others (like homosexuality) are not illnesses at all and are perfectly normal. 

But many other behaviours are yet to be recognised and formally classified as mental illness by the criminal justice system. Even perfectly normal behaviours like homosexuality continue to be criminalized in less developed legal systems and unfortunately in India as well.

Just as in other areas of life, I expect technology to play a major role in the coming two decades in this area. So far, psychiatry has not had the technology to look at things like genetic profiles or body chemistry at hormonal and other levels. The causal relationships or correlation between these and mental illnesses is neither visible nor well understood. I think that very strong relationships most likely exist and they will be found.

This opens up the possibility of cures or methods of containment. 

Maybe in future, we will be able to treat these people as victims and help them to reverse the condition or contain it. Maybe many of the people who go to jail today, don’t really belong there.

Alok Sarin makes an interesting case here on an associated topic –


WhatsApp, Government, Traceability – Who is lying?

In a country like India, people easily believe malicious rumours. Often, these rumours whip up mob hysteria and we have mobs doing all kinds of things- lynching someone, parading someone naked, rioting, arson, destroying property and more.

Whatsapp is not only increasing the number of such rumours but also accelerating their spread and a hydra headed monster of mob violence is making itself felt all over the country. People are getting killed.

The solution obviously is not to ban WhatsApp. The solution is to create a mechanism to identify the originators of these rumours and make an example of them. Arrest them and ensure justice.

Every society has a written law and the law acts as a deterrent to crime. However, the law is emasculated and rendered ineffective by WhatsApp’s refusal to share the identity of the originator of the rumour with the enforcers of the law – the police, the courts, the government.

Minister Ravi Shankar Prasad recently said that he was successful in getting WhatsApp to agree to implement traceability. He confirmed to me on a LinkedIn message exchange that this is the case. The picture on this page is a screenshot of the exchange.

Today, I read news reports that this is not true. And that WhatsApp has REFUSED the Indian Government’s request to implement traceability.  A couple of news report examples are here and here.

Now who has got it wrong? Minister Ravi Shankar Prasad or the Press?

I would like to see a formal announcement by the minister or his ministry telling us what exactly WhatsApp has agreed to.

Hazardous work and no protection in New Delhi

This is a photo I took today in New Delhi. In the heart of Lutyens Delhi, where our ministers and senior bureaucrats live.

These are sanitation workers cleaning the underground sewers.

The men you see are wearing no protection. 

No gloves. No boots. They are bare bodied. They also do not wear any masks before opening the manholes and descending into the sewers.

Who are the people who employ them? Why does the New Delhi city government allow this? Is this not illegal? 

These workers could fall victim to an accident. They may contract illness due to exposure to pathogens or toxins. And given India’s fairly dysfunctional justice system, they will have no recourse. Nobody will pay for illegal worker treatment like this and nobody will pay for the damage that will happen to their health and well-being.

This is in Delhi. Less than 4 kilometers from the seat of our government. Just imagine what the situation is, in other parts of India…

The Government has no idea how many doctors India has!

This is a pretty sad state of affairs. It appears that the government of India does not have the correct data – they don’t know how many doctors India has.

And policy decisions as well as governance decisions are made using the wrong data.

And  when they don’t know how many doctors exist, how will they know how many of them actually practice? Many doctors don’t.

It is very difficult to believe that in this day and age when it can be safely assumed that all these doctors have Aadhar numbers, they can’t be tied into a national database which requires them to confirm their presence once a year.

It looks like our data on how many cars and trucks we have on the roads is better than our data on the number of practicing doctors.

Any ideas for our government on how to solve this problem?









Unintended pregnancies and abortion law

An amazing statistic from Dr Malhotra in this article –

48 percent of all pregnancies in India are “unintended” pregnancies.

I also find the use of the word “unintended” fascinating. Is it the same as “unplanned”? I think not. Is it the same as “unwanted”? Again I think not.

There is published information elsewhere that  half of the children in India are victims of sexual abuse.

If I correlate these two statistics, I assume it follows that a significant percentage of the unintended pregnancies are a result of sexual abuse outside of wedlock. And a very large number of the mothers are children/teenagers.

This lends a lot of gravity to Dr Jaideep Malhotra’s views. The abortion law must be changed as she says.

20 weeks is too short a time and does not deliver justice to these young victims who should not be and do not want to be mothers. This is not just an issue of justice or gender justice. This is also about child rights.

Referenced articles –

One in two children in india are victims of sexual abuse

A Law Past Its Sell-by Date








Healthcare Insurance for 500 million people?

I am all for universal healthcare insurance and I really hope that the Ayushman Bharat scheme delivers on its promise to adequately insure the healthcare for 500 million people.

But I have serious concerns and questions that nobody seems to have answers to.

Public sector healthcare facilities in India are in very poor shape and grossly inadequate. The private sector delivers over 70% of healthcare in India. In any case, the insurance scheme is meaningless when applied to  public sector healthcare because it is available free of cost anyway.

So then, here is a first principles approach to asking some questions –

1. Adequately insured communities are an incentive for doctors and businesses to invest in medical care facilities for those communities. This means that these facilities must have profitable income from insured patients.

2. It therefore follows that premium incomes earned by the insurance companies must be higher than the cost of healthcare delivered.

Even if we discount the cost of universal healthcare in countries like Canada and UK by 90 percent, we still need something like 50 billion dollars a year to cover healthcare costs for 500 million people, which is what Ayushman Bharat aims to cover.

I can’t see the budgets. Where is the government going to get this much insurance premium from?

Some would argue that the budgets are sufficient by pointing to the insurance schemes that already exist in states like Tamil Nadu. But that only strengthens my argument. Most good private sector medical facilities do not accept the mandated rates of those schemes. The  adequate availability of good quality healthcare for the people covered by those schemes has not happened.

Where is the money?

Kanti Bajpai’s post in TOI raises a different set of questions. But those are not the points I raise –