India: the state of healthcare

 

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

 “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.” 

Dr. Richard Charles Horton (2018)

The Lancet's editor-in-chief

 Healthcare has the potential to lead to economic growth and to alleviate poverty. It is because health is a relative state in which one is able to function well physically, mentally, socially, and spiritually in order to express the full range of one’s unique potentialities within the environment in which he/she is living. In other words, “health is primarily a measure of each person’s ability to do and become what she wants to become.”   It is, therefore, an important component of human capital formation responsible for the higher level of productivity. It can enhance workers’ productivity by increasing their physical capacities, such as strength and endurance, as well as their mental capacities, such as cognitive functioning and reasoning ability.

By the dawn of the 21^st century, non-communicable diseases are sweeping the entire globe, with an increasing trend in developing countries like India where, the transition imposes more constraints to deal with the double burden of infective (communicable) and non-infective (non-communicable) diseases in a poor environment characterised by ill-public health systems. That may be the reason, why 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”.[1]

 

One of the serious negative impacts of this situation will be the slow formation of human capital. Available literature reveals a positive relationship between health and productivity for both unskilled and skilled workers, and evidence of this link is increasing at the microeconomic level.

 

So it is generally said that health is wealth.  To be healthy and fit one needs to eat properly and live in a hygienic or clean environment. Because living in polluted and dirty area impacts negatively on health. In addition, availability of basic health services is fundamental in improving the health outcomes.   It means health in a broader sense includes not only health services but also sanitation. A growing body of research has documented the positive impact of health and sanitation on earnings and economic growth by raising the productivity. 

Although India’s productivity improvements are impressive, the process of catch-up with other developing/ developed nations still has a long way to go. India's labour productivity is about 40 per cent of that of China. In fact, India recorded one of the lowest productivity in the world. There are many reasons behind this slow growth in the labour productivity including a sluggish progress in achieving the mission of “Health for All”.

The paper discusses a variety of mechanisms through which the vision of ‘Health for All’ (HFA) or Universal Health Care (UHC) could be achieved within a decade. The positive health outcomes ultimately contribute to better educational outcomes and a more productive and higher-skilled labor force. India, therefore, must convert its young population to a competitive advantage.

 

Emerging health scenario: India’s current state of health is appalling as brought out by the coronavirus pandemic and the lockdown it triggered. The data released by the MoHFW indicates that it had severe impact on routine health care services. Several national goals, including the programme to treat TB, malaria and non-communicable diseases such as heart diseases, diabetes and cancer, has suffered a severe setback.

 

The ministry figures have revealed the enormous price incurred in healthcare deficits by non-COVID patients between April and June, 2020 compared to the same period last year. Immunisation dropped 27 per cent, institutional deliveries 28 per cent, major surgeries fell 60 per cent, outpatient treatment for heart ailments and cancer by over 70 per cent, and 51 per cent  fewer acute cardiac emergencies were performed. Treatment for ailments like tuberculosis, diabetes and asthma, screening of newborns for birth defects etc were also badly affected. 

 

It appears that the Indian healthcare structure is not geared up enough to face the unexpected calamities, which are going to be a frequent phenomenon in coming times due to climate change and arising poverty. More than half of the 1.4 billion people are poor and the income inequality is widening.

 The pollution is the leading environmental cause of death in India. The US-based Health Effect Institute (HEI) paints a grim picture for India. Overall long-term exposure to outdoor and household air pollution contributed to over 1.67 million annual deaths from stroke, heart attack, diabetes, lung cancer, chronic lung diseases, and neonatal diseases in India in 2019. The pollution also contributed to the deaths of more than 1, 16,000 Indian infants in their first month of life last year. More than half of these deaths were related with outdoor PM2.5. Air pollution deaths in India are the highest among the South Asian countries – it is 9 times higher than neighbouring Bangladesh and 8 times higher than Pakistan.

In addition, India faces a double curse on the disease front: lifestyle diseases that are the bane of the rich world, as well as the traditional communicable diseases of the developing world, as reported by the study entitled: Health of the Nation’s States: India State-Level Disease Burden.[2]  The key metric used for calculating the burden of diseases is disability-adjusted life years (DALYs), which is the sum of the number of years of life lost due to premature death and a weighted measure of the years lived with disability due to a disease or injury.

Of the total disease burden in India measured as DALYs, 61 per cent was due to communicable, maternal, neonatal, and nutritional diseases (termed infectious and associated diseases in this summary for simplicity) in 1990, which dropped to 28 per cent in 2016. There was a corresponding increase in the contribution of non-communicable diseases from 30 per cent of the total disease burden in 1990 to 62 per cent in 2016, and of injuries including suicides from 9 per cent to 10 per cent.

While the burden of most infectious and associated diseases has reduced in India from 1990 to 2016, five of the ten individual leading causes of disease burden in India in 2016 still belonged to this group: diarrheal-diseases, lower respiratory infections, iron-deficiency anemia, preterm birth complications, and tuberculosis. According to the National Health Profile 2019, over 50 per cent of all deaths due to communicable diseases in 2018 were because of respiratory diseases and pneumonia. As a result, deaths from communicable diseases in India are much higher than the global average, latest data from the Global Burden of Disease Study shows.

 

The burden caused by these conditions generally continues to be much higher in the eight socioeconomically less developed states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, referred to as the Empowered Action Group (EAG) states  than in the other states, but there are  notable variations between the states within these groups as well.

The contribution of most of the major non-communicable disease groups to the total disease burden has increased all over India since 1990, including cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, cancers, musculoskeletal disorders, and chronic kidney disease, having greater impact on productivity. Among the leading non-communicable diseases, the largest disease burden or DALY rate increase from 1990 to 2016 was observed for diabetes, at 80 per cent, and ischaemic heart disease, at 34 per cent.

The contribution of injuries, which includes road injuries, suicides and non-fatal outcomes of self-harm, to the total disease burden has increased in most states since 1990. The highest proportion of disease burden due to injuries is in young adults. 

In sum, one can draw the conclusion that India at present faces a combination of communicable diseases and non-communicable, with the burden of chronic diseases has exceeded that of communicable diseases. Projections nevertheless indicate that communicable diseases will still occupy a critically important position up to 2030 or even 2040. 

India's position in the middle of the transition from a poor, healthcare-deficient country to an advanced country is brought out starkly when compared with examples from other countries. In Niger, one of the poorest countries in the world, with a per capita gross domestic product less than one-fifth of India's, eight of the top ten causes of death are communicable diseases. At the other extreme, Norway, with per capita gross domestic product over ten times that of India, has just one communicable disease — lower respiratory tract infections — among its top ten, with the other nine being non-communicable diseases. 

China, which started off from conditions similar to India, has moved much further towards the advanced end of the transition. It too has only one infectious disease among its top ten causes of death. 

In conclusion, while the disease burden rate in India has improved since 1990, it was 72 per cent higher per person than in Sri Lanka or China in 2017. It means India has failed to achieve in healthcare goals, badly lagging behind China, Sri Lanka and even Bangladesh in terms of accessibility and quality. 

To put things in perspective, the Global Burden of Disease (GBD) study published in the Lancet said that “newborns in India have a lesser chance of survival than babies born in Afghanistan and Somalia”.

 

In the GBD rankings for healthcare access and quality (HAQ), India has fallen 11 places as compared to last year, and now ranked 154 out of 195 countries in 2017, far behind its neighbours like China (48), Sri Lanka (71), Bangladesh (133), and Bhutan (134). In 2016, India was ranked 143 among 188 countries. 

The preceding discussion underline the urgent need to improve both access to and quality of health care across service areas and for all populations; otherwise, health systems could face widening gaps between the health services they provide and the disease burden experienced by local communities. Moreover, our policymakers have to mark that why ‘one size fits all’ doesn’t work in health and education. 

What does India need to do to create a vibrant, dynamic and progressive 21st century public health system, as will be discussed t in the next post?

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[1] Refer at: http://timesofindia.indiatimes.com/india/Brtish-medical-journal-Lancet-to-take-Modi-to-task-for-ignoring-health-sector/articleshow/49484703.cms. 

[2] Health of the Nation's States - The India State-level Disease Burden Initiative. New Delhi, India: ICMR, PHFI, and IHME; 2017.