“How far can a mother on foot walk with a sick baby? Healthcare must be available within that distance.”
– The First Chinese National Congress on Health
A new government brings new hope and possibility of new approaches. The new government led by Prime Minister Modi has included health as the priority and proposed developing a new National Health Policy and National Health Assurance. A window of opportunity has opened for fresh thinking on the challenges and solutions in the health sector. While developing a comprehensive National Health Policy will take time – may be few years, what can be the new National Health Action Agenda ?
The challenge
The challenge of providing healthcare to 125 crore people carrying a double burden of disease is a formidable one. In the long history of mankind, germs and diseases have killed more people than the arrows, guns and bombs have. When the stock markets are rising every day to new heights, we must remember that economic growth can not be maintained by sick people. Good health is a precondition for economic growth. We need to protect as well as nurture our human capital to be able to actualise the growth opportunities. However, good health is not just a precondition for economic growth; rather, it is a goal of economic growth. The increased income must ultimately enhance health, human development and happiness.
India faces a double burden of disease. The first burden, the diseases of poverty, includes malnutrition, maternal and child health problems and communicable diseases. The infant mortality rate (IMR) is at 42; nearly 15 lakh children die every year – the most in any single country. More than half of these deaths, total nine lakhs per year, are deaths among neonates – within one month of birth. Nearly 42 per cent children are malnourished, 55 per cent women are anaemic (NFHS-3), and every year two million new cases of tuberculosis occur.
While we continue to face the first burden of diseases, albeit at a reduced level than earlier, India faces another, more difficult burden of non-communicable diseases (NCD) – diabetes, hypertension, stroke, heart disease, cancer, addiction and mental health. The medical science has no vaccine or cure for the NCDs. They are lifelong. It is better to prevent them than struggle to treat millions of incurable patients with enormous medical and social costs.
The choice
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| Dr Abhay Bang |
How should we provide healthcare to people living in nearly one million villages, hamlets, towns and cities? India currently spends about five per cent of its GDP on healthcare, roughly $100 per capita per year at PPP (Shiva Kumar, Lancet, 2010). Only 20 per cent of this care is provided by the public sector (about one per cent of GDP) and nearly 80 per cent by the private sector.
Should we go the way of the developed countries – a hospital-based, high-cost curative care model? This model costs the European countries 8 to 10 per cent of GDP, or when private insurance financed, 17 per cent of the GDP in the US. The per capita annual cost of healthcare in the US is $6,000. Worse, if the current trend continues, in the year 2100 the US will need to spend on health care an absurd 97 per cent of GDP! Such healthcare will kill any country.
These healthcare models from the West are wasteful, generate perpetual dependence and are impossible to sustain economically. Access to healthcare certainly needs to be assured, but in doing so, generating new disease called ‘unlimited consumption of medical care’ or ‘dependence for health’ should be avoided. Then what is the alternative?
The Sanskrit word for being healthy is ‘Swa-stha’, which literally means one who is based in the power of self, is independent. One who is not is called ‘A-swa-stha,’ unhealthy or sick. The concept of health, in India, is inalienably linked with autonomy and freedom. New Health Policy must include the freedom to be healthy as well as the capacity to care for health. This can be better expressed by the term – Aarogya Swaraj.
Let me propose a ten point action agenda for the new health minister.
Control the 20 health terrorists
The landmark Global Burden of Disease Study (2010) found that the top ten causes of death and life-years lost in India were respiratory infections, three main causes of neonatal deaths i.e. preterm birth, birth asphyxia and sepsis, coronary heart disease, stroke, diarrhoea, tuberculosis and self harm (suicides and injuries). The same study identified high blood pressure, tobacco and alcohol as the top three risk factors causing diseases in the world. The list of top ten risk factors in India includes, in addition – indoor smoke, air pollution, child malnutrition, anaemia, inadequate breast feeding, diabetes and low fruit intake.
Healthcare will be needed for several diseases, but control of these ‘20 health terrorists’ – ten diseases and ten risk factors – needs to be the highest national health priority. A national plan of control with time bound goals and targets needs to prepared and pursued relentlessly.
Universal Health Literacy by 2020
Knowledge about health is the greatest protection. Each citizen, especially the women, children and youth should be empowered by making them health literate. Knowledge of health should be an essential content of education at every level. Schools, work places, media, advertisements, distance learning, mobile phones, social media, healthcare movements like yoga – all need to be harnessed creatively to achieve the goal of Universal Health Literacy by 2020.
Freedom from tobacco
Tobacco as the major cause of disease, death and healthcare cost is now globally acknowledged. India is no better. A sample survey by SEARCH in Gadchiroli, one of the poorest districts in Maharashtra, revealed that people annually spent Rs 73 crores on tobacco, more than the total annual expenditure by government on health (Rs 10 crore), ICDS (Rs 14 crores) and MNREGA (Rs 22 crores). Following the success of ‘Tobacco-free New York’ several cities in the world are now aiming similarly. A national drive to make villages, towns and cities tobacco free will be a highly desirable mission. This will require policy, regulation, enforcement, education, de-addiction and monitoring.
Child-death-free village
Nearly 15 lakh child deaths occur each year, mainly in villages and slums, most often without access to healthcare. The global reviews (Lancet 2003, 2005) have concluded that two thirds of these can be averted by ensuring that a selected public health interventions reach all newborns and children. India has its own home grown scientifically proven Home-based newborn and child care (HBNCC) model which is now a part of the National Rural Health Mission (NRHM). It is the most cost effective health care intervention ($7 per life year saved) for child survival. Proper implementation of this package can reduce child mortality by nearly 50 per cent. Moreover, immunisation including newer vaccines, better maternal care, optimum breast feeding and introducing complementary feeding at the age of six months will permit India not only achieve the Millennium Development Goal (MDG) of IMR less than 28 but even exceed.
A scheme of awards for making the village or slum child death free for three successive years will be an attractive, awareness raising, popular and achievable goal. That will mobilise communities and the healthcare system to achieve a measurable goal.
Tribal Health Plan
Tribal people (10 crores) have the worst socio- economic as well as health indicators. States with large tribal population, and 150 districts with more than 25 per cent of population being tribal invariably have poor health and healthcare. The promise of the Constitution of India, the sense of justice and the public health considerations all suggest that health of tribal people should be specially focussed up on. After failing for 65 years to provide an equitable health care in tribal areas, at last there is an urgent need to develop a Tribal Health Plan in a bottom up manner, to redesign the healthcare delivery system in tribal areas appropriate to the terrain, culture, healthcare needs and availability of human resource. Tribal health will be the ultimate test of the healthcare system in India.
ASHA and ASHOK Empowered communities
Community Health Worker (CHW) is a globally accepted concept. They can make health knowledge and care available in villages and slums, to each home and hut ! India already has deployed 9 lakh female accredited social health activists (ASHAs) in rural India. Based on the studies done by SEARCH in rural population we estimate that there is a need for 12 hours of daily healthcare work per 1000 population. (HLEG Report, 2011, Planning Commission) Thus at least two CHWs in each village are needed. Addition of a second CHW, preferably a male, to reach out to men, is highly desirable. He may be named ASHOK (free of grief).
The ASHAs, and ASHOKs, each one million, to become effective will need several improvements in the step motherly way the ASHA scheme is currently executed. High priority, wider job description, 100 days of training, a functional support structure in the field and more resources with rational incentive structure will make these two million women and men in communities true ASHAs (hope) and ASHOKs. Based on their potential impact on health care to people, ASHA and ASHOK Training Units (AATUs) one per 200,000 population, will be as important as the medical colleges.
Healthcare costs – the out-of-pocket expenses – cause nearly three to four crore people slip below poverty line annually. A larger number is deprived of the wonderful gifts of medical science due to the economic barriers. The largest financial hardship and deprivation is caused by two component costs – the cost of medicines and the cost of medical emergencies. Two initiatives will largely mitigate this hardship, save lives and reduce suffering.
Medicines for all
Since the cost of medicines constitutes nearly half of the out of pocket expenses, and since India has a large drug manufacturing capacity, a goal of making medicines available to the needy is highly feasible. Its essential features will be:
< Include only the essential drugs
< Rational use of medicines
< Use of generic drugs
< Procured by the Tamil Nadu model
< Made available through the public healthcare institutions and through ‘Janaushadhalayas’.
Researchers have estimated that such scheme, at a cost of about 0.5 per cent GDP, can make ‘Medicines for All’ a reality. This will be a vote catcher, note (money) saver and suffering reducer initiative with a mass appeal.
Healthcare assurance
Several countries – Mexico, Brazil, Sri Lanka, China, Thailand have already introduced Universal Health Care partially and incrementally. Principally, India has already accepted the concept in the 12th Five Year Plan. The challenge is how to implement and finance it. Highest level of political will, management skill and the engagement of all stakeholders will be needed. India needs to make the beginning. It is important that it becomes universal, is preventive and primary care oriented, empowers people, and finally becomes a health assurance and not a medical insurance of sky rocketing costs as in the US.
Information and accountability
What is monitored gets done. A complete and real time information system reporting the health and healthcare data is essential for programme management.
Involvement of communities in planning, monitoring and social auditing will make healthcare system efficient and accountable. Outcome audit and accountability are essential for making the health care a reality.
Public-Private-People Partnership (PPPP)
Who will deliver all these ? A policy framework which engages the public, private and the people sector; and a governance culture which permits each sector to play its role will be the only way to meet our original challenge – to provide health and healthcare to 125 crore people or, in other words, the Aarogya Swaraj.
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