Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem.

Indian society is going through a catharsis. In an increasingly interactive but ever more disintegrated world, Indians are finally finding both the confidence and the desire to transform their own society. A country of 1.3 billion people is no longer prepared to accept being an “also ran”. In this process of churning, undeniably, there will be much pain but from this one hopes, will emerge an India – confident, strong, and sure.

There is a lot wrong with contemporary Indian society – it’s thinking, it’s structure, it’s systems but we still have a chance. Each one of us alive today will not be here in say just less than 100 years time. Almost every single house in the country will become inhabitable in not too distant a future, and our cities will almost completely have to be rebuilt. We just need to ensure that the “new” that replaces the “old” is robust and before you know India would be transformed. I sincerely believe that with appropriate corrective action, we can resurrect almost every aspect of the Indian society – yes it’s thinking, the structures, and even the systems.

This corrective action, however, will only become possible if we come out of our current situation where failure has led to arrogance rather than introspection. We will have to start by admitting freely and openly what is wrong with our society and then engage in a collective discourse to fix it. We need to raise both the level and the intellectual quality of our public discussion and move forward slowly – a step at a time – but decisively.

Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. The task at hand is enormous.

Human Resources

Healthcare industry is heavily dependent upon human resources. You can’t look after patient without doctors, nurses, technicians, etc. and yet little thinking has gone into ensuring an adequate work-force for the future that we can retain to work in the country. The current situation is that we are creating doctors and nurses but without the adequate hospitals and clinics for them to work in. The government keeps saying doctors and nurses don’t want to work in rural India but without understanding that doctors and nurses need adequate facilities, diagnostics, and other supporting services to deliver healthcare. Doctors and nurses need decent houses, schools for their children and facilities for a productive and entertaining social life. Given the fact that this is unlikely to change anytime soon in rural India, we will need to provide incentives for people to work in the villages – the same sort of thing that can force a doctor or a nurse to go and work in a small town in Saudi Arabia can also take them to a village in their own country. Our planners simply need to wake up to this reality. If a doctor or a nurse sees that he’ll save for four years by working for a year in a village, he is likely to drag himself there and also ensure he works hard to keep his patients and employers happy. The current situation where nobody wants the job in the first place does not leave the government with any levers when those in it don’t perform or simply don’t turn up! Adequate salary and tax incentives can go a long way in helping retain our homegrown talent and will ultimately pay back for itself by ensuring a healthier society. Health, after all it used to be said, is wealth.

The Role of the Government

In modern societies, we have left it to the governments to set the appropriate structures upon which we can all build our individual lives. If the structure is robust, our lives can indeed be very fulfilling but if it is not, the whole system can degenerate into chaos. The policy has failed Indian healthcare at every step and exploited by the very people entrusted to protect and develop it. Doctors continue to be educated and trained in a system that rarely keeps pace with the changing needs of the patients and the scientific developments. Underfunded medical colleges continue to treat the impoverished in shabbiest of the conditions and produce little in the name of research and scientific

output. They struggle to recruit world-class faculty while those who take up these jobs find they can neither deliver world-class care nor engage in academics or research because of the lack of funding and bureaucratic controls. Our corporates happily donate millions of dollars to foreign institutes as they have well-established mechanisms for publicity that our institutions have failed to establish. And while our educational institutions and hospitals are crumbling due to lack of resources, our temples are one of the wealthiest in the world. There is much for us all to reflect over in the contemporary Indian society.

The Profession

At the same time, it cannot be denied that healthcare is fundamentally the doctors’ responsibility in any society. If any of the other stakeholders’ are falling short, it is up to us to make noise and ensure we can deliver quality healthcare to the people. However, Indian healthcare is remarkably short in this area too. A large number of doctors, let down by the system, have become so cynical that greed and self-aggrandisement have taken over empathy and ethics. The profession has got infested with one corrupt practice after the other and the doctors have simply chosen to look the other way. Yet, they complained bitterly when medical services were brought under the purview of the consumer courts. I agree that involving courts was not the right thing to do but what options did the doctors leave for the patients when the regulator, the Medical Council of India (comprising entirely of doctors), does not have an effective patient complaint cell or even a register of all qualified doctors. It is true that the desire of the medical profession in India to protect each other is much stronger than their will to protect patients. And while the rot was setting in, the so-called leaders of the profession were building their own hospitals and nursing home. Isn’t it amazing that not a single leader from the profession has spoken against the widespread lack of healthcare provision in the country for the poor or the ethical abyss that the profession has sunk into? It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. If you don’t believe me, just think how many of hundreds of medical societies in the country come out with anything useful for the people. Where is the desire to develop the local evidence base to guide local care? Where are the local guidelines for common clinical conditions that can be used by doctors and nurses working in remote towns and villages? Despite this, hundreds of conferences are organised annually at considerable expense and much fanfare where the emphasis is on reciprocating lectures and chairmanship rather than any real scientific data sharing. There will no doubt be islands of excellence in this vast sea of greed and corruption but I hope I have been able to give you a general idea of the state of the affairs. Many of these problems are not simply confined to India either.

The Private Sector

The private sector rose to fill in the vacuum left by the state and it is a fact that without private healthcare, large sections of our communities will have nowhere to go. But once again, the private sector has been allowed to mushroom without any attempt to match demand to supply. This has led to a situation where they are killing and pulling each other down into a moral quagmire with over competition in urban areas while vast sections of rural parts of the country are left un-served. Private nursing homes, diagnostic facilities, and hospitals are functioning without a regulatory overseeing mechanism and poor patients have no alternative, as the state hospitals are not fit for human treatment.

Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem. We need reform across the board. We need to reform our state primary health care provisions, our medical colleges and how we fund them, medical education and postgraduate training, continued medical education, regulation of the profession and the hospitals, mechanisms for patients to voice complaints, planning to distribute provisions evenly, and systems for accountability from all. And even if we did all this, there will be yet more left to do.

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In most other countries, the constitution requires the government to provide some form of healthcare. The implementation, however, suffers from deficit of policy, government or resources even in the countries that consider healthcare as a part of social justice. The Author talks about how India can lead with innovations in legislation, policy, governance and finance to provide health for all.

Adequate healthcare is both, a prerequisite and a consequence, of the growth of a country. A health system can deliver public health and medical services, if its solid foundation includes skilled workforce, information systems, medical products, technology, adequate financing and governance. While technology can provide innovative tools to improve health, it is the regulatory framework whichcan provide the enabling ecosystem. It is important that Innovations not be limited to drugs and devices but also include regulations.Ultimately,it is laws that determine financing and structure of healthcare.

The nations of the world have included healthcare in their legal framework in some form.Almost all countries are signatories to one or more international human rights or health rights declarations.

One third of the countries include healthcare as a constitutional right for individual citizens. Russiaand former countries of the Soviet bloc Italy, Spain, Brazil, Philippines and South Africa have maintained health as human right in their constitution. On the other end of the spectrum are countries like the USA, which have no individual constitutional right to healthcare.

In most other countries, the constitution requires the government to provide some form of healthcare. The implementation,however, suffers from deficit of policy, governance or resources even in the countries that consider healthcare as a part of social justice.

India extrapolates health rights from other parts of the constitution.The right to health in India is outlined the Directive Principles of State Policy- Articles 42 and 47 and the fundamental right to life as stated in article 21.

Article 42 states that the State shall make provision for securing just and humane conditions of work and for maternity relief.

Article 47 states that the State shall regard the raising of level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and of drugs which are injurious to health.

Article 21,“The Fundamental Right to Life” guaranties individual life.

The Indian judiciary has interpreted the “Right to Life’ in many ways. It has held that humane working conditions, health services and medical care are an essential part of Article 21. Public interest litigation, as well as litigation arising out of claims made by individuals,has generated substantial case law showingright to health is an integral part of the Right to Life.

For technological innovations to flourish in its current stage of development, India needs more proactive regulations to progress towards universal healthcare.

Currently the Indian government spends about 1 percent of GDP on healthcare. Compare that to 3 percent in China and 8.3 percent in the USA. Private expenditure on healthcare is in addition to public expenditure; approximately 70% of health expenditure in India is from private sources.

A study done by PGI Chandigarh, suggests that universal health care services for entire 1.2 billion population, the annual cost of providing preventive and curative services will be INR 2415 billion (USD 54 billion). This would amount to increasing the allocation to health sector from current nearly 1% to 3.8% of GDP.

Indian business association, FICCI and consultants EY, estimated in 2012 that universal health cover would require government health spending to increase to 3.7-4.5 percent of GDP.

The current government, under the National Health Assurance Mission, would provide all citizens free drugs and diagnostic treatment and insurance cover to treat serious ailments. It would cost an estimated $11.4 billion annually.

In 2010, a High Level Expert Group on Universal Health Coverage recommended increasing public financing from 1% of the gross domestic product to at least 2.5% to provide essential health care package through tax funding and employer-provided insurance.

The Lancet published an India focused issue on health in Jan 2011. The lead authors (K SrinathReddy, Vikram Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar, Lalit Dandona),summarized the recommendations of various working groups as ‘call to action’ as follows. They propose the following targets to be achieved by 2020 through the creation of the Integrated National Health System with three overarching goals: ensure the reach and quality of health services to all in India; reduce the financial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.

Service delivery

• The entire population should be covered by an entitlement package of health care with

financing from a combination of public, employer, and private sources. Full range of relevant diseases need to be included in the entitlement package of health services with cost-effective interventions that include health promotion and disease prevention.

• All health practitioners and facilities in the public and private sectors have to be registered with the Integrated National Health System.

Health Financing

• Public spending on health should be increased from 1% to 6% of the gross domestic product, and 15% of tax revenues—including new taxes on tobacco products, alcohol, and food with little nutritional value—should be earmarked for this purpose.

• Reduce the proportion of out-of-pocket spending from 80% to 20% of the total health expenditure.

• Increase spending on health research to 8% of the health budget.

Human resources for health

• Establish the Indian Health Service with guidelines developed through an autonomous National Council for Human Resources in Health.

• An updated training curriculum should be fully in place for medical and allied professions that is relevant to the situation in India.

• Establish suitable incentive structures to retain health providers in underserved areas.

Health information system

• Have in place comprehensive health information and surveillance system that covers all major diseases, health-system issues, and key social determinants, which also facilitates assessment of public health interventions.

• Establish adequate research capacity in India to investigate and report key issues that affect the health system and policy for further improvements.

• Have in place a fully functional autonomous council that compiles and synthesizes relevant information to develop guidelines for evidence-based health care and its assessment.

Drugs and technology

• Implement a national network of pharmacies for generic low-cost drugs for the entire population.

• Establish mechanisms for bulk purchase of patented drugs at low cost.

• Have in place mechanisms to check and control the use of perverse incentives by pharmaceutical and biotechnology companies for health-care providers.

Governance

• Have in place mechanisms to make functional the components of the National Health Bill.

• Have a system in place that requires all middle and senior functionaries in public health to have relevant training in public health.

• Ensure devolution of responsibility for health care to district management systems along with accountability mechanisms and explicit community participation (The Lancet, Jan 2011).

India, at current stage of development needs more healthcare in every form and not less. Multiple studies have confirmed the fiscal feasibility and for technological innovations to flourish we needs a progressive enabling ecosystem.

Opposition to right to health emphasizes that it could increase the fiscal deficit;it could create shortage and increase the wait time for medical services, which would lead to rationing and lower the quality. It could also cause people to overuse health care resources. While appreciating valid opposing view, human development is not possible without guaranteed healthcare. Financial burden of a single episode of disease pushes millions of Indians into poverty, which stifles the market for technological progress.

Health and longevity have improved as never before in human history. And with explosive growth in the knowledge of human biology and genetics, it is likely that the life span will increase exponentially. It may even change the very definition of health to include happiness, intelligence and aesthetics as components of a new paradigm. It is imperative that innovations in legislation, policy, governance and finance will have to stay ahead of the burgeoning technologic innovations and not fall behind to irrelevance. It is important to have innovative strategic thinkers in the leadership positions that understand biology, healthcare, governance and finance.

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