Healthcare agenda for the Indian government

World Health Organization recognizes health as a human right and the common denominators for ensuring social well-being1. We know that there exists a positive correlation of economic growth with improved health indicators. However, such a trend has not been observed in India despite a high economic growth rate of 7 per cent even during world economic slowdown. For capital to be translated into positive healthcare outcomes policy goals should be clear and healthcare should be given priority in the budget; less than 1 per cent of GDP (Gross Domestic Product) is grossly inadequate2. Health makes an important contribution to economic progress, as healthy populations live longer, are more productive, and save more. This has huge human and economic costs: India is losing more than six per cent of its GDP annually due to premature deaths and preventable illnesses3.

India encapsulates a paradox; its relatively unimpressive performance in healthcare; inability to deliver affordable health services to its over 1.2 billion citizens co-exist alongside biggest generic drugs industry which exports affordable medicine to more than 100 countries and which has earned India the sobriquet of “pharmacy of the world”; also booming healthcare industry and thriving medical tourism. A weak public sector infrastructure includesnon-availability of drugs, lack of advanced laboratory facilities and equipment, a severely constrained health workforce, poorly financed public health system (less than 1.04% of the GDP), along with poor delivery mechanism for health care are the bottlenecks of Indian healthcare system which prevent health system to provide appropriate and affordable care.

India's political and public health leadership has led innovative schemes and translated the best of those into policy, and made substantial contributions for advancing population health. Since the launch of the National Rural Health Mission in 2005, over 157 thousands personnel have been employed to health sector4. The Infant mortality rate (IMR) has declined from 68 to 42 per 1000 live births between 2000 and 2012. The Janani Suraksha Yojana was successful in ensuring delivery of more than 120 to 130 million women in government facilities and more than 600 thousands newborn babies are receiving care in neonatal care nurseries in district hospitals each year4. Polio has been eliminated from the face of the country. This is exciting, but not enough. Each year, more than 40 million people, mostly in rural areas, are impoverished and run into massive debts to access healthcare5. Non-communicable diseases and injuries account for 52 per cent of deaths in India. Burden of non-communicable diseases and resultant mortality is expected to increase6. Therefore, India's healthcare needs radical changes.

India's healthcare challenges and poor health indicators are widely discussed at various public health forums; but rarely acknowledged in political discourse. For the first time in the history of India all the main political parties have prioritized healthcare in their manifestos7. The current government promised radical reforms in healthcare with “National Health Assurance Mission (NHAM)”8. Healthcare must be made a core priority for the next decade, to enable transformation of the healthcare system, while promoting pro-health policies in other sectors. Here, I take this opportunity to illustrate India's public health challenges and the way forward.

Universal Health Coverage (UHC): The UHC in its simplest definition means access to quality, effective and affordable health services for all, without imposing financial burden9. The three greatest challenges being faced by India's healthcare system are accessibility, availability and affordability2. Cumulatively, these lead to very high out-of-pocket (OOP) medical expenses.

The government should institutionalize UHC as a way to remove barriers to good health and expand access to quality, affordable care. In the UHC model, all citizens should be entitled to a comprehensive package of healthcare services, and have access to public health and accredited private facilities for attaining services such as diagnostics, medicine, vaccines or surgeries as an entitlement, without having to pay at the point of use2.

Establishment of National Medical Service Corporation (NMSC): Healthcare access in India is affected with 70:70 paradoxes; 70 per cent of healthcare expenses in India are incurred by people from their pockets, of which 70 per cent is spent on medicines alone, leads to impoverishment and indebtedness. As a result of high OOP payments, 40 million Indians are pushed into poverty each year5. The right to health and universal health coverage cannot be achieved without access to affordable essential drugs on a viable basis. Millions of Indians could access better care if the government decided to procure generic medicines in bulk and distribute them free of cost at public health facilities. The government should constitute NMSC with mandate to procure and provide generic medicine, surgical and suture goods to all public health institutions across the country10. Free distribution of medicines through public systems helps increase’ citizens’ trust in such systems. A centralized public procurement and decentralized distribution of essential medicine model has been successfully implemented in the States of Tamil Nadu and Rajasthan10. This initiative has been shown to lower the cost of medicines and allow free access to generics. This model with some improvements can be implemented in other States also.

More emphasis on evidence based public health policy and health research: Undoubtedly well planned health research plays pivotal role in impressive health outcomes. In India, health research activities do not match with public health priorities, which is necessary for better health outcomes. The generation of evidence for policy needs to be led by State funded and autonomous research funding organizations - such as the National Institutes of Health (NIH) in the United States. Without accurate data, we will not be able to allocate resources appropriately. All the major public health programmes and policies need to be rigorously evaluated to improve health outcomes and equity. With the help of Department of Health Research (DHR) and Indian Council of Medical Research (ICMR), the government should enable an environment for collaborating major research institutes for preparing a plan of action and methods and generating knowledge based health information system to achieve healthcare for all in India11. It should make research initiatives more interactive with policies and implementation of health programmes for making health research more relevant to health system and policy. The government should focus on research capacity building and institutional strengthening for research.

More spending on health: One fundamental reason for poor functioning of health system and ill health indicators is the low level of investment on healthcare. Due to this India is saddled with a high burden of preventable illnesses that traps households in poverty. Public health financing is pivotal to provide financial entitlement in terms of purchase of services so that the out-of-pocket expenditure is taken care of. It is also needed for creating better infrastructure, expansion of health workforce and provision of essential drugs free of cost. In India the public spending on health is around 1.2 per cent of its GDP which is among the lowest in the world. Therefore, the government should increase public spending on health with a minimum of 3 per cent of GDP by 2020, and 4 per cent by 20252. However, increased healthcare financing alone will not suffice unless it is backed by accessible and efficient delivery mechanism. The approach has to take into account a package of services, not piecemeal. The increased spending on health alone is insufficient to improve the health indicators. Development of standard treatment guidelines, prescription audit and quality assurance methods are also needed to improve performance, efficiency, and accountability in the public and private sectors.

Human resource for health: India has a severe shortage of human resources for health. The public health facilities continue to face staff shortage as over 85 per cent specialist doctors, 75 per cent doctors, 80 per cent laboratory technicians, 53 per cent nursing and 52 per cent ANM (auxilary nurse midwife) posts are vacant across States12. Even with increased public funding in healthcare, there would be little or no absorption of these funds in the absence of adequate human resource, hence building the capacity of the health system is important. National Council for Human Resource for Health (NCHRH) should be set up for addressing all issues comprehensively in terms of policy guidance and mechanisms. A comprehensive national policy for human resources is essential to achieve universal health care in India.

Strengthening primary health care: Urban India has four times more doctors and three times more nurses than rural India13. There is a need to strengthen the primary care as a key means to delivering health to all. The government may need to adapt the UK's National Health Services (NHS) model in Indian context for providing universal primary health care through public-private partnership (PPP). Primary health care should be prioritized, since it is the greatest need of the vast majority and, if effectively delivered, will substantially reduce the demand for secondary and tertiary care. At the same time the government should come up with policy for improving the health status of the urban poor by adopting effective, efficient and sustainable strategic intervention approaches. There is a need to carry out reforms in accordance with the WHO framework for strengthening health systems, which includes the following six discrete “building blocks”: (i) service delivery; (ii) health workforce; (iii) information; (iv) medical products and technologies; (v) financing; and (vi) leadership and governance14.

It is important to go beyond merely having doctors and invest in improving the quality of healthcare professionals in India. We need more action on safe drinking water, sanitation, nutrition and clean environment to promote good health. Policies in other sectors, from agriculture to urban development must become responsive to public health concerns. We do not need to look far for inspiration or to believe that this dream can be realised. Kerala (with its strong action on social determinants) and Tamil Nadu (with its efficient public health system) are role models within India.

India's public health has failed both because of poor public financing and a weak health system, which adversely impact each other. There is no alternative but to strengthen the public health system and above mentioned areas should form the core national health agenda to ensure access, delivery, quality and affordability. A healthy India is also crucial for the country to sustain economic prosperity. With political will, backed by administrative efficiency, professional skill, India's health can be transformed over the next decade.