Healthcare: Unhealthy India

Become a doctor, says a hindi sign posted on a two-storeyed building in a narrow lane in a Lucknow slum. It touts six-month courses for “bachelor’s degrees” in Electronic Medicine (BEM) and Magnetic Medicine (BMM), and a one-year MD. The eligibility requirement: Class 10 pass/fail. There’s the name of a doctor (BEM, of course) to contact for admission.

Such signs are no rarity in India, where public health is grossly neglected. Only 30 per cent of Indians have access to modern medicine, and most of its 1.2 billion people consult quacks. India ranks 112th out of 190 countries in the World Health Report on key health indicators. The hope that flared when the current government came to power, promising a robust health policy, is fading. The Narendra Modi government had promised to implement the National Health Assurance Mission (NHAM), which envisaged universal health coverage and higher public spending on health, but it has now put it on hold, citing fund constraints.

India is set to become the global capital of non-communicable ailments such as diabetes, cardiac problems, and cancer. Preparations to tackle sudden outbreaks of communicable diseases aren’t satisfactory, either. India’s public health spending, at 1 per cent of GDP, is among the lowest in the world. True, it has made some progress over the last few decades, including the eradication of polio, and a slight improvement in child and maternal mortality rates. But continued negligence on the policy front has ensured that India is one of just five countries that are home to 60 per cent of the world’s one billion extremely poor people.

Public health – a top priority in most countries – is yet to earn its due recognition in India. Primary health care is especially neglected, leading to the progression of illnesses that could be treated or prevented cheaply, into chronic ailments. This adds to India’s overall disease burden.

India’s limited health insurance scheme, the Rashtriya Swasthya Bima Yojna, under the ministry of labour, provides coverage only for families below the poverty line. By contrast, China rolled out universal health coverage five years ago. It spends about five per cent of its GDP on public health. Even poorer neighbours, such as Bangladesh and Sri Lanka, have made health care a basic right, and their governments are obligated to provide free health coverage.

In the absence of a proper primary healthcare ecosystem – an integrated approach to improve quality of life through health awareness, sanitation, predictive and preventive healthcare and treatment for basic ailments for all – India is on the edge of collapse, experts say.

Policy Reforms vs Political Will
In India’s complex administrative environment, different centres of power handle social development projects. The country has always faced challenges in implementing healthcare and education reforms. “India never suffered from lack of ideas. But lack of political will has always been a challenge,” says former health secretary Sujatha Rao.

She was instrumental in several policy recommendations as health secretary and as secretary in the department of AIDS Control. She says implementation of systemic reform in health care is long overdue, to meet the objectives of equity, efficiency and quality. To achieve them, she says, “The central and state governments need to make strategic interventions with strong determination to reach the benefits to the poor.”

Health is a state subject, so implementation of reforms often has varied outcomes. Some states have progressed substantially, while others lag due to poor policies and underutilisation of funds. Key public health challenges are clean water, sanitation, persistent malnutrition among women and children, and primary healthcare mechanisms.

In the 12th five-year plan, the health ministry estimated an expenditure requirement of Rs 10.7 lakh crore to address these. But the allocation was just Rs 3.8 lakh crore, and at the end of fourth year, only Rs 30,000 crore has been disbursed.

India is well below the global average in terms of hospital beds (0.9 per 1,000 people) and doctors (1 per 1,700 people). Health ministry data indicates there are around 650,000 doctors, but another 400,000 are needed by 2020.

Policy Doldrums
NHAM was to be rolled out in 2015. The proposal, whose estimated cost had escalated to some Rs 18.5 billion in the last five years, was cleared by the Prime Minister’s Office, as it was part of Modi’s election manifesto. But the policy is stalled as the government seeks to slash the health budget.
The national pharmaceutical policy was announced in 2013 after a long wait. While it helped reduce prices of essential medicines, the impact is limited as medicines account for less than a third of healthcare costs in India.

Hospital costs are unregulated, and most people are uninsured, so the average Indian still has poor access to healthcare. The National Clinical Establishment Act, 2010, which aims to control the quality and cost of services in hospitals and clinics, is a non-starter, due to strong resistance from the industry.

The Modi government created a ministry for AAYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy), but a policy framework for enforceable standards is nowhere in sight.

Despite warnings by international experts that India’s inaction on public health carries serious risks, and despite the hopes raised by the Modi government, the country has yet to formulate a comprehensive policy and commit funds.

“I don’t see any new policies, any new ideas, any significant public commitment, and most importantly no financial commitment to the health sector in India,” said Richard Horton, editor-in-chief of the leading global medical journal The Lancet, in a recent media interview. The Lancet recently published a research article on India’s negligence on public health policies.

The Modi government has announced reforms in sectors such as infrastructure, energy, manufacturing, and aviation, and launched high-profile campaigns such as Swachh Bharat, Digital India, and Make in India, but it has done nothing for the crucial healthcare sector. “Swachh Bharat is good. But it doesn’t make much sense in a country with no basic sanitation for the majority,” says Gautam Sen, former member of the Board of Governors, Medical Council of India (MCI).
The Lancet study warns about a “collapse” if India fails to invest in combating non-communicable diseases such as diabetes and heart problems. The Lancet article, written by a group of global health experts, has also strongly criticised Modi for not delivering on his poll promise of universal health coverage.

The Lancet’s editor was also quoted by media in October saying “Health is an issue of national security for India, but the new administration hasn’t taken it seriously.” The Organisation for Economic Co-operation and Development (OECD), a global forum that promotes policies on economic and social well-being worldwide, cautioned in its 2014 assessment of the Indian economy that it sees India’s poor health outcomes as a major developmental challenge. “India lags in healthcare outcomes not only by OECD standards, but also by the standards of the developing world,” it noted.

High Disease Burden
India has 63 million people with diabetes, and 60 per cent of the world’s heart patients. Several million Indians die each year from communicable and non-communicable diseases. India’s disease burden is much higher than that of other emerging economies such as China, Indonesia, Brazil, Mexico, and Sri Lanka. According to 2012 figures, there were 253 deaths per 100,000 population in India due to communicable diseases in one year. The global average is 178.

A 2010 World Bank estimate states that India loses 6 per cent of its GDP annually because of premature deaths and preventable illness. The OECD assessment notes that while India’s economy is growing, and millions have been lifted out of poverty, progress in improving health outcomes has been slow.

A study by the World Economic Forum and Harvard School of Public Health predicts that India will lose at least $4.5 trillion before 2030 because of the economic impact of non-communicable diseases. Of this, $2.17 trillion will be due to cardiac diseases alone.

The main reason for India’s poor healthcare outcomes, according to OECD, is the low level of public investment in preventive health measures such as sanitation and waste management, and also in medical care. The OECD report notes that even where public health facilities exist in India, they are of poor quality.

“It’s not the decision to set up half a dozen more AIIMS (All India Institute of Medical Sciences), but the decision to strengthen primary care mechanisms in every village, covering each and every citizen, which can help drastically reduce the country’s disease burden,” says former MCI board member Sen, who is also chairman of the College of Surgeons of India and founder of primary healthcare chain Healthspring.

Medical Education
Hundreds of private medical colleges have mushroomed across the country, offering MBBS and MD courses for students who can make up in capitation money (Rs 75 lakh to Rs 2 crore each) what they lack in merit. The quality of doctors they churn out is often comparable to the quacks who “graduate” from that institution in the shanty in Lucknow.

Medical education was opened up to the private sector with the aim of increasing the supply of professionals. But exorbitant capitation fees force new doctors to recover costs by working with private hospitals in metros, and to choose lucrative super-specialisation.

Many doctors don’t want to work in rural areas – a major hurdle in primary healthcare coverage. When Ghulam Nabi Azad was health minister, in the previous government, the health ministry tried making rural service mandatory for all government medical college graduates. But there was resistance from the medical community, which cited inadequate facilities at primary health centres as a sticking point.

“It’s a vicious circle. The managements of private medical colleges pay crores to get ill-equipped institutions approved by the government, aspiring doctors pay huge fees to get admission, and the poor patients are forced to pay the doctors and hospitals through the nose for treatment,” says former MCI member Sen.

The MCI is the government body that regulates medical education in the country. But the 2010 arrest of MCI president Ketan Desai on serious corruption charges by the Central Bureau of Investigation (CBI) led the government to dissolve the body. The CBI caught Desai accepting a Rs 2-crore as bribe to turn a blind eye to an attempt by Gyan Sagar Medical College, Patiala, to enrol more students than it was allowed to.

“Unless private medical education and hospitals are made accountable, and standards under the direct regulations of the government, one can’t expect healthcare goals to reach the needy fully and effectively,” says former health secretary Rao.

The industry-politician nexus ensures that eight reform documents submitted by various expert committees, appointed by governments between 2006 and 2015, to improve India’s dated medical education system continue to gather dust in the health ministry. Meanwhile, a hurried attempt is on to bring the tainted Ketan Desai back into the reconstituted MCI.

After the charges, Desai was elected to the Gujarat University senate as a doctor. The university, which can nominate a member to the MCI, has endorsed him. Sources attribute the abrupt removal of former health minister Harshvardhan and a former health secretary, to their opposition to the medical college approval racket, but this could not be confirmed officially.

Government on the Defensive
India has made progress on some indicators, such as child and maternal mortality. Infant mortality has dropped to 48 per 1,000 live births from 126 in 1990, and maternal mortality to 190 per 100,000 live births from 560. But it is a far from the millennium development goals for 2015, of 42 and 109 respectively.

“New policies and ideas are necessary but it is equally important to consolidate work being done to ensure that services reach the people they are meant for,” the health ministry said in response to foreign criticism that the government is ignoring health issues. “Launching an alphabet soup of programmes... and not being able to implement them... is a disservice to the people we serve,” wrote Rakesh Kumar, joint secretary in the health ministry, in a letter to The Lancet’ editor. The ministry maintained that no programme had been curtailed due to lack of funds, and said the government had rationalised funding.

As for a new policy, India is yet to hear from the government.

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(This story was published in BW | Businessworld Issue Dated 28-12-2015)