The Future Of Healthcare In India

Nachiket Mor is the India Country Director for the Bill & Melinda Gates Foundation. In this role, he oversees the foundation’s efforts to improve health, sanitation, financial inclusion, and agriculture in India’s most vulnerable communities. He, and the foundation team based in New Delhi, work closely with India's central and state governments, local and global nonprofits, community groups, researchers, and the private sector to help India achieve its ambitious health and development goals.

In an interview with Neeta Misra, our executive editor for sustainability, Nachiket Mor talks about the health care needs of the country and outlines a framework for building a robust health care system that will cover the broad spectrum of health issues.

NM: How would you characterise the present situation on health care?
NM: We have shown remarkable progress in improving our healthcare standards over the last 25 years. During this period, the proportion of Indian babies who do not make it past their first birthday has fallen by half and that of mothers who die in childbirth by more than two-thirds. Despite these gains, last year we lost over 45,000 mothers due to complications related to pregnancy and more than a million babies did not live to see their first birthday. Sadly, more than 95 per cent of these mothers and babies could have been saved, had they access to good healthcare. Estimates also indicate that healthcare costs drive an additional 4% of Indian families, over 50 million people, into poverty each year - this problem has all but disappeared in the developed world and is shrinking rapidly in several developing countries. We in India have the capacity to deal effectively with it as well.

The challenge before us is not one of resources. As a country we are already spending more than enough money on healthcare; we produce almost all of the drugs that we need locally, at a fraction of global costs; we have the finest physicians and nurses; and our technological capabilities are internationally recognized. What we need is a health system that uses these resources effectively.

NM: What is the approach required for building a health system?
NM: Building a health system in a country as large as ours is going to be difficult but not impossible. We have already deployed large numbers of women to provide essential healthcare and nutrition services in the remotest parts of our country. Early evidence on the ground from the poorest Indian states of Bihar and Uttar Pradesh clearly shows that careful on-site mentoring and on-the-job training, provision of simple tools and technologies, and some essential supervision, can have a transformative impact on their performance. The facilities that have fully adopted such practices have already demonstrated a dramatic reduction in the death rates of infants who are born there. With some effort, these methods can be scaled up across the length and breadth of our country.

If we continue to build on such experiences and take a few more necessary steps, we can create a health system that saves the lives of mothers and babies and goes on to also serve the middle-aged, the elderly, and the mentally ill.

NM: Within this framework what are the priorities?
NM: There are three priorities for the Indian health-care system that now need urgent attention: the availability of surgeons and specialists within our districts; the use of technology within the health system; and the fact that most patients need to pay from their pockets each time they receive healthcare. If we focus on these three issues and successfully address them, we will make considerable progress towards our goal of building a stronger health system.

While there is a continuing need to find additional specialists and surgeons to staff our advanced medical facilities, at district and sub-district hospitals the shortage of such professionals is estimated to be as high as 80%. Attempting to fill these vacancies by gradually increasing the number of post-graduate seats in our medical colleges will take years, if not decades. Instead, a large-scale program of focused training and certification at accredited local hospitals of existing doctors who have already bachelor's degrees in surgery and medicine (MBBS) would provide an adequate number of anaesthetists, paediatricians, obstetricians, gynaecologists, and orthopaedic surgeons in relatively short order.

NM: You also mentioned the role of technology?
NM: Information technology has transformed industry after industry in India. We know the power of IT. We have seen it change our lives. The cardboard railway ticket is a distant memory, as is the hand-scrawled bank passbook, both now replaced with the most up-to-date computer technology in the world. Yet when we visit hospitals, we still carry fat folders of prescriptions, test results, and X-rays, and our health workers are still required to fill up register after register in long-hand. And, at a time when even small rural cooperative banks supply data to the regulator through an automated data bridge, we still do not use technology to adequately track drug supplies or manage human resources in healthcare. This results in regular stock-outs of essential antibiotics and lifesaving drugs and much confusion in the transfers and postings of nurses and doctors. The use of information technology needs urgent attention and can have a transformative impact on our health system in many different ways. The formalization of Aadhaar and the rapid expansion of data-connectivity offer an unprecedented opportunity to do this.

NM: Health expenditures are a major driver of poverty, why?
NM: Far too many of us are required to pay from our pockets when we visit any type of health facility - this is one of the principal factors that drive families into poverty, and it also deters many people from seeking primary care at all. Other countries have replaced their own broken systems with ones where most or all healthcare is essentially free at the point of service, whether offered by the public or the private sector. It is instead paid for by citizens either contributing more by way of direct taxation or by being required to pay into some form of national health protection scheme. Moving in this direction will require India's government to significantly improve its ability to collect taxes; to allocate substantially higher sums from its budget to health; and to use the national health protection scheme to collect mandatory health-insurance contributions from those who aren't poor. Making these changes is not likely to be easy, but they are at the core of any transformation of the health system, and we will need to find the will to implement them.