Burns in India: a call for health policy action
Authors: Vikash Ranjan Keshri, Jagnoor Jagnoor
Journal: The Lancet Public Health (2021)

Globally, burns are one of the major causes of disability, with more than 8 million disability-adjusted life-years (DALYs). The burden of burns falls disproportionately on low-income and middle-income countries (LMICs).1James SL Lucchesi LR Bisignano C et al.Epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study.Inj Prev. 2020; 26: i36Crossref PubMed Scopus (70) Google Scholar A trend of increased incidence of burns is observed in south Asia during the festive season of Diwali, celebrated each year in the months of October or November.2Tandon R Agrawal K Narayan RP et al.Firecracker injuries during Diwali festival: the epidemiology and impact of legislation in Delhi.Indian J Plast Surg. 2012; 45: 97-101Crossref PubMed Scopus (28) Google Scholar The situation in India is particularly worrying.1James SL Lucchesi LR Bisignano C et al.Epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study.Inj Prev. 2020; 26: i36Crossref PubMed Scopus (70) Google Scholar In 2019, more than 23 000 fire-related deaths were estimated in India, which is about 20% of the global mortality burden. Additionally, 1·5 million DALYs were attributed to burns.3WHOGlobal health estimates: Leading causes of death.https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-deathDate: 2020Date accessed: October 10, 2021Google Scholar Burn survivors can be financially distressed, vocationally challenged, and socially excluded.4Bhate-Deosthali P Lingam L Gendered pattern of burn injuries in India: a neglected health issue.Reprod Health Matters. 2016; 24: 96-103Crossref PubMed Scopus (15) Google Scholar The burden of burns among women (aged 15–49 years) in India is three-times higher than that among men.3WHOGlobal health estimates: Leading causes of death.https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-deathDate: 2020Date accessed: October 10, 2021Google Scholar Women have differential exposure to risk, often arising from unsafe cooking and kitchen practices, suicides, and homicides associated with domestic violence and dowry-related conflict.4Bhate-Deosthali P Lingam L Gendered pattern of burn injuries in India: a neglected health issue.Reprod Health Matters. 2016; 24: 96-103Crossref PubMed Scopus (15) Google Scholar Prevention of burns requires attention to gender-based inequities and upstream social determinants of health. The surge in burn cases during Diwali sees an increased representation of children.2Tandon R Agrawal K Narayan RP et al.Firecracker injuries during Diwali festival: the epidemiology and impact of legislation in Delhi.Indian J Plast Surg. 2012; 45: 97-101Crossref PubMed Scopus (28) Google Scholar In high-income countries, the incidence, severity, mortality, and disability due to burns have reduced significantly due to advancement in prevention, management, and rehabilitation; whereas in LMICs, and particularly in south-Asian countries and India, the burden continues to be high.5Stokes MAR Johnson WD Burns in the third world: an unmet need.Ann Burns Fire Disasters. 2017; 30: 243-246PubMed Google Scholar In 2010, in response to this burden, a National Programme for Prevention and Management of Burns Injury was launched in India. However, the scope of the programme remains limited. Burn services in India are delivered primarily through a network of specialised tertiary care burn centres. There are 67 burn centres, of which 30 are in the public sector and 37 in the private sector. The geographical distribution of these centres and service availability are uneven and heterogeneous.6Ranganathan K Mouch CA Chung M et al.Geospatial mapping as a guide for resource allocation among burn centers in India.J Burn Care Res. 2020; 41: 853-858Crossref PubMed Scopus (7) Google Scholar In the public sector, many burn centres are constrained in terms of infrastructure and human resource capacity, and concerns have been raised about the quality of care.7Jagnoor J Bekker S Chamania S Potokar T Ivers R Identifying priority policy issues and health system research questions associated with recovery outcomes for burns survivors in India: a qualitative inquiry.BMJ Open. 2018; 8e020045Crossref PubMed Scopus (13) Google Scholar Another bottleneck in the public sector is out-of-pocket expenditures for dietary supplementation, medicine, transport, and rehabilitation services. Being a patient with burns and poor financial means can also lead to poor burn services and poor recovery outcomes. Running a medical burn centre has a high cost, and thus the financial viability of running such services is a major challenge for the private sector. Besides, burn care in the private sector is mostly located in big cities. Patients with burns often require long treatment that can lead to very high out-of-pocket costs and catastrophic expenditure for the family.8Prinja S Jagnoor J Sharma D et al.Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India.PLoS One. 2019; 14e0224721Crossref PubMed Scopus (29) Google Scholar In 2017, a new National Health Policy (NHP) was formulated with a stated aspiration to progressively move towards Universal Health Coverage (UHC). The NHP brought a major strategic shift in public health care, aligning the private sector for public health goals, and thus expanding the role of government from just being a provider to being the purchaser. The subsequent introduction of the Ayushman Bharat scheme in 2018 consolidated this approach by introducing a major public financed health insurance scheme, the Pradhan Mantri Jan Arogya Yojana (PMJAY). In this changing landscape of health-care delivery in India, there is an opportunity for renewed health policy action for burns management. The PMJAY scheme includes burn treatment under its service package, but the extent of coverage is limited to about 40% of Indian families with low socioeconomic status. Burn service coverage under PMJAY is restricted mainly to acute and hospitalised care, and the cost of coverage is also limited.9National Health Authority, IndiaAbout Pradhan Mantri Jan Arogya Yojana (PM-JAY).https://pmjay.gov.in/about/pmjayDate: 2021Date accessed: October 10, 2021Google Scholar Available evidence suggests inadequacy of the publicly financed health insurance scheme in averting catastrophic expenditure for patients with burns in need of emergency care.8Prinja S Jagnoor J Sharma D et al.Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India.PLoS One. 2019; 14e0224721Crossref PubMed Scopus (29) Google Scholar This situation highlights the need to expand the coverage and ensure adequate financial risk protection for patients with burns. One such example is a dedicated scheme by the local government in Delhi, which mandates free and cashless treatment for burn cases in all facilities.10Saxena A Arvind Kejriwal: will cancel licences if private hospitals deny free treatment to accident, burn victims.The Indian Express. 2019; https://indianexpress.com/article/cities/delhi/arvind-kejriwal-will-cancel-licences-if-pvt-hospitals-deny-free-treatment-5865171/Date accessed: October 10, 2021Google Scholar Universal provision of such a scheme might enable equitable access to burn care in India, reducing death and disability from burns. Strong regulation and effective stewardship are needed to support the effective implementation of these reform initiatives. We call for making burn service free at the point of care across the country. The scope for PMJAY needs to be expanded to cover all patients with burns and all associated costs. At the same time, there is an urgent need to reform and broaden the scope of the national programme to strengthen burn care in the public sector and to ensure better rehabilitation of burn survivors. Social reintegration of burn survivors needs a welfare and justice approach guided by effective policy. In pursuit of UHC in India, a strong policy statement backed by clear strategies for effective response to burns is urgently needed. We declare no competing interests.