Healthcare Regulation in India; from Medical Council of India 1933 to National Medical Commission 2017, problems, pitfalls and progress - a critical analysis of past and present along with recommendations to Parliamentary Standing Committee for a future with better checks and balances. By Dr Jagadish J Hiremut

Regulatory oversight in Healthcare:

Regulation of healthcare sector and its professionals has become increasingly important over past few decades. Regulation in healthcare, ensures compliance to set standards of healthcare for patients benefit and regulatory oversight is especially more important to healthcare administration as it carries the responsibility of safety in public health.

Conforming to set standards in training and practice of medicine ensures that, correct procedures and requisite level of care to patients are met in a transparent process  ². This is essential from patient care point of view and also from cost saving perspective for public healthcare bodies and authorities concerned (Due to our federal structure, states carry burden of implementation and execution in healthcare while central government is more involved in planning, policy making and regulation). 

Recommendations for regulation in Medical education and Healthcare to be made more pervasive and improved than it is today, stems from fundamental concerns due to failure of Medical Council of India in adapting to changing times and nature of healthcare delivery, consequently rendering itself inadequate and failing in its job ^{6, 7}. This has been discussed regularly in meetings of Parliamentary standing committees on healthcare almost on a permanent basis ^{6. 7}. Key stake holders (Government, Doctors, Administrators, Assorted Health workers, Medical colleges, Patients, and now Corporate hospital business owners etc..) and public in general; acknowledge that regulatory oversight is needed when factors as essential as life, health and medical education are involved; including myself, albeit suspicious of heavy-handed government bureaucracy see public interest in some form of external supervision in Healthcare. Policy debates, for most part, swirl not around whether oversight should exist or not but, instead, around the way it should be structured. Public Healthcare apparatus and it’s regulatory oversight today has evolved from an amalgamation of professional, social, economical, organizational and political factors ¹

Aim of regulatory oversight is not just standardization of performance and uniform end points, but also provision of assurance to stakeholders that Healthcare services meet certain standards and also to establish a reasonably competent mechanism for holding organisations and individuals involved in healthcare to account ⁴. Work of regulators includes that of setting standards, detection of wrongs/wrongdoings, measuring/ monitoring performance and enforcement of the rule. There are two basic models of regulation used by regulators, that of deterrence and compliance, however a move towards an intermediate area of responsive or smart regulation has been emerging in recent years in Healthcare for better results ³. In practical terms, model of deterrence can be viewed as a hard law approach prevalent in United States ^{2, 3}.  A divergent “model of compliance” more akin to a soft law approach has been followed by Europe, England and India. Recent regulatory reforms of healthcare systems in both United States and the United Kingdom, show an interesting move by regulatory bodies towards a middle ground or hybrid model of regulation which combines the best of both the deterrence and compliance models  ^{2. 3}.

Contemporary evolution of healthcare regulation developing across globe (not only US,UK, EU or India) in last two decades has brought  some very positive results with better defined end points or goals to regulatory oversight in Healthcare. India’s regnant approach (precipitated by abject failure of MCI in its mandate) to regulatory reform in its healthcare sector is not only following  the path taken by England (and to some extent US)closely but it is also points to the fact that, we are moving towards a more responsive regulatory regime, despite differences in our respective healthcare systems (UK provides UHC to its citizens; whereas US spends almost $ 10000/- per capita on its healthcare ¹¹). What we are witnessing now as changes in healthcare regulation in the form of National Medical Commission, is an evolving  global phenomenon in almost all countries where mature governments understand importance of regulation of medical education and practice to public health and it is not  unique to India. Consequently, it is pertinent for the stakeholders to play their rightful part to establish an efficient regulatory system which is goal oriented, evolves according to changing needs of our citizens and brings the nation’s healthcare from deep depths of 3^rd world status to a pioneering 1^st world status.

History and Evolution of Medical regulation in India:

Formation of British government in India after failed first war of independence in 1847 led to initiation of several services including Indian Medical Service. Central and Provincial Medical Services, and Subordinate Medical Services were initiated to provide medical services and improve public health. A public health commissioner and a statistical officer were also appointed to Government of India ¹³. In 1869, medical departments in the three presidencies were amalgamated into a (Pan) Indian Medical Service. A competitive examination was conducted in London to recruit people into Indian Medical Service. European officers of Indian Medical Service headed military and civil medical operations in the three presidencies. However, they needed trained assistants and supporting staff such as apothecaries, compounders, and dressers in their work. European doctors came with a large financial cost, this prompted the British government to look towards establishing a system of medical education in India to recruit local staff ^{14, 15, 21}.

Whilst, evolution of medical education and regulatory oversight in healthcare in India, can be discussed at great length, it is not the scope of this article - it suffices here to say that, formation of Indian medical service and  starting of medical college in Calcutta, then Bombay followed by Madras gave rise to a cadre of doctors called “Native Doctors” ^{15, 21} or the colloquial sobriquet ‘Brown Sahibs’, which led to formation of a Register of practitioners was probably the first baby step in development of regulatory apparatus for medical practice in India. Even so, the medical register of 1877 had a list of 8000 doctors, among them only 450 were trained in modern medicine or allopathy ¹⁶ and rest were practitioners of Indic systems of medicine. This intermingling cauldron of several systems of medicine (Modern medicine, Ayurveda, Unani, Siddhar etc) in British India, did not continue for long, the very discriminatory Madras Medical Registration act of 1914 stopped registration of doctors practicing all forms of indigenous or Indic medicine ¹⁷. Practitioners of Indic systems of medicine, who served about ninety percent of people of the land of that time, were reduced to untouchables of the profession by allopathic practitioners who considered themselves as ‘Seraph-im Illuminati’ of the day in Healthcare ¹⁸. This Colonial yoke of state sponsored discrimination against Indic systems of medicine and native system doctors continues even today after 70 years of independence as allopathy continues to be accorded the status of official state sponsored healthcare system by government of India.

The bright spots for modern medicine during colonial times were the initiation of public health measures, vaccination, and elevation of tropical diseases to a special subject/department of studies. The state took responsibility for sanitation and hygiene. Collection of vital statistics was initiated and a number of epidemiological and research studies were conducted on cholera, plague, malaria, tuberculosis, and leprosy leading to better outcomes in management ¹⁹.

The act no XXVII of 1933 passed by British parliament ²⁰, led to constitution of Medical Council of India, through this act section 2(d) modern medicine was accorded the status of ‘official medicine’, section 2(g) recognized only those educated in modern medicine as practitioners of medicine in India and section 2(f) allowed licencing and entry of names in the provincial  medical practitioners register only to those trained in modern medicine. By this Indian Medical council Act of 1933 of British parliament; regulation of Medical education and it’s practice became monopoly of Medical Council of India and thus even today, the archetype ‘Brown Sahibs’ or allopathic practitioners continue to be inheritors of this usurped legacy.

I invite the readers of this article to indulge in reading the original Indian Medical Council Act of 1933 pages 161 to 171 to understand two issues ²⁰: (no 20 in reference section below)

i)                How Indic systems of medicine was kept out of Indian Healthcare by a British act  and understand, to analyse why Indian state continues to sponsor the same to this day.

ii)             How nothing has changed in Medical Council of India since its formation in 1933, the thought process behind it, it’s modus operandi, its constitution, it’s composition, it’s discrimination of Indic systems of medicine etc... Not surprisingly even the medical education methodology and medical practice regulation  have not changed to suit the changing needs of independent India, even after 70 years of independence.

The questions which the stakeholders and especially the government, should answer is “Why Government of India continues to practice rules and regulations which were deemed suitable to India as a British province, even after 70 years of independence?”. Are will still a British province?

Subsequent Indian Medical Council Act of 1956 which came into being after repeal of IMC Act 1933 did not change much with regards to basic structure and function of regulatory apparatus of medical education and practice. If anything, it further strengthened the hold of practitioners of allopathy (the Brown Sahibs) on our Public healthcare apparatus converting it into a even stronger monopoly. Successive governments brought in amendments several times in 1958, 1964,1993, 2001, 2005, 2010, 2012 and 2013, nevertheless, the basic monopolistic structure of MCI remains unchallenged. Pluralistic Indic systems of medicine continue to be neglected by the state completely, as if they are a pseudoscience.

Medical Council of India after 1956 Indian Medical Council Act ²²:

This act, to be fair provided a solid foundation for development of post graduate medical sciences in first two decades of its enactment. Notwithstanding the same, by early 1990s regulation in medical education and practice by a group of elected representatives in MCI, had given way to lobbying and quid pro quo for permissions given and inadequacies spared (by the MCI as a regulator)in private medical colleges and sometimes even in sate run government medical colleges too. MCI by year 2000 had grown completely monopolistic and all powerful in its control over the most sought after medical education and practice regulation in India. Entry of unscrupulous Ketan Desai in 2001 as President of MCI through electoral process destroyed its sanctity as regulatory powers of MCI were used as a bait and bargaining tool to collect bribes converting MCI into a rent seeking body. Analysis of healthcare regulators globally during the same period demonstrates that; elections as a means to appoint regulators to medical education and practice had fallen out of favor and abandoned in all countries ⁶. Ketan Desai a manipulator par excellence oversaw a 10 year bull run of corruption as president of MCI. He was finally arrested by CBI after multiple complaints in April 2010, caught red handed accepting bribe, actually exposes that, the permissible level of corruption index was breached by him in an era of corruption and scams in India. If Lalit Modi and Indian Premier League scandal ever needed a competitor in sheer audacity of its main player, India’s medical establishment had one to offer in the form of Ketan Desai. While IPL was about game and entertainment, Desai and his coterie of elected members of MCI oversaw destruction of this institution involved in regulation of medical education and practice beyond repair. A dedicated chapter on corruption in MCI (chapter XII) in the 92^nd parliamentary standing committee report tabled in RS has recorded the unqualified admission by MCI president that there was “corruption in sanctioning of medical colleges or increasing or decreasing medical seats” ^{6, 7}, should be enough for government of India to repeal MCI and supersede it with an ad hoc committee until a fresh better start with checks and balances takes over.

Above facts have been in public domain for some time now and have been reported, analysed, reviewed, commented upon, Op-eds written, also extensively debated and discussed by: the parliamentary standing committees on health and family welfare, Ranjit Roy Chaudhary committee, Niti Ayog Vice President Arvind Panagaria led committee on IMC act 1956 and finally the oversight committee set up by the Supreme Court of India. Those who want to know more can go through the above committee reports from reference section below. I will relegate myself to expose the stark failure of MCI to fulfill its mandate as corruption discussed above  and incompetence discussed below are two separate issues and MCI was plagued by both.

MCI as regulator of medical education in India has repeatedly failed on all its mandates over the decades. Deteriorating quality of medical education can be assessed by the fact that a fresh medical graduate today is not competent enough to manage something as simple, as a straight forward, uncomplicated normal labour and other similar common issues he might face as an independent practitioner. Less said about the quality of post graduates the better; as I do not want people to lose faith completely in the system. Selection of most students in private institutions is seldom on merit thereby reducing overall quality of people entering medical field to become doctors. Standards of education in both undergraduate and postgraduate categories leave a lot to be desired. Under MCI, medical education in India became pro affluent, class conscious, condescending, deficient, sub-standard and yet an aristocratic elitist hubris. In addition to this, required number of graduates to reach stated goal of doctor population ratio of 1:1000 was unmet; the current ratio is 1:1800 ²³. Criminal activities within the MCI ⁵ and others in medical colleges like ghost faculty ^{24, 25} which ended up in CBI arresting few doctors and deans of medical college’s shows how disgraced and immoral medical education and its regulator MCI have become.

MCI as regulator of medical practice and ethics is an outright failure is an understatement. Even under watchful eyes of the oversight committee set up by Supreme Court you can notice that most of the members of MCI come from corporate hospital practice without any representation for public healthcare intellectuals and patient rights groups. Medical practice regulations and policy are being ghost written by council members and elected members of MCI who come from cheesy corporate practice background, destroying the “social calling” which formed the very core for many of us to take up medical practice as a vocation. Corporate hospitals today are nothing but profiteering businesses run by MBAs and business leaders masquerading as doctors with zero social responsibility, thriving on business of scale and/or referral fees and cut practice (with marketing department budgets bigger than the overall salaries they pay to doctors and nurses put together). Doctors in Corporate hospitals have been reduced to treasury gatekeepers and the bigger income they create for hospital, the better their remuneration arrangement has killed the very spirit of medical practice as a vocation and its code of ethics. Imagine regulations to practice under direct control of these unscrupulous corporate business leaders (not doctors anymore), MCI today has the dubious distinction of having precipitated and brought to pass that dreaded circumstance in our everyday life and practice of medicine.

Out of 40 disciplines in modern medicine, cardiologists, cardiac surgeons, general surgeons and general medicine practitioners from corporate hospitals get maximum representation. It is as if other disciplines and academicians are non-existent or are considered incapable of contribution towards regulation of medical profession by MCI. Cut-practice or referral fee based practice has reached such alarming criminal proportions under MCI that, there are actual books written on it. Criminalisation of medical practice in India has been reported in many medical journals including international journals of repute like BMJ and Lancet. Government should address this menace separately by enacting a law criminalizing the same with severe punitive measures like fine and jail term. In addition to above issues, dispute resolution by MCI, with regards to complaints of medical negligence lacks credibility, as we rarely see negligent doctors punished by MCI; apparently shielding bad or incompetent brother doctors from accountability appears to be the norm. As in so many spheres, concentrated monopoly of power is the underlying problem, and safest remedy is to abolish the MCI, form ad hoc committee to take over functioning and allow bodies like National board of Examination to assist while a better system is put in place, notwithstanding current status of NMC bill in PSC. According to me and many doctors amenable to reason, there is no reason for a corrupt and incompetent MCI to stay in any capacity.

Indian Medical Association (IMA) and the guild mentality:

As an active member of IMA, I write this with a lot of pain, IMA lost a great opportunity to be the bellwether and watch dog to MCI and save it from the clutches of corrupt and inefficient people. The last few years of functioning of MCI has taken its toll on the IMA. Acceptance that self-regulation has failed leading to newer legislation taking away the monopoly enjoyed by medical establishment constituting MCI and IMA had over medical education and practice is a sobering reality. Notwithstanding this, the fact is IMA unlike MCI is here to stay and it should be a guiding force to the newer regulatory body formed by NMC bill rather than behave like a guild. The NMC bill has been referred to a parliamentary standing committee currently; there will a tug of war between champions of self-regulation and proponents of state controlled regulation in healthcare. Circumstances demand that, IMA as a professional body should adhere to the social code of ethics and become an independent body capable of standing in judgement to guide the future of our profession in India. The authority of medical profession rests partly on science and partly on public respect for tradition of medicine as a vocation. Today, the challenge of IMA is to discover how best to rebuild this spirit and to ensure doctors are not treasury gatekeepers in corporate hospitals but are actually custodians of patient’s well-being. History will stand in judgement of office bearers of IMA during this period, to distinguish whether IMA stuck by the code of ethics in favour of the patients or behaved like a guild trying to safeguard the monopoly of medical establishment.

The National Medical Commission Bill ²⁶:

A lot has already been said and written in articles, blogs, Op-eds and prime time shows on “Newstainment” channels about the NMC bill which is set to replace the corrupt, archaic, incompetent, feudalistic and British raj residuum MCI.

For starters, the best thing about NMC bill is that, it is disbanding the MCI, personally as a practicing doctor inside the system; I was even okay with Hammurabi’s code, as long as MCI was disbanded and a fresh start to proper regulation of nation’s medical education and healthcare was made. Here below, I relegate myself to critically analyzing NMC with suggestions for improvement to parliamentary standing committee (PSC) to which it has been referred to now, I hope PSC considers my suggestions made as a public health intellectual and policy expert. For those interested in contents of the bill I refer them to reference number 26 in reference section ²⁶.

Monopolistic and discretionary powers in hands of few has always led to corruption, even a professional body of highly educated practitioners of medicine have fallen prey to corruption as in the case of MCI. NMC should not fall into the same trap which, apparently it is falling into now in current format. Let us begin with the composition of NMC;

In Current form, NMC Bill proposes a 25-member all powerful “Commission” appointed by Central Government, a Chairperson, a Member Secretary, 12 ex-officio members and 11 part time members ²⁶. Of these members, 20 will be appointed by a search committee chaired by Cabinet Secretary. Nomination will be done for 12 ex-officio and 6 part-time members. Three of these will be from disciplines such as management, law, medical ethics, health research, consumer or patient rights advocacy, science and technology, and economics. Only five will be elected by registered medical practitioners from among themselves from regional constituencies ²⁶.

Search and selection committee for the above appointments will be headed by cabinet secretary. Commission apart from overseeing board functions shall also be the appellate authority with respect decisions of the boards ²⁶.

Above composition of the commission and the brute power, central government controlled bureaucracy wields in it, is unacceptable. According to above structure of NMC; the health and family welfare ministry of central government has absolute control over NMC and consequently on medical education and practice, converting it from earlier self-regulated monopoly of MCI to a State controlled monopoly of NMC now. NMC in current form looks like a subservient department of this ministry. Politicians with influence on this ministry and those who own private medical colleges can change policy to suit their needs. We may have just moved from frying pan to fire unless change in the structure and composition of NMC made to bring in checks and balances in the organisation.

Author’s recommendation: Addition of members who are independent of influence of central government is a must and there should be an acceptable balance of government nominated members and independent members of NMC. In current form, all are directly or indirectly serving the central government.

In matters as important as regulation of medical education and practice which affects nation’s well-being directly, states have no say in current form of NMC. It is state councils which do all the hard work on the ground and it is states which run most number of medical colleges and universities. Giving adequate representation to states is a federal obligation. NMC in present form is failure of federal structure at the very least. Leaving NMC under total control of central government and its bureaucrats and politicians is a recipe made for disaster.

Author’s recommendation: Every state must be represented in the commission at least once in 2 years, in current form it happens only once in 20 years. This will increase the number of members in the council from current 5 to 15; it also brings in the federal nature of our governance to the fore as the individual states inputs will contribute for nation’s well-being.

MCI in its presentation before the NITI ayog Vice President Arvind Panagariya led committee, had asked for expanding representation of doctors in MCI by 1 person for every 20,000 practicing doctors ⁶. In current composition of the commission, practicing doctors are represented by only 5 members in the commission. This is brazen injustice to the nearly 8 lakh practitioners of the country. It appears as if committees which wrote the structure of the commission starting from Ranjit Roy Chaudhary led committee to the NITI ayog VP Aravind Panagaria led committee and experts who contributed to the same have a prejudice against IMA and practicing doctors of the country.

Author’s recommendation: Every 50,000 (fifty thousand) practicing doctors must have a member representing them on the commission. They can be selected by lottery from the medical registers of the state. That will be an addition of 11 members to the commission from the current 5, taking the total of independent practicing doctor members of the commission to 16. This will bring the acclaimed “checks and balances” system into the organisation of the commission. I strongly recommend a fool proof method of selection by lottery to be done using a computer algorithm to select the practicing doctor member here. Involving the biggest voluntary membership organisation of doctors the IMA is the key to make the doctors feel their contribution is valued, in this change, from monopolistic MCI to a pluralistic NMC. This will remove the elitist nature of the commission and also strengthen the element of self-driven regulation most needed in practice.

Although central government wields more power in the commission which it should, increasing state representation and representation of practicing doctors who are not nominated by central or state governments, will bring more stability to the organisation and structure of the commission.

The Medical advisory council is a joke with only advisory role and no powers to enforce anything at all. The PSC should work a mechanism to make it more productive than what it is proposed now.

The 4 autonomous boards: (a) the Under-Graduate Medical Education Board, (b) the Post-Graduate Medical Education Board, (c) the Medical Assessment and Rating Board, and (d) the Ethics and Medical Registration Board are by their very structure, made elitist, with ample room for owners of private medical colleges and corporate hospitals to manipulate as insiders. Again, the checks and balances approach, needed for fool proof functioning of these boards are missing. Selection criteria are such that; the chairmen of the boards and its members can be filled with cronies of political masters from corporate hospitals and private medical colleges and justified too.

Author’s recommendation: Addition of two independent members into each of the boards (as an additional responsibility) from among the independent 16 practicing doctors in the commission will change the elitist nature of these boards. The decision making has be on unanimous basis and not majority. This will most certainly address the need for checks and balances in decision making of these boards.

The equating of post graduate degrees from medical institutions and universities with DNB from NBE is unacceptable clause 36(2) ²⁶. Norms laid by MCI for conventional post-graduation with regular full time teachers and professors is definitely superior to the DNB degree got from corporate hospital training or training in nursing homes from full time practitioners and part time teachers. If an independent body inspects this arrangement, it will conclude that DNB students are abused and exploited by corporate hospitals and nursing homes (which are approved for the course) as cheap labour. These students join DNB because they did not get post graduate seat in conventional teaching institutions and it is seldom their first choice. Ideally, NMC must take steps to increase number of PG seats available for post-graduation or bring in stringent teaching and training norms to elevate DNB training to that of conventional PG training. Equating DNB postgraduate presently with conventionally trained postgraduate is gross injustice to medical colleges, post graduate institutions and universities. Such a step will eventually lead to demise of conventional training and thereby research too, as there is no added incentive for full time professors teaching students their trade and post graduate training will become a casualty of corporate greed. Will NMC and Government of India equate the training of postgraduate from AIIMS/PGI to DNB training? If yes, why spend so much money on training institutions? GOI can as well build corporate hospitals and nursing homes instead.

Author’s recommendation: Confirming with MCI standards, DNB postgraduate must complete 2 years of post DNB status to be considered equal to postgraduate degree from conventional medical college/university. Commission has to appreciate the difference in training of both these post graduate courses and not be influenced by corporate hospitals lobbying for DNB, looking for cheap labour.

Clause 49 sub clause (3): regarding development of specific educational modules to be introduced in UG or PG courses of different systems of medicine to allow a pluralistic approach: needs to be studied further, research and pilot studies must prove beyond any doubt, that such an interface between different systems will benefit the patient, until such time the commission must not indulge in bringing it to public domain.

Clause 49 sub clause (4): Training of AYUSH doctors with a bridge course and allowing them to practice allopathy is a foolish decision on many counts and must be abandoned. The Commission has a prejudiced notion (owing to UN prescribed standards and also lobbying by corporate hospitals looking for cheap labour) that there is shortage of doctors in India. The shortage of doctors is mostly in rural areas while in metros and major cities, there is an oversupply. Government has to work to improve redistribution of doctors to rural areas ²⁷.

Author’s recommendation: Abandon the bridge courses, the various state governments must study and replicate Tamil Nadu model ²⁷ where today there is a wait list of doctors wanting to join rural health force, instead of experimenting on patients’ lives with bridge doctors or mini doctors as is being done now in Jharkhand. Job of the commission is to regulate medical education and practice and ensure better doctors, not to dance to the tunes of government or corporate hospital lobby looking for cheap labour.

The accreditation and rating function of the Medical Assessment and Rating Board (MARB) should be out of the ambit of NMC. This was the recommendation of the Parliamentary Committee report in March 2016. The author recommends that it should be kept out of ambit of NMC as earlier experience with MCI shows that, this is an area prone for corruption, lobbying and rent seeking.

Finally, the chairperson of the commission must not come from corporate hospital or private medical college background at any cost. Criteria for selection of chairperson of NMC are easily met by many millionaire and billionaire doctor business leaders owning or running single or multiple hospitals and/or colleges. It is not in the interest of medical education or practice to hand over the reins of such an important regulatory body to them.

Author’s Recommendation:  Selection criteria for chairman of commission and presidents of 4 autonomous boards must include exclusion criteria to exclude doctors from corporate for profit hospitals and those closely associated with running of private medical colleges.

The author appreciates NEET and NEXT concepts brought to fruition by NMC.

Regulatory oversight in medical education and practice is evolving to suit changing needs of the stakeholders and public, globally. It is our duty as stakeholders to work together to create a responsive regulator which suits to the changing needs and meets goals set. I hope the changes made in NMC by the PSC it is referred to now, can bring about all these and be a model regulatory organisation.

[Special note by the author: Along the way, we have completely ignored Indic and non-western concepts of disease and discarded alternative ways of providing succor to humanity. Even today in my observation, traditional Indic medical systems prevail in the primary levels of health care in rural areas and among urban poor, while Western medicine is more popular as people  move up the social and economic ladder. Focus of Indic systems of medicine has always been on health promotion and prevention of disease (prime among them is Yoga), rather than the curative bias seen in Western medical systems. Had a dialogue been successfully initiated under proper regulatory oversight and on specific outcome based research, between these two systems, the resulting  symbiotic growth and outcome might have probably got us our Nobel in medicine ²⁸ (Traditional Chinese Medicine expert “To Youyou” won Nobel for her contribution in 2015 ²⁸) and would have contributed to better health of people. The abject lack of communication and learning between the Western systems of medicine on one hand and indigenous Indic systems of medicine on other hand has not worked well for the country. Indic systems of Medicine will greatly benefit from induction of scientific temper, standardization and quality control, improving and providing uniform educational standards along with clinical research, better curricula and peer review from doctors across the aisle from western system of Medicine. It is the government’s job to bring in necessary changes in the regulatory apparatus of Indic systems of medicine to inculcate the above and grow as a proper science based on the concept of evidenced based medicine. This will ensure development of a symbiotic relationship between modern medicine and Indic systems of medicine leading to mutual respect among the practitioners and the nation too will be better served. Trying shortcuts like bridge courses is reckless and unwise].

References:

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A Brief Overview of Indian Public Healthcare, 5 proposed strategic interventions for high impact on National Health, And the question: Is Prime Minister Narendra Modi willing to pledge his political capital to take our public healthcare system to 1st world country status? by Dr Jagadish Hiremut

“The enjoyment of the highest attainable standard of health is one of the fundamental Rights of every human being without distinction of race, religion, political belief, economic or social condition” – Preamble of WHO, declaring Health as fundamental right.

In the history of Independent India nothing comes even close to the spectacular failure Government run “Public Healthcare” has been in every aspect of planning and execution. It wasn’t so always, in the later days of British rule, Sir Joseph Bhore led committee set up in 1943, prepared its comprehensive set of recommendations & submitted them in 1946 upon which our nation’s healthcare delivery system was supposed to be built. Here are some of the a highlights of its recommendations:

1)      Integrate Preventive & Curative systems at all administration & execution levels

2)      Development of Primary Health Centres in 2 stages (remember, this is for 1946)

a)      Immediate short term measure: 1 PHC for a population of 40000, manned by 2 doctors, 1 nurse, 4 public health nurses, 4 mid wives, 2 sanitary inspectors, 2 health assistants, 1 pharmacist & 15 other class IV employees. A secondary centre was planned to provide support a cluster of PHCs, to coordinate & supervise their functioning.

b)      Long term Plan: Setting up of PHCs with 75 bed Hospital for every 10000 – 20000 people and secondary units with 650 bed hospital supporting a cluster of PHCs and regional hospitals to support secondary units with huge 2500 bed Hospital infrastructure.

3)      This is a very farsighted vision & execution policy document prepared which, if and only if, had the governments of independent India adhered to; India would probably be today boasting of a healthcare system far superior to any other country in the world. It is available in 3 volumes and can be downloaded in the link given below ¹ in reference section.

a.       Vol  1 discusses in detail; Maternity & child health, Health of School children, Health of Industrial workers with specific reference to women workers and substance/alcohol abuse, Important diseases like Malaria, TB, Smallpox, Cholera, Plague, Leprosy, Venereal Diseases, Hookworm, Filariasis, Guinea worm disease, Cancer & Mental disorders + deficiency, Environmental hygiene & quarantine methodologies, R&D, Medical Research Institutes ( 10 in number) & finally scope of modern Medical + Nursing education.

b.      Vol 2 discusses about future & long-term trends in Healthcare. Gives a plan to stay ahead of the curve apart from discussing in detail about important diseases individually. The concept of Public Health Engineering is described for probably the first time in  great detail, in relation to healthcare, with importance of water, drainage + sanitation systems, Pollution, Control of vector borne diseases explained with achievable end points.

c.       Vol 3 gives long term execution plans with plausible expenditure also in this volume Leprosy & Mental health get extensive coverage.

Reading the above document (for preparing India Public Healthcare Vision document - 2030) along with other available records in relevant government departments & planning commission, left me thoroughly spellbound and disillusioned at the same time; that, such a fundamentally strong and pragmatic ‘vision + execution’ document prepared so early in the life of our Independent nation, did not find any takers till now among our Political leaders and policy makers. That political leadership even now does not recognize Health-care as an important aspect of human life is exposed by the fact that even in the latest National Health Policy (NHP) of 2017 the current regime is unwilling to declare “Right to Health” as a fundamental right of citizens of India. Lack of political leadership & political will; is a disease affecting all parties across all ideologies.

Subsequent governments post 1946 formed different committees: the Mudaliar Committee of 1962 (Government of India, 1962), and the Shrivastav Committee of 1975 (Government of India, 1975, 1976)^{13, 14}. The Mudaliar Committee (1962) concentrated on medical education and development of training infrastructure for static medical units¹³. The Shrivastav Committee (1975) urged the govt for training a cadre of health assistants to serve as links between qualified medical practitioners and multipurpose workers (e.g. school teachers, post masters, gram-sevaks, etc.)¹⁴. However, none of them were visionary & comprehensive like Bhore Committee report. They were as short sighted as the political leadership of those times.

The NHP 1983 declared a lofty resolution of taking health services to the doorstep of people and ensuring fuller cooperation of community, however; it failed to declare health care as a fundamental right of the people and neither did the NHP of 2002 ¹⁷. 

Both the NHP of India 1983 and 2002, failed to confer the status of a ‘Right’ to "Health^{" 17, 18}. Both have some worthwhile proposals, no doubt, but the major social thrust and vision to convert their commitment to Health into a Right was lacking. This was/is due to poor awareness among the ruling politicians where ministry of health was/is treated as a reward to loyalists instead of being seen as place which needs committed planning & execution. Planners and bureaucrats with no hands on experience in healthcare delivery to masses/patients and having zero knowledge of ground realities were/are in-charge of planning & execution of such an important aspect of human life as healthcare. Truant demands from a community unaware of its fundamental rights, a private medical establishment which seeks to drown itself in short-sighted profiteering strategies and business of scale, further complicate matters making Indian healthcare rank among the lowest (154 among 195 countries) in the world, performing much worse than our 2000 ranking of 112².

Worldwide; goals of medicine, has undergone a paradigm shift from curative to preventive, preventive to social and social to community medical strategies aimed at improving healthcare, not just to achieve a disease free state but also to improve the overall quality of life. Whereas; India which could have been a beacon holder for all developing countries; had they simply followed Sir Joseph Bhore committee recommendations, has still to reap the benefits of this original philosophy which was handed to them in 1946 on a platter, to any significant degree.

Let us further analyse the havoc that has been perpetrated by successive governments in the name of Healthcare:

Comparative analysis: India’s current GDP which is at 2.264 trillion$ spends 1.04% of its GDP equivalent to $ 267 per capita (2014 data), whereas US with current GDP of 18.54 trillion$ spends 18.57% of its GDP equivalent to $9990/- per capita³. If you understand the population base effect difference between the countries, you will appreciate the inadequacy of the amount allocated to our large Public healthcare needs by subsequent governments in India; thereby destroying the efficiency of our Public Healthcare system.

Each year more than 40 million people in India, mostly rural folk and urban poor are impoverished, get entangled in financial crisis and run into massive debts to access secondary/ tertiary/quaternary care⁴. This is mainly because the government does not want to spend (in the name of fiscal prudence) forcing the people to spend out of their pockets leading to personal & family disasters¹¹. This Out Of Pocket Payment (OOPP) is the single most common cause of sudden emergent financial crisis among rural folk & urban poor¹¹. Read vide supra again to understand the enormity of what I am trying to present here. 

India loses 6% of GDP annually due to premature deaths of economically productive citizens, expenditure on preventable illness, Non Communicable Diseases (NCDs) & accidents ⁵. NCDs & accidents/injuries account for 52% of deaths in India (and will keep increasing with decrease in deaths due to communicable & infectious diseases) ⁶. The above two studies (ref 5&6) is proof that successive governments have been asinine in their approach towards healthcare expenditure. Had the governments made up their mind to increase healthcare expenditure to just 5% of GDP, the country would be richly rewarded back with increased economic productivity of its healthy citizens; Such far sighted visionary thinking and political leadership was never present in Independent India, at least till now.

Global average expenditure on healthcare is around 9.981% of World GDP¹⁵ & India as a whole spends less than half of that amount at 4.7% of its GDP on Healthcare¹⁵; whereas, Government of India currently spends only 1.14% of its GDP on healthcare¹⁶, forcing the citizens to spend a whopping remainde 3.56% of GDP from their pockets (get the drift), leaving them at the mercy of profiteering and burgeoning corporate healthcare providers & unregulated private players in healthcare. This OOPP has led to increased incidence of sudden financial crisis especially among the rural folk and urban poor¹¹. According to the World Bank and National Commission's report on Macroeconomics, only 5% of Indians are covered by health insurance policies ¹⁹. Government of India does not make any efforts to increase insurance coverage among the lower middle class and middle class or any class of its citizens, who can purchase the same thereby reducing the instances of OOPP and financial crisis. The citizens of this country are left to fend for themselves and forced to spend from their pockets for healthcare, even after 70 years of Independence

Sometimes looking at the GDP numbers & the amount of money involved (81.88 million dollars in this case (back of cover calculations, figures need to be authenticated further)), to my fertile imagination, it appears like a Healthcare scam waiting to be unearthed/ exposed.

Analysis of healthcare with respect to: current inherited healthcare status of nation, failure to meet accepted Millennium development goals by 2015, adaptation of UNDP’s Agenda for Sustainable Development and release of National Health Policy 2017.

For our better understanding, let us do a recap of BJP manifesto for 2014 for Healthcare (highlights)

Health Services: Increase Access, Improve Quality & lower Cost

1)      Health assurance to all Indians & to reduce out of pocket spending on HC

2)      National Health Policy & National Health Assurance Mission

3)      Utilise the ubiquitous platform of mobile phones for healthcare delivery and set up “National-e-Health Authority”

4)      AIIMS in every state

5)      Swatch Bharat by 2019

The quintessence of BJP’s manifesto regarding healthcare is captured in NHP 2017.

The “goal” as described by NHP 2017 ¹⁶

Goal: “The policy envisages as its goal the attainment of the highest possible level of health and wellbeing for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.

The policy recognizes the pivotal importance of Sustainable Development Goals (SDGs). An indicative list of time bound quantitative goals aligned to ongoing national efforts as well as the global strategic directions is detailed at the end of this section”¹⁶.

Personally, I admit here that, post Sir Joseph Bhore’s committee recommendation 1946, NHP 2017 is the most comprehensive & extensive document the public healthcare leadership, planners and bureaucracy has produced; however, there is a curative bias in approach which needs to be addressed for achieving better far-reaching results.

The Organization as inherited by the current government:

Public Health Infrastructure inherited (Data as of 31^st March 2017)⁷:

1)      2,08,596 Sub Centres

2)      31,938 Primary Health Centres

3)      7,541 Community Health Centres

4)      648 District Health Centres

5)      AIIMS & other Autonomous institutions

Total number of beds owned by Public Health Infrastructure as per data published by Government in June 2014 is 6, 28,708. Urban Health Infra holds 4, 32,526 beds and Rural beds are 1, 96,182, which is a little less than a third of urban bed strength. As per population statistics there is 1 bed for every 1946 people in urban areas whereas; in rural areas it is 1 bed for every 4639 people⁸. Population distribution statistics indicate that 70% of population stays in rural areas making this more skewed than it appears to be. 

This brings us to the “Jinx of 70” we face in Healthcare¹²:

70% of people stay in rural area with little access to healthcare

70% of people pay from their pockets (actually it is 75%)

70% of expenditure is on medicines alone

To overcome the existing infrastructure deficiencies, requires imagination, out of the box search for solutions, innovative implementation methods & supra-optimal use of existing infrastructure. It requires Political will & leadership – the question is can the health minister & Prime Minister provide the same?

India’s Political and Public health leadership in the past, has led innovative schemes and translated the best of those into policy, made substantial contributions for bettering population health. Since the launch of the National Rural Health Mission in 2005, over 157 thousand personnel have been employed to health sector⁹. 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 thousand new-born babies are receiving care in neonatal care nurseries in district hospitals each year through Janani Shishu Suraksha Karyakram ⁹. 

Polio has been eliminated from the face of the country, Yaws eradicated, Kala-azar, Endemic Filariasis, Leprosy, Measles on their way to eradication. This is exciting, but is not enough; failure to achieve UNDP’s millennial developmental goals by 2015 which were signed in 2000 is a sobering lesson to the Government, Healthcare Planners, Administrators and Managers¹¹. It requires much more capacious hard labour, purposeful action, thorough planning & execution to achieve goals with respect to healthcare monsters like Tuberculosis, Malaria and HIV-AIDS. UNDP’s sustainable development goals and NHP 2017 are the right way forward, however; Government of India, its political leadership & bureaucracy should work to ensure that these goals are met at least with regards to healthcare.

Has anything changed since 2014 and does Narendra Modi as Prime Minister, indicate a change in approach towards public Healthcare?

Yes & No

Yes: because, after Narendra Modi took up the job we could see a distinct shift in approach towards the health of the nation. Personally for me, two of his standout programmes in healthcare are:

1)      Swatch Bharat Abhiyan

2)      Promotion of Yoga

Swatch Bharat or Clean India is the best antidote for communicable, infectious & vector borne diseases put together. Not only does it make our country clean, tidy and appealing; Swatch Bharat if implemented in totality will result in far reaching results with, vanishing communicable, infectious and vector borne diseases. The contribution to GDP through savings on health expenditure and increased economic productivity will be enormous. UNDP’s goals with regards to Malaria, Tuberculosis and other vector borne diseases will be met easily and we may actually surpass them. The drawback I see: Bureaucracy, it is not as enthused about this program as the ruling polity is; there is an implementation failure as volunteers/amateurs cannot carry this burden beyond their time & capacity limitations, therefore slowly this is a case of diminishing returns developing overtime post the initial euphoria. 

Promotion of Yoga is synonymous with fight against advent of Non Communicable Diseases. NCDs today are the leading cause of death, surpassing 50% as cause of death in our population ⁶. Like Swatch Bharat, in this program too, a case of diminishing returns is developing. Both the programs need to be professionally managed with targets to achieve, for better outcome & influence on Public Healthcare to be realized.

No: because, despite the above two programmes which caught the imagination of people, there is no change in the continued, curative bias (in Healthcare bureaucracy) which consumes huge amount of money with insignificant results in overall improvement of health of nation. In my opinion, the healthcare bureaucracy is the bane of our nation, it behaves like a “Ponzi” leftover of British raj bent on decaying the health of the nation from inside like a worm inside a fruit.

I have expressed earlier my earlier articles that; National Health Policy 2017, despite its limitations, is the best vision document on our healthcare; post the recommendations of Bhore Committee in 1946. What is the benefit of a good document if nothing gets accomplished on the ground? Narendra Modi has to take up the cudgels himself, finish the job under his direct supervision and not leave it to even his cabinet colleagues (Like a captain batting through the innings, playing captain’s knock).

Changing Strategy; Adapting to the pitch to score better with 5 purposeful interventions:

NHP 2017, 2.3.1 says: Progressively achieve Universal Health Coverage ¹⁶

A. Assuring availability of free, comprehensive primary health care services, for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable, non-communicable and occupational diseases in the population. The Policy also envisages optimum use of existing manpower and infrastructure as available in the health sector and advocates collaboration with non -government sector on pro-bono basis for delivery of health care services linked to a health card to enable every family to have access to a doctor of their choice from amongst those volunteering their services ¹⁶. 

B. Ensuring improved access and affordability, of quality secondary and tertiary care services through a combination of public hospitals and well measured strategic purchasing of services in health care deficit areas, from private care providers, especially the not-for profit providers ¹⁶

 

C. Achieving a significant reduction in out of pocket expenditure due to health care costs and achieving reduction in proportion of households experiencing catastrophic health expenditures and consequent impoverishment ¹⁶.

1^st Strategic Intervention - Comments & suggestion of the author: India is today a 2.3 trillion dollar economy & growing, it is the right time for the government to go big, allocate 3% or more of GDP for health, “declare Health as a fundamental Right” and provide - Universal Health Coverage (UHC). It is time to take charge and go for big audacious goal. Strong governments can pull through the impossible and achieve results beyond the bounds of human imagination due to collective efforts and the goodwill of people. This is actually Narendra Modi’s moment in history to seize and leave an indelible mark, more importantly; it is the right thing to do.

UHC in its simplest definition means access to quality, effective and affordable health services for all, without imposing financial burden ²⁰. This can be achieved through various methods using Government & private sector expertise and the costs borne by insurance premium paid by the government on behalf of citizens and other methods feasible. 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 use ²⁰.

Caution: A large body of evidence suggests that up to 25% of “quality” care may be unnecessary & inappropriate and higher utilization of resources is not associated with improved health status/outcome or quality of care ²¹. The push therefore should be for appropriate care & not quality care as part of UHC. Replacing quality care with appropriate care will make UHC in the changed Indian context defined thus:  Access to appropriate, effective and affordable health services for all without imposing financial burden. Let me explain this with an example: In 99% of patients requiring CT scan, findings can be assessed with a low cost-low end, 4slice or 16slice CT scan machine, only 1 to 2% of patients will require CT scan machines of higher capability and cost, therefore it does not make sense to subject all patients requiring CT scan to a 128/256slice machine in the name of quality healthcare. Only those who will benefit from such quality improvement must be provided with it. SOPs & management regimes developed should opt for lower-cost approach unless value is demonstrated in higher-cost alternative. This pragmatic approach of appropriate care will bring down the cost of UHC by minimum of 20 – 25%.

2^nd Strategic Intervention - Establishment of National Drug procurement policy: The “Jinx of 70”, it is well established that 70% of healthcare expenses are due to cost of medicines ¹². Right to health and universal health coverage cannot be achieved without access to affordable essential drugs on a regular and viable basis. Millions of Indians could access better care, if government decides to procure generic medicines in bulk and distribute them free of cost at public health facilities. The government should establish a National drug procurement and disbursal policy with mandate to procure and provide generic medicine, surgical implants, stents, devices, suture goods etc..., to all public and private institutions participating in UHC across the country ²². Distribution of free medicines and treatment accessories through public healthcare systems helps increase citizens trust in our public healthcare system and in the government of the day. A centralized public procurement and decentralized distribution of essential medicine (drugs only) model has been successfully implemented in the States of Tamil Nadu and Rajasthan ²². This initiative has been shown to lower the cost of medicines and allow free access to generics. India is called the pharmacy of the world due to the huge concentration of companies manufacturing generic drugs and exporting them to developed countries including the USA; it is time to ask those companies to manufacture for India thereby promoting Make in India too.

3^rd Strategic Intervention - Universal Standard Operating Protocols: A body of practicing clinicians with peer acceptance, must be set up to formulate Universal SOPs, Standardisation of treatment regimes, Prescription standardisation, Treatment audit methodology & treatment audit, Quality/value assurance methods to improve performance, efficiency and accountability of the UHC. With standardisation of treatment, outcome across the country can be assessed, audited and monitored in a better way. Data obtained through such a system is of immense value and can be used in various ways including disease outcome prediction and development of AI and its implementation in medical device technology increasing their efficiency and overall medical device intelligence.

4^th Strategic Intervention - Focus on Impact Areas in Healthcare: Availability and accessibility of Primary care in the time & place of need especially rural areas leaves an impact, it also allows the person to suffer minimum in terms of illness and also economic losses. The other area of impact is “Care in Critical illness”. Here more than the economic losses, it is about saving patient’s life which leaves a lasting impact with the whole family and society. UHC should look at these two areas as priority areas on focus. The rest of healthcare services patients have time on hand, can wait and schedule them as per their convenience. AIIMS and the enormous expenditure on it can wait, right now government should go after Primary care & critical care as they are high impact areas and will produce quick results – Public healthcare and government, will be seen as if they are punching above its weight.

5^th Strategic Intervention - Research & Development: After Ronald Ross discovered Malaria parasite in female Anopheles mosquito on 20^th August 1897 ²³, there has been no touchstone moment in the history of medical R&D in India. The number of National Research Institutes on TB, Tropical Medicine, Malaria, Vector borne diseases, VDs and now NCDs should have made us a powerhouse in global healthcare but we are not. India is nowhere in the map of R&D in healthcare, countries like South Korea have taken a giant leap as they allocate substantial percentage of their GDP towards R&D in healthcare, linked to performance ensuring results from their scientists. India needs to start allocating serious money to develop newer methodologies of disease treatment, develop more efficient drugs, develop low cost efficient equipment, develop methods to reduce burden of disease, increase disability free living in geriatrics and develop database of traditional medicines and their APIs. Our scientists are not pushed enough from the healthcare administration to deliver results, it is time now to do it, Narendra Modi must take personal interest in this similar to what he has done with ISRO. R&D can encompass much more than what is written here and must be developed as an important adjuvant to UHC.

A note of caution and advice to be vigilant: The task of integrating plural systems of Medicine, which was not attempted till now, has been attempted in NHP 2017; however, it needs to be closely monitored. The National Medical Commission bill will lead to lot of heart burn among the allopathic practitioners; PM and Health Minister will have to intervene here if required, change some provisions of the NMC bill to reassure them. Government should work hard to reach common ground and goals with private healthcare providers too, assign practical roles to the private sector and ensure public duties from private professionals for greater impact on our public health.

No Indian citizen should be forced to choose between illness and financial hardship due to out of pocket payments to his or his family’s healthcare – Author

The question I want our ruling establishment and healthcare establishment and common man to ponder about is this: Is the Prime Minister Narendra Modi willing to pledge his political capital to take our public healthcare system to 1st world country status? 

Finally, it is not all about sickness – wellness is the key to a healthy life. Clean water, Clean Air, Cleaner environment (core principles of Swatch Bharat), Adequate nutrition, Lifestyle modification (core principles of Yoga), Judicious use NeHA, grooming of good healthcare assistants, Good Doctors, and also sex education of Adolescents are all equally important to achieve our commitment to sustainable development.

Author: Dr Jagadish Hiremut also known as The Good Doctor is a practicing Medical professional and a public healthcare intellectual. He runs a company “ACE Intensive Care services and consulting” which provides Intensive Care services at low cost to hospitals outsourcing it to his company. Consistently believes value is quality divided by cost and trusts in Value based Healthcare services over Cost effective healthcare services. This article is his intellectual property and will appear on his personal blog; those wanting to quote from it should do so with permission and due credits. He can be contacted on Twitter on @Kaalateetham and email: drjagadish10@gmail.com

References:

1)      Sir Joseph Bhore Committee 1946 download 3 volumes website: https://www.nhp.gov.in/bhore-committee-1946_pg

2)      Who Healthcare index rankings: http://www.who.int/countries/ind/en/

3)      UN & WHO data & https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita

4)      Marten R, McIntyre D, Travassos C, Shishkin S, Longde W, Reddy et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China & South Africa (BRICS). Lancet 2014; 384: 2164-71

5)      WHO country cooperation strategy at a glance India – 2013:  http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ind_en.pdf

6)      Burden of NCDs policies & programmes for prevention & control of NCDs in India. Indian J. Community Medicine 2011; 36 (suppl 1): S7-12

7)      Number of Rural Health Centres, Sub-Centres, PHCs, CMCs & DHCs run by Govt of India as on 31-03-2017 https://mohfw.gov.in/sites/default/files/DMU%20report%20for%20website.pdf

8)      Bed strength as per data published on June 2014 http://cbhidghs.nic.in/writereaddata/mainlinkFile/Health%20Infrastructure-2013.pdf

9)      Nair H, Panda R. Quality of maternal healthcare in India: has the National Rural Health Mission made a difference? J Glob Health. 2011; 1:79–86. 

10)   Eight Goals for 2015 – India: http://www.in.undp.org/content/india/en/home/post-2015/mdgoverview.html

11)   WHO report: Trends in catastrophic health expenditure in India: 1993 to 2014: http://www.who.int/bulletin/volumes/96/1/17-191759/en/

12)   Rule of 70: Derived from Central bureau of Health intelligence “National Health Profile 2016”.

13)   Mudaliar Committee 1962: https://www.nhp.gov.in/mudaliar-committee-1962_pg

14)    Shrivasthav committee 1975: https://www.nhp.gov.in/shrivastav-committee-1975_pg

15)   Health expenditure, total (% of GDP): https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS

16)   National Health Policy 2017: http://cdsco.nic.in/writereaddata/National-Health-Policy.pdf

17)   National Health Policy 1983: https://www.nhp.gov.in/sites/default/files/pdf/nhp_1983.pdf

18)   National Health Policy 2002 : https://www.nhp.gov.in/sites/default/files/pdf/NationaL_Health_Pollicy.pdf

19)   “Healthcare in India Whitepaper” Columbia University

20)   Planning Commission of India. High level expert group report on universal health coverage for India. 2011:http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf 

21)   Naylor CD: What is appropriate care? NEJM 338: 1918-1920, 1998.

22)   Golechha M. Priorities for the next Indian government's reform of healthcare. BMJ. 2014;348:g2733

23)   British Journal of medicine December 1897.