“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 31st 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.
1st 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%.
2nd 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.
3rd 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.
4th 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.
5th Strategic Intervention - Research & Development:
After Ronald Ross discovered Malaria parasite in female Anopheles mosquito on
20th 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
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
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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”.
18)
National
Health Policy 2002 : https://www.nhp.gov.in/sites/default/files/pdf/NationaL_Health_Pollicy.pdf
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.
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