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“The health of people is the foundation upon which all their happiness and all their powers as a state depend”

 – Benjamin Disraeli, Former British Prime Minister.

The prosperity of a nation can be measured by its population which is healthy. A nation thrives if its population lives healthy. Healthcare has a great emphasis in India since the times of Charaka[1] and Sushruta[2]. Ayurveda - traditional healthcare system of India - is considered equivalent to vedas.

In India, health had been a neglected investment during the British era. In 1943, Government of India appointed a committee headed by Joseph Bhore- only such committee depicting healthcare system in British India- severely criticised the healthcare in India when it made dramatic comparisons between the values of health statistics in England and in India. And post-independence, various social sectors including health received meagre resources and were highly neglected. It was only in 1983 India officially adopted the National Health Policy (NHP).

India suffers from major health and healthcare crises. According to the Global Burden of Disease study published in Lancet in 2016, India ranked 145th among 195 countries in terms of quality and accessibility of healthcare.  With Maternal Mortality Rate (MMR) at 130 and Neonatal Mortality Rate (NMR) at 24, India has still a long way to go in reducing its MMR and NMR. According to the World Health Organisation (WHO) statistics of 2011, India is the highest TB burden country in the world with 2.2 million cases. India has 2.4 million people living with HIV/AIDS and is the third largest HIV epidemic in the world.  Almost every state of India remains vulnerable to vector-borne diseases. For instance, according to National Health Profile 2018, dengue outbreaks have continued since the 1950s but the severity of disease has increased in the last two decades. India is also witnessing an epidemiological and demographic transition of disease burden associated with the lifestyle changes and ageing population respectively. According to WHO estimates, nearly 61% of all deaths in India are now attributable to non-communicable diseases, including heart disease, cancer and diabetes. There is also a rise in incidences of pollution-related and climate-change related diseases like lung cancer and skin cancer. And nearly one-third of its population suffers from hidden hunger, malnutrition, stunting, underweight and wasting. One of the neglected and stigmatised areas is Mental Health as one in every five Indians suffers from depression in their lifetime. Further, a problem unique to India is incidences of disease correlated to social hierarchy in terms of caste, community, gender, and occupation.

Article 21 of the Indian Constitution recognises “Right to Life” which subsumes “Right to Health for All”. Article 47 of the Indian Constitution regards improvement of public health as State’s primary responsibility. India’s major hindrance in healthcare is its focus on clinical and curative measures rather than preventive measures. Early intervention can prevent expensive healthcare problems in practice. This is especially true because India carries a significant proportion of preventable disease burden. The state should provide accessible, affordable, assured health services and should prevent the spread of disease and promote the wellbeing of communities. The public sector has performed poorly in this regard. For instance, according to a 2017 study published in Social Science Medicine, Rashtriya Swasthya Bima Yojana (RSBY) has not led to any reduction in out-of-pocket expenditure by its 150 million beneficiaries. Further, public healthcare centres suffer from a shortage of funds, drugs, equipment, staff, water supply, irregular electricity, poor working conditions, and poor hygiene and are over-crowded.

However, Government has shown remarkable commitment. India has successfully eliminated polio and smallpox. Studies indicate a rise in nutritional level among children due to Mid-day meals. The National Rural Health Mission has seen an increase in institutional deliveries, which has been successful in arresting maternal and infant mortality considerably.

Meanwhile, the private sector has added significant capacity. According to National Family Health Survey (NFHS 3), the private medical health sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. However, NFHS 4 revealed a rise in caesarean deliveries and unethical practices in the private facilities. There was also a case recently, where a private facility billed Rs 16 lakhs for dengue treatment. 

Further, passing of Mental Health Act 2017 envisaged a justiciable right to mental healthcare. The government also capped the prices of the stents. AMRIT Kendras and Jan Aushadhi Kendras have been started to provide drugs at affordable rates. Mission Indradhanush is launched to immunise children and pregnant women against vaccine-preventable diseases. With the boost to Yoga and AYUSH initiatives, health is being recognised as comprehensive well-being. These initiatives are in line with the Sustainable Development Goal 3, ensuring healthy lives and promoting the well-being of all, at all ages.

However, India spends just 1.4% of its GDP on healthcare. NHP 2017 pledged to boost healthcare spending up to 2.5% of GDP by 2025. NHP emphasized ‘strategic purchasing’ of private care which would bridge the critical gaps in public health and help create demand in the private healthcare sector in alignment with public health goals. It is clear that the role of State cannot be undermined and the potential of the private sector can be effectively tapped.

Since poverty and health are closely related, widespread insurance coverage could mitigate out-of-pocket expenditure. The government has rightly recognised this and launched Ayushman Bharath –National Health Protection Mission (AB-NHPM). AB-NHPM aims to provide healthcare facilities to over 10 crore families covering rural and urban poor and is the biggest government-sponsored healthcare scheme in the world. The scheme offers insurance cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization. In its first 100 days more than 6 lakh patients have been provided hospital treatment. There are substantial concerns on financing and sustainability of a project of this size. There are also possibilities of emergence of conflict of interests with the insurers, hospitals and patient claims. However, there is hope. A poor person can assert rights and access to healthcare with this initiative.

Thailand implemented Universal Coverage Scheme and turned the insured population rate from 25% in 2001 to almost 100% today. With the well-researched system and dedicated leadership, Thailand effectively lightened the financial burden of families on healthcare. These learnings from Thailand healthcare could be utilised.             

With the penetration of internet, start-ups have a great scope in this space for innovations. The private sector, although needs regulation, can be made an effective partner as a major healthcare provider. The State can play a major role in inter-sectoral coordination. The emphasis and focus should continue to be on strengthening Primary Health Centres. Staffs should be motivated and incentivised. Low-cost innovations like Bike Ambulance should be promoted. Still, the importance of Information, Education and Communication (IEC) workshops cannot be undermined, especially in rural areas. Technologies like the Internet of Medical Things, Robotic Surgery, Health Portal databases and Telemedicine could be effectively leveraged also ensuring cost cut-downs, effective resource allocation and quality.

With an effective State role, private participation and community intervention in defining and implementing health agendas, universal access, coverage, and equity can be achieved. With commitment from all stakeholders, healthcare in India can be transformed creating truly empowered community and a healthier India.

[1] Charaka authored Charaka Samhita, in the second century AD. It is a book on Indian Medicine, contains a description of various types of diseases including fever, leprosy, hysteria and tuberculosis. It also contains the description of plants which could be used as medicines.

[2] Sushruta authored Sushruta Samhita, is a treatise on Indian Medicine and Surgery. The work contains the description of the use of more than a hundred surgical instruments used in operations. The treatise also deals with dietary regimen and hygiene for well-being.

References:

Bader, S (2018, September 4). In India, can universal health care become a reality? Devex. Retrieved from:  https://www.devex.com/news/in-india-can-universal-health-care-become-a-reality-92650

Duggal, R (2006, August) Evolution of Health Policy in India. CEHAT

George, S (2016, May 24). What Thailand can teach the world about universal healthcare. The Guardian. Retrieved from: https://www.theguardian.com/health-revolution/2016/may/24/thailand-universal-healthcare-ucs-patients-government-political

Lakshminarayanan, S. (2011, April). Role of government in public health: Current scenario in India and future scope. Journal of Family and Community Medicine, 18(1), 26-30. doi:10.4103/1319-1683.78635 

Mehta, K (2018, August 2). The challenges before Ayushman Bharat Scheme. Livemint. Retrieved from: https://www.livemint.com/Money/cTLp5La8xA6P8PmeXiMDmL/The-challenges-before-Ayushman-Bharat-Scheme.html

Image Credit: iamwire

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Written By Harish Nalawade

I am an Engineer, observer, and a thinker with a firm belief in research-driven and outcome-oriented approaches for solving the problems in our society.

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