Dr. Devendra Kothari
Population and Development Analyst
Forum for Population Action
Happy Doctors’ Day 2016!
"At the moment, India is on the edge and it can take two routes. It can take a route of investing in health and investing in its people and creating a thriving and flourishing future for India which has a part to play in world affairs or it can do what it is doing now and ignore health in which case it will see epidemics sweep across the country creating an unsustainable future and destroying national security.”
Lancet's editor-in-chief Richard Horton.
The world's most revered medical journal - The Lancet - has censured severely Government of India for ignoring health sector and has warned that India is on the “verge of a collapse under the weight of its own ill health”. In an exclusive interview to Times of India, Lancet's editor-in-chief Richard Horton said that failing to combat non communicable diseases like diabetes and heart disease and reduce maternal and child health will cost India's health system and social care "enormously making India collapse”. 
Horton’s comments have stirred the ire of Indian health officials, who called them "derogatory" and "not borne out by evidence. The Ministry of Health and Family Planning sent a strong worded letter to him and noted that “India has moved from strength to strength and some recent initiatives will ensure improved outcomes for the most vulnerable”. The letter added that the country has made great strides in reducing infant and maternal mortality through its immunization programs as well as increased efforts to control drug-resistant tuberculosis and HIV. 
No doubt, in recent years, India has managed to control communicable diseases like malaria, cholera and polio. However, the nation now has to deal with a new breed of lifestyle diseases like diabetes and cardiovascular ailments. Coupled with a sedentary urban lifestyle, increased alcohol consumption and smoking, the urban youth are particularly prone to the aforementioned lifestyle diseases. In addition, large health disparities between states, between rural and urban populations, and across social classes persist. Further, a large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care.
Healthcare in India is a big mish mash of great achievements as well as miserable failures. On one hand, we have medical tourism and cutting edge equipment as well as technology and the other we have kids dying of undernourishment and people with treatable conditions. In other words, despite substantial improvements in some health indicators in the past couple of decades, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavorably with other middle-income countries and India's regional neighbors. Known as the diabetes capital of the world, for example, India has about 70 million people with diabetes, which makes a significant proportion of working population. Even its South Asian neighbors like Bangladesh, Nepal, Afghanistan and Sri Lanka have fewer diabetics. Only Pakistan fares worse. One can easily prevent diabetes by effectively controlling its various risk factors such as smoking, obesity and inactive lifestyle.
India has neglected its health care, as per the Geneva-based World Economic Forum (WEF). According to the latest Human Capital Index, released by WEF in June 2016, India ranked low at 105th position globally on the Index, which measures countries' ability to nurture, develop and deploy human capital for economic development. Finland topped the list. India ranks much below China's 71st position while Bangladesh, Bhutan and Sri Lanka are also placed higher on the index. Giving India 105th rank out of the total 130 countries, WEF said the country has optimized just 57 per cent of its human capital endowment - placing it in the top of the bottom quartile of the index. Among BRICS countries, India is ranked lowest as against Russia's 28th, China's 71st, Brazil's 83rd and South Africa's 88th. It is interesting to note that India was ranked 100th last year out of total 124 countries.
The post argues that India needs an effective healthcare system, which addresses both acute and chronic health-care. Also, it must offer choice of care that is rational, accessible, and of good quality. For this, India needs to “adopt an integrated national health-care system built around a strong public-primary care system with a clearly articulated supportive role for the private and indigenous sectors”, as argued by the researchers in their paper published in The Lancet.  In addition, India has to establish effective regulatory mechanisms to monitor the cost and quality of healthcare system.
Despite rapid economic growth over the past two decades, successive union governments have failed to invest generously in health. Most of the challenges facing India’s health system can be attributed to underinvestment and the inefficient use of resources, as argued by Dr. Prabhat Jha of the Centre for Global Health Research, University of Toronto.  Further, the promise of universal health coverage will remain unfulfilled unless health is prioritised, as noted by Dr. K. Srinath Reddy, President of the Public Health Foundation of India.  In addition, an inadequate number of doctors and a poor network of public hospitals, coupled with bureaucratic bungling, means India often struggles to spend even its allocated budgets.
Asia's third-largest economy spends around 1 per cent of its gross domestic product (GDP) on public health, compared with 3 per cent in China and 8.3 per cent in the United States. (Indian states manage their health budgets separately.) As a result, the per capita spending rates are extremely low at US $ 109 (in Purchase Power Parity terms) as compared to the USA ($7,285) and Brazil ($837). The global figure is US$ 863 (WHO World Health Statistics 2010). As such, there is an urgent need to increase the budgetary allocation for health.
With government expenditure on health as a percentage of GDP stagnant or falling over the years and the rise of unregulated private healthcare sector based on the profit motive, the poor are left with fewer options than before to access health care services. Most healthcare expenses in India are paid out of pocket by patients and their families, rather than through insurance. This has led many households to incur Catastrophic Health Expenditure (CHE) which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living. One study found that over 35 per cent of poor Indian households incur CHE and this reflects the detrimental state in which Indian healthcare system is at the moment.  As per Dr. Reddy, Indian health system allows 63 million of its people to sink into poverty each year as a result of unaffordable health care costs. That could be reason, why Lancet's editor-in-chief Richard Horton has warned that India is on the “verge of a collapse under the weight of its own ill health”.
The healthcare insurance is slowly picking up pace in India. But the pace of increase is very slow. According to an Indian government study about 17 per cent of India's population had some form of health insurance in 2014. Government or public healthcare is free for those below the poverty line in many States of India, but there is a question of quality. The NSSO survey (released in April 2016) found that people rely more on private hospitals, with over 70 per cent spells of ailment (72% in rural areas and 79% in urban areas) being treated in the private sector. As such, government has to expand insurance coverage. Plans are currently being formulated for the development of a universal health care system in India, which would provide health coverage through “national health assurance”, as per the draft National Health Policy (NHP) 2015. Some community health insurance schemes targeting poor families in different states are showing encouraging trends. The governmental agencies need to expedite its role to play a more active role in facilitating and ensuring health insurance coverage for people, particularly the poor.
In addition, there is an urgent need to develop an effective healthcare delivery system, which addresses both communicable and non-communicable healthcare needs. For this, India needs to adopt an integrated national healthcare system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors, as noted earlier. Now question arises how to achieve this?
A major barrier to service delivery is the severe shortage of qualified health care personnel. Although there are around 400 Indian medical colleges with an annual intake of 52,000 students, there are shortages of both generalist and specialist doctors, which are aggravated by urban concentration and emigration, noted by Dr. Reddy. Shortfalls of properly trained nurses and allied health professionals are even more acute.
Recently, GoI has taken steps to address the problem of shortage of medical professionals. The Medical Council of India, responsible for medical education, is set to be replaced by a Medical Education Commission as per the Niti Aayog Panel (formerly Planning Commission). The panel has framed the detailed guidelines to ensure a wider talent pool to bridge shortages of skilled health workers and address a major hurdle in meeting growing quality healthcare needs.
How to provide health care services on ground? The draft National Health Policy 2015, which provides a broad roadmap for health system reforms, calls for strengthening primary care services to provide comprehensive care for several health conditions including non-communicable diseases. Further, continuity of care would be ensured through linkages with secondary and tertiary care facilities. Both public and private sector providers would be engaged to deliver the service package, which would be paid for by the government-funded health insurance schemes, as noted by the draft NHP.
No doubt, the draft NHP 2015 is an improvement over its predecessors of 1985 and 2002. However, it does not “provide a more concrete road map with doable timetables and practicable end-points”, as argued by the Forum for Medical Ethics Society.  Looking to the ground realities, we suggest the following broad interventions to provide healthcare services (details will be worked out later).
Firstly, there is an urgent need to reevaluate the existing public primary healthcare system. Presently there are about 23,100 Primary Health Centres (PHCs) in India. They were established to provide preventive and promotive health care with special reference to maternal and child health as well as family planning services. However, they have gradually become clinical centres. There is an urgent need to concentrate on reproductive health (maternal and child health and family planning).
Although there has been progress with child and maternal mortality, India has the highest number of child and new born as well as maternal deaths in the world. Two million children still die every year due to preventable causes. The World Bank estimates that the prevalence of underweight children in India is among the highest in the world with dire consequences for productivity and economic growth.  Further, winner of the 2015 Nobel Prize in Economics Prof. Angus Deaton, who spent a considerable amount of time working on ‘stunting’ among Indian children, concluded that widespread growth faltering was a human development disaster as height reflected early life nutrition which helps brains to grow.  In addition issue of unwanted fertility is very serous one. India’s population has grown from 846 million in 1991 to 1210 million in 2011- that is by 364 million in the twenty years, and is still growing by around 17 to 18 million every year. Current population growth is mainly fuelled by unwanted fertility. More than four in ten pregnancies are unintended/unplanned or simply unwanted by the women who experience them and half or more of these pregnancies result in births that spur continued population growth. Today 26.5 million babies are born each year and out of this about 6 million births could be classified as unwanted or unplanned.  The consequences of unintended pregnancy are serious, slowing down the process of socio-economic development as well as process of change, and is being reflected in widespread hunger, poor health, poverty, under educated labour force, unemployment, regressing governance as well as increasing scarcity of basic resources like food, water and space despite concerted developmental efforts since 1991.
As such, existing Primary Health Centre should be the cornerstone of reproductive health services. Effective reproductive health practice requires skillfully combining a number of theoretical models and frameworks to support systems addressing the health needs of women, children, and families. Future improvements in RH should be built on this legacy but it will come only from a 'paradigm shift' in primary health practice, as noted by Dr. Starfield in her recent paper entitled “ Politics, primary healthcare and health: was Virchow right?” . She writes further, “primary healthcare provides a considerable contribution in reducing the adverse impact of social inequalities in health”. 
Secondly, the general medical/clinical care will be provided in a given jurisdiction by the General practitioners (GPs) both in rural and urban areas. In the medical profession, a general practitioner is a trained medical doctor who treats all common medical conditions both acute and chronic illnesses and refer patients to hospitals and other medical services for urgent and specialist treatment. They focus on the health of the whole person combining physical, psychological and social aspects of care. Also, GPs may be routinely involved in pre-hospital emergency care, community hospital care and performing low-complexity surgical procedures. The government may provide some basic facilities like space, essential equipments, etc. to run the services. The contract is (re)negotiated every 5 years. The units will be fully computerized, that is, with computer-based patient records. GPs will be the corner stone of Indian healthcare system at the bottom in the proposed framework.
The secondary healthcare will be provided by a specialist or facility at the District/Tehsil level hospitals or Community Health Centers upon referral by a primary care physician including GP and that requires more specialized knowledge, skill, or equipment.
There has been mention of public-private partnerships for tertiary care in the NHP 2015, but this has yet to take concrete shape by imposing pubic duties on private professionals and hospitals. In our proposed model, most of the tertiary care will be taken care by the private sector, and referred cases will be paid by the public exchequer or through insurance. Recently, GOI has decided to invest to the tune of Rs 30,000 crore in 10 institutes of medical sciences (Like AIIMS). According to Ministry of Health and Family Planning setting up of these “institutes would address regional imbalances in availability of affordable and reliable tertiary health care services”. In addition, GoI would spend a very large amount as recurring expenses to run these institutes. I think such amount could be spent as subsidy to help poor and middle class patients to avail tertiary care at the private hospitals
Lastly, the disease profile is changing rapidly in India. Modern science through improved sanitation, vaccination, and antibiotics, and medical attention has eliminated the threat of death from most infectious diseases. However, the World health organization has identified India as one of the nations that is going to have most of the lifestyle disorders in the near future. Nowadays, not only are lifestyle disorders becoming more common, but they are also affecting younger population. The population at risk shifts from 40+ to may be 30+ or even younger. Already considered the diabetes capital of the world, India now appears headed towards gaining another dubious distinction of becoming the lifestyle-related disease capital as well. A study conducted jointly by the All India Institute of Medical Sciences and Max Hospital shows the incidence of hypertension, obesity and heart disease is increasing at an alarming rate, especially in the young, urban population. As such, effective public health measures are urgently needed to promote physical activity.
In addition to sports, yoga needs to be promoted as a non-sectarian wellness initiative. On the occasion of the second International Yoga Day, Prime Minister Narendra Modi has done well to highlight the non-sectarian character of yoga. Emphasizing that yoga was not religious in nature; he asserted that the traditional practice was even meant for atheists. Moreover, he described yoga as an instrument that provided health assurance with zero spending. A mass movement that promotes yoga can be one way of following the dictum that prevention of ill health is better than cure.
The National Cadet Corps is the Indian Military cadet corps and it is open to school and college students on voluntary basis. Now few schools and colleges are continuing with this activity. The cadets have no liability for active military service once they complete their course but it helps in grooming the youth of the country into disciplined and healthy citizens. The Government of India must rethink about reintroducing it in all the schools and colleges on the voluntary basis.
Many more such initiatives need to be facilitated. All these can and should be used to tackle lifestyle diseases especially obesity and diabetes. This in turn can help the country save millions of rupees that are lost to early onset of illnesses among people. But such initiatives cannot become a mass movement if any of it is made mandatory and forcibly pushed down the throats of people, schools or colleges. The challenge of promoting physical activity is as much the responsibility of government, as of the people. And India must take it seriously.
In conclusion, most Indians, who pride themselves on being part of the world’s fasted growing economy, “miss a heartbeat when they read about India’s grossly inadequate healthcare infrastructure”.  Not enough hospital beds (less than nine for 10,000 patients). Not enough doctors (just seven per 10,000 patients). Not enough medicines. Not enough preventive healthcares. Despite some impressive gains, India’s health continues to lag behind that of many of its Asian neighbors. Basic services like water, sanitation and sewage systems at best remained patchy barring some larger towns, and that may be the main cause of communicable diseases.
No doubt, Indians deserves better healthcare. For this, India needs to re-define its vision for healthcare. The above discussions provides broad picture to revamp the existing healthcare system to make it pro people especially pro poor. However, this needs a bigger mindshare of the healthcare planners. The plan must also focus on fixing issues of providing clean safe water. In our zest to build toilets as part of Swacchh Bharat campaign it is essential not to forget that we also need a robust sewage system that works and is built to last. In addition, any plan to revamp the healthcare must rely on appropriate induction of technology. Today, digital technology, electronic health records, wearable sensors make it possible to remotely deliver healthcare and these must be part of the healthcare plan.
As per WHO report, India is fast turning as the world capital of lifestyle diseases, as noted earlier. Just to give a number, there are some 70 million diabetics currently and another 70-80 million who will get it in the next 5 years in India and plenty will not get diagnosed. The abnormal thyroid prevalence in India is over 8 per cent. These are significant numbers that burden human productivity and have an impact on the national economy.
Prime Minister Modi is leading from the front. He is a leader with immense energy and commitments to the people. He must take concrete steps that “create an entitlement for all citizens to equitable, high quality services”. Otherwise it will defeat his development agenda.
In an interview to Times Now on June 27, 2016, PM Modi said: My development parameter is simple: how the poorest of the poor benefit from development. The poor is the central focus”. In this agenda, we think, health and education are intrinsically important, as argued earlier.  A society that does not provide quality universal healthcare and universal primary education is “morally repugnant in this day and age”.
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. Refer at: http://www.fiercepharma.com/regulatory/indian-health-officials-slam-lancet-editor-s-comments.
. Refer article: Patel, et al. 2015. Assuring health coverage for all in India, The Lancet, vol. 386 (10011), p. 2422-2435.
. Jha and Laxminarayan. 2009. Choosing Health: An entitlement for all Indians, Centre for Global Health Research, Toronto.
 . Reddy. 2015. India's Aspirations for Universal Health Coverage,
 Refer article: “Catastrophic Health Expenditure and Poor in India: Health Insurance is the Answer?” by T V Sekher at: http://iussp.org/sites/default/files/event_call_for_papers/T.V%20Sekher-IUSSP%20pdf.pdf
 Refer article: “National Health Policy 2015”, Economic & Political Weekly, Vol. 50, Issue No. 36, 05 Sept, 2015.
 Refer: World Bank, India Malnutrition Report, 2009 at: http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-
 Angus Deaton. 1913. The Great Escape: Health, Wealth, and the Origin of Inequality, Princeton University Press
 Kothari, Devendra. 2014. “Managing Unwanted Fertility in India: Way Forward”, Institute of Economic Growth (ed.): National Rural Health Mission: An Unfinished Agenda, New Delhi: Book Well, pp.25-36.