Express Healthcare chronicles 16 areas of change in Indian healthcare and retrospects on their impact
Augmenting Health Indices
The last 16 years have been eventful for India, dotted with significant achievements and failures. The recently released United Nations Development Programme’s Human Development Report highlights that India’s gross national income has more than doubled over the last 15 years, from $2,522 (PPP) to $5,497 between 2000 and 2014. This period also registered better human development outcomes; it went from 0.462 to 0.609 between 2000 and 2014.
There have been noteworthy improvements in health indicators such as life expectancy, infant mortality rate (IMR), maternal mortality rate (MMR) etc as well due to increasing penetration of healthcare services across the country, extensive health campaigns, sanitation drives, increase in the number of government and private hospitals in India, improved immunisation, growing literacy etc. Initiatives such as Janani Shishu Suraksha Karyakarm, Janani Suraksha Yojana, Reproductive, Maternal, New – born, Child and Adolescent Health Services; and national programmes to curb incidences of diseases such as polio, HIV, TB, leprosy etc have also played pivotal roles in improving India’s health indicators. Malnutrition in children, another serious concern in India, is also being addressed at a rapid rate than ever before, as evidenced by the findings of India Health Report: Nutrition 2015, also released by PHFI recently. As per the report, the rate of decline in child undernutrition has grown exponentially between 2006 and 2014. It reveals that stunting rates for children under five reduced from 48 per cent to 39 per cent, resulting in less stunted and wasted children.
Yet, a huge disparity in the availability of healthcare resources continue to exist in India. The rural-urban divide is considerable when it comes to healthcare access. This is clearly reflected in the health indicators as well. While fairly-developed states like Kerala, Maharashtra and Tamil Nadu have brought down their IMR, TFR and MMR rates to achieve the MDG goals of 4 and 5, states like Assam, Jharkhand etc continue to grapple with these issues even today. Thus, the need of the hour is to scale up public health services, increase the number of trained health professionals and augment public healthcare spending to ensure adequate healthcare coverage.
Crackdown on Corruption
Corruption, a social evil in India, has not spared the healthcare sector. Recently, several articles in various national and international publications have highlighted this issue. For instance, the British Medical Journal (BMJ) ran a series of stories on corruption in healthcare, with special focus on India. It revealed that the kickback policy is rampant within the healthcare sector in India. The National Public Radio in the US also aired a news in March this year about Dr Kunal Saha, an Indian doctor who won a case of medical negligence that resulted in his wife’s death and was given a compensation of Rs 11.41 crores. The story was about the prolonged legal battle he had to fight over 15 years before India’s apex court finally gave him the compensation. Dr Kunal’s story was an eye opener about the kind of fraudulent activities happening in some well-known medical institutes in India. Satyamev Jayate, a popular television show hosted by renowned actor Aamir Khan, also turned the spotlight on the various malpractices in India’s healthcare sector. A recent Bollywood movie ‘Gabbar is Back’ was also based on the corrupt practices within Indian hospitals.
A story covered by Express Healthcare also unearthed that several parents whose children have given the medical entrance exam in 2015 were receiving text messages by agents who claimed to represent various medical colleges in and around Mumbai. One of the parents shared the snapshots of these messages with Express Healthcare correspondent. As per these messages, colleges had quoted capitation fees that range anywhere between Rs 30-50 lakhs. Moreover, these parents also informed that they receive calls with claims that they can hold seats in government as well as private medical colleges. It was also revealed that agents quote around Rs 5 crores for a post graduate seat in Navi Mumbai’s premium medical college.
The government has taken some measures to curb corruption in healthcare. In a bid to prevent the practice of kickbacks, the government has introduced stringent rules under the Uniform Code of Pharmaceuticals Marketing Ethics (UCPMP) which make it extremely difficult for pharma companies to provide any freebees to medical practitioners. Yet, corruption, a deep-seated evil in our society will not be rooted out with few random measures. More concerted efforts and policies would be needed to bring it under control.
Improved Immunisation
Prior to 1990s, India was a breeding ground for several communicable diseases. Epidemics such as poliomyelitis, diphtheria, haemophilus influenza type B, tuberculosis, pertussis, measles and hepatitis B cost several lives. Polio in the 70s left around 50,000 children crippled every year. TB, HIV and hepatitis had a devastating effect on the economy during the 80s. India’s Universal Immunization Programme (UIP), launched in 1985, sought to bring these diseases under control and better health indices. The programme consists of vaccination against seven diseases-tuberculosis, diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, measles and Hepatitis B.
India’s Universal Immunization Programme is one of the largest public health interventions in the country with an extensive vaccine delivery system. It comprises over 27000 vaccine storage units in 35 states across the country. 80 per cent of vaccination takes place in the outreach sessions, held in thousands each year in more than six lakh villages and other urban belts.
This programme has steadily improved public health in India. In fact, India was declared as polio-free in 2014, a major milestone in the country’s public health scenario. Best practices and lessons learned from India’s initiative are being applied by polio-endemic countries like Nigeria, Afghanistan and Pakistan. The programme now serves as a model for health programmes globally – a case study which demonstrates that it is possible to achieve ambitious health goals through high vaccination coverage, even in areas with weak health systems.
This year, the government also introduced the pentavalent vaccine which will provide protection to infants from five life-threatening ailments. Moreover, Mission Indradhanush launched in 2014 also seeks to strengthen immunsation coverage in India as it aims to cover all those children who are partially vaccinated or unvaccinated. This initiative has a special focus on 201 high focus districts. Of these, 82 districts are in just four states of UP, Bihar, Madhya Pradesh and Rajasthan. Moreover, 297 will be targeted for the second phase. These districts account for nearly 50 per cent of the total partially vaccinated or unvaccinated children in the country.
Mission Indradhanush also provides protection against seven life-threatening diseases. In addition, vaccination against Japanese Encephalitis and Haemophilus influenza type B will be provided in select districts of the country. Vaccination against tetanus will also be provided to pregnant women.
These measures have helped improve immunisation coverage to a great extent. Between 2009-2013, it has increased from 61 to 65 per cent. The programme is being expanded and implemented at full throttle to achieve the target of full coverage by 2020. It seeks to accelerate the process of immunisation by covering five per cent and more children every year.
Thus, India has come a long way in immunisation but has to traverse far before achieving its targets.
Enhancing Safety in Healthcare
Healthcare workers are constantly exposed to several safety and health hazards such as needlestick injuries, latex allergy, bloodborne pathogens, potential chemical and drug exposures, laser hazards, radioactive material and X-ray hazards, waste anaesthetic gas exposures, workplace violence, and stress. Protecting healthcare workers from the many risks they are subjected to is a big challenge for Indian hospitals.
In the last few years, rising incidences of needle stick injuries, transmission of HINI influenza virus to healthcare workers while treating patients, terror attacks on hospitals, growing mob attacks on doctors in public hospitals, the life and death of Aruna Shanbhag, a victim of assault and rape at Mumbai’s KEM hospital drew attention to the urgent need for measures to asssure safety and security of healthcare workers in India.
These incidences became a point of debate on several occasions, making it imperative to take stock of the current situation and implement measures to ensure healthcare workers’ safety. Today, most hospitals in India have set up departments and grievance cells that look after surveillance and monitoring of infection rates, needle stick injuries, safety incidents, etc.
Indian hospitals have also introduced training programmes for their employees on several topics related to hygiene, safety, security and overall well being. Some of them consist of sessions on how to deliver care and handle blood samples of patients suffering from HIV, hepatitis B and C, and many other blood borne infections. Hospitals are also conducting vaccination programmes for their hospital staff. Apart from this, Indian hospitals are focussing on HR policies that offer better working environment and security to their employees. For instance, the implementation of the Sexual Harassment Act at Workplace offers a certain measure of protection to women healthcare employees.
Yet, much more needs to be done in this arena to improve the working conditions for health workers in India, in the coming years.
Boosting Access to Medicines
Despite being called the pharmacy of the developing nations, over 65 per cent of India’s population did not have access to essential medicines till the government renewed its focus on procurement and distribution of medicines.
Experts report that during the mid-1980s, approximately a third of the medicines prescribed during hospitalisation in public health-care facilities were supplied for free; however, during 2004, the mean availability declined sharply to approximately nine per cent. For outpatient care, free medicine supply declined from 18 per cent to about five per cent over the same period. There were reports of significant variations in the availability and stock-outs of essential medicines among different states in India.
Several factors have influenced the supply and use of essential medicines in the public healthcare system. Poor and incomplete stocking of essential medicines because of inadequate budgetary support is one of the main reasons. Other factors are poor supply chain management leading to frequent stock-outs; prevailing prescription practices leading to inessential and costlier prescriptions for medicines from outside the public healthcare system; and a lack of confidence in the quality of medicines supplied through the public healthcare system. In addition, while availability may not be a significant barrier in the private sector, affordability often becomes a critical issue. To combat this problem, the Jan Aushadhi scheme was initiated by the government in 2008. The aim was to achieve three objectives: make generic medicines available in the market; encourage doctors in government hospitals to prescribe generic medicines; and lastly, reduce out-of-pocket expenses for patients. Although 150 more such stores were opened subsequently over the years, 85 are working currently. Under the programme, 319 essential drugs were identified to be supplied through these stores, but only 85 drugs belonging to 11 therapeutic groups could be sold due to several reasons. The Bureau of Pharma Public Sector Undertakings of India has been designated as the nodal agency for running the programme. The programme, however, did not make much progress as expected even after seven years of its launch on account of the half hearted approach of the main stakeholders.
As on December 10, 2015, there were 112 Jan Aushadhi stores operational in the country. The government is trying to start 200 new Jan Aushadhi stores by the end of the current financial year across the country. With the government’s plan to expand the number of drugs under the programme to 504, including the 85 available now so that more drugs required for treating lifestyle diseases could be covered, the Jan Aushadhi scheme has received a fresh lease of life.
Emphasis on Accreditation
Quality standards for hospitals and other medical facilities improve the structure and process of care, with a good body of evidence showing that accreditation programmes improve clinical outcomes. In India, the healthcare sector is unstructured, both in terms of infrastructural capability and availability of medical personnel. There is a vast difference in the quality of rural and urban healthcare, and the services provided by private and public healthcare systems are accompanied by a significant difference in cost. Against this backdrop, accreditation appears as a favourable option to standardise care.
Experts believe voluntary accreditation of nursing homes and hospitals began in the 1930s in India with some refinement to standards being set in 1952. However, there was renewed demand for accreditation in the 1990s and recently, there has been a dramatic increase in stakeholder interest due to growing awareness of rights, media coverage, greater consumer (patient) involvement, increasing costs of care and medical tourism.
National Accreditation Board for Hospitals & Healthcare Providers (NABH), a constituent board of the Quality Council of India, has been set up to establish and operate an accreditation programme for healthcare organisations. The board sets benchmarks for the progress of the healthcare industry. Further, the accreditation standards released by NABH are, in turn, accredited by International Society for Quality in Healthcare (ISQua). NABH has accredited about 320 Indian hospitals in India till date. Several hospitals in India have also gone for Joint Commission International (JCI) accreditation.
Thus, we have come a long way from the time when accreditation was a term that patients had rarely heard about.
Bettering Treatment Outcomes With Organ Donation
Accessibilty of medicines, advancements in medical technology, growing health research, organ donation, improvement in the quality of care, enhanced health indices etc have led to better treatment outcomes in India. In fact, organ donation is playing a major role in saving a lot of lives. Cadaver transplants is also gaining acceptance in the community, especially in Tamil Nadu. In 2008, the state government put together systems and procedures to introduce the Cadaver Transplant Programme (CTP).
The majority of organ donations in India are by living related donors, often involving considerable risk. Deceased donation following brain death can bridge the huge gap between the requirement and availability of organs in India. It is estimated that there is a need for more than 1, 75,000 kidneys, 100,000 livers, 50,000 hearts, and 20,000 lungs in a year. A robust organ donatio programme could give many terminally ill patients a fresh lease of life. The government should support the programme by providing better storage and transportation facilities.
In the last two years, donations resulted in 1150 solid organs like kidney, liver, heart, lung, pancreas and intestine being retrieved.
One of the major reasons for this success is the improved transport facility called ‘green corridor’. The first green corridor was initiated in Chennai to transport an organ from one hospital to another within the city itself. However, in September 2014, a heart was transported from Bengaluru to Chennai in two hours with the help of different stakeholders. Following this, many cities understood the value of green corridor and similar feats was achieved in Mumbai where the donor organ came from Pune, Delhi-Gurgaon and even Indore.
Fortifying Legislations
Legislations play a vital role in improving public health. They assist in creating public health agencies, defines their roles and provides authority to ensure quality health services. However, given the multi-faceted and fragmented nature of the Indian healthcare industry, challenges in regulating the sector is immense. Yet, several important policies and laws have been drafted and brought into effect in the last two decades. A few notable mentions would be:
The Clinical Establishments (Registration and Regulation) Act, 2010: It was enacted by the Central Government to ensure registration and regulation of all clinical establishments in India and assure minimum standards of facilities and services provided by them. The Act is applicable to all kinds of clinical establishments from the public and private sectors, of all recognised systems of medicine including single doctor clinics. It sought to standardise healthcare services to an extent.
PC-PNDT Act 2003: The Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 (PNDT), was amended in 2003 to The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition Of Sex Selection) Act (PCPNDT Act). This move was to prevent the use of technology in sex selection and reduce female foeticide and was more stringent than its predecessor.
The Cigarettes and Other Tobacco Products Act (COTPA) 2003: This Act was passed to curb tobacco consumption, a leading cause for rising incidences of cancer and several other non-communicable diseases. It consisted of three important provisions:
- Prohibition on smoking in indoor public places.
- Ban on advertisement of tobacco products at all venues, with a few exceptions.
- Prohibition on tobacco sales within 100 yards of schools to prevent children below 18 years from getting access to such products.
Drugs and Cosmetics Act: It sought to create regulatory provisions for import, manufacture, sale, distribution and export of medical devices and for regulating conduct of clinical trials in India. It also comprises provisions for setting up of a Central Drugs Authority (CDA) for regulation of drugs and cosmetics. Several recent reforms also sought to improve safety and efficacy of clinical trials in India. An Expert Committee set up by Central Drugs Standard Control Organisation (CDSCO) has formulated a good clinical practice (GCP) guideline for generation of clinical data on drugs.
Several other crucial bills such as the proposed Assisted Reproductive Technology (ART) Bill, Mental Health Bill etc are also under consideration. Yet, as it is often the case in India, despite the good intent we fail to implement laws effectively. A lot needs to be done under the this area to ensure more effective legislations to regulate healthcare in India.
Streamlining AYUSH
The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, abbreviated as AYUSH, has been integrated into the Indian national healthcare delivery system to strengthen public health in rural India. The department was created in March 1995 as the Department of Indian Systems of Medicine and Homoeopathy (ISM&H) under the Ministry of Health. AYUSH received its current name in March 2003.
In 2005, the Indian government launched the National Rural Health Mission (NRHM) to improve healthcare delivery in the rural areas of the country, in which AYUSH was integrated as an important strategy. This was done with the objective of offering more treatment options to people as well as a strategy to overcome the shortage of doctors working in the government health facilities. However, the planning and implementation of AYUSH differs across various states, depending upon the existing level of development of AYUSH services in the state. It became a full-fledged ministry in November 2014 after the Narendra Modi-led government came to power.
According to Minister of State (Independent Charge) for AYUSH, Shripad Yesso Naik, in April 2015, the country had 7.37 lakh practitioners of alternative medicine streams registered with them and over 3,600 AYUSH hospitals—including 2,827 ayurvedic, 252 unani, 264 siddha and 216 homeopathic centres operating across the country.
Among them, ayurveda practitioners’ number stands at 3.99 lakhs, while homeopathy practitioners amount to 2.8 lakhs. There are 47,683 unani, 8,173 siddha and 1,764 naturopathy practitioners registered in the country. The minister also informed that there are 25,492 AYUSH dispensaries in the country.
Currently, the government is planning to create a special cadre of AYUSH practitioners and paramedics for village postings to tide over the shortage of doctors in rural India. Sources in the Health Ministry say that the Medical Council of India (MCI) and the Indian Medical Association (IMA) are both being consulted on the proposal and have been asked to come up with modalities. The move legally permits practitioners of the Indian systems of medicine or AYUSH to practice allopathy by getting the required permissions from the MCI, the medical education regulator. The proposal envisages development of training modules in integrated medicine for AYUSH practitioners and paramedics who can then be posted in villages to enable treatment access to the rural population. A good move indeed, if implemented effectively. This strategy can help in increasing access to healthcare in the hinterlands of India. However, there is a need for policies and laws which will ensure quality and standardised care by the AYUSH practitioners.
Strengthening Community Health
The role of community health workers (CHWs) is pivotal to countries like India, which has witnessed phenomenal successes in various fields, yet continues to grapple with several challenges when it comes to healthcare. A WHO Study Group defines them as members of the communities where they work, selected by the communities, answerable to the communities for their activities, supported by the health system but not necessarily a part of its organisation, with shorter training than professional workers. Either paid or voluntary workers, CHWs in India are part of government or national programmes, and have contributed significantly to have help reduce health inequity, one of the biggest hurdles that emerging economies continue to face.
They have helped revitalise primary healthcare and improve community participation in the attempts to achieve targets such as ‘Millenium Development Goals’. CHWs interact with families to improve their health and nutrition and facilitate access to treatment. Through their efforts, India has managed to increase outreach of health services, enhance patient adherence to treatment regimens and provide better health education to the masses. The support and supervision of the community worker is indispensable to the success of community health programmes.
Accredited Social Health Activists (ASHAs), introduced by the National Rural Health Mission (NRHM) in 2005, are the key cadre in India’s community health programme that seeks to improve maternal and child health. The ASHAs have played three major roles: they function as a ‘link worker’, between the underserved population and the health service centres, secondly they are also trained and provided with a kit that comprises condoms, oral contraceptive pills, delivery kits and simple life saving drugs. They are also ‘health activists’ who create awareness on health and mobilise the community towards health planning.
The Khoj programme by the Voluntary Health Association of India (VHAI) is another project which has effectively used community health workers to enhance the knowledge and practice of community members on health, nutrition, water and sanitation.
The Comprehensive Rural Health Project, Jamkhed (CRHP) is another endeavour which works towards the betterment of the rural poor and marginalised. They also mobilised and strengthened communities through a primary community-based healthcare (Jamkhed Model). Recognised by the WHO and UNICEF, CRHP has been introduced to 178 countries across the globe. Reportedly, it has also trained over 22,000 local and 2,700 international representatives from NGOs, governments and healthcare professionals in the CRHP approach. Thus, community health has got an impetus in the last two decades.
Increased Insurance Coverage
In India, most of the health expenditure is out-of-pocket. The amount of money individuals spend on medical treatment come to around Rs three lakh crores annually in India, of which only Rs 20,000 crores are through insurance cover. The rest Rs 2.8 lakh crore is spent on medical treatment, particularly by the poor and lower middle class through out-of-pocket expenditure.
Health insurance, in the form of healthcare financing (Mediclaim), was introduced in India during the 1980s. Through the years, health insurance in India has increased with both private and public companies offering various packages. Although one thing remains the same in India’s health insurance scenario, it is limited to in-patient hospitalisation, outpatient services are not payable under health policies in India.
The World Bank suggests that more than 550 million Indians now have some form of health insurance coverage, representing nearly ten-fold increase over the number a decade back.
The Rashtriya Swasthya Bima Yojana (RSBY), a centrally sponsored health insurance scheme, has been one of the most successful ones. Launched in 2007, it provides coverage to the population below the poverty line. The health insurance cover provided to the poor in Tamil Nadu has also been vastly successful. It has not only helped the poor get treatment but also helped the government to earn money through the insurance claim. The Tamil Nadu government’s popular health card scheme that provided insurance up to Rs two lakhs per family or individual has helped the General Hospital in Chennai alone earn Rs 18 crores last year by way of insurance claims for treatment of poor people covered under the scheme. At present, the RSBY is being implemented in 19 states/ UTs through the insurance mode. Total 3, 68, 36,005 beneficiary families have been covered under the RSBY Scheme.
Yet, medical insurance in India is yet to take off fully and several measures are needed to improve and expand insurance coverage.
Enhancing National Health Programmes
National health programmes, launched by the Government of India, have been playing crucial roles in tackling several serious health concerns, communicable and non-communicable diseases, over the last two decades. They have helped handle increasing disease burdens of emerging and re-emerging diseases such as drug-resistant TB, malaria, AIDS and leprosy with considerable success. Some of them saw accelerated progress in the last two decades and have helped improve the healthcare facilities to the underserved.
Some leading national health programmes are as follows:
Pulse polio programme: Introduced in 1995, it aimed to immunise children in the age group of 0-5 years by administering polio drops during national and sub-national immunisation rounds (in high risk areas) every year. Celebrities like Amitabh Bachchan were roped in to educate the masses about immunisaton against polio. Through extensive campaigning and public awareness ads, the cases of polio reduced drastically. The last polio case in the country was reported from Howrah district of West Bengal on 13 January, 2011. Thereafter, no polio case has been reported in the country. WHO declared India polio-free last year, a major achievement.
The Revised National Tuberculosis Control Programme: It was initiated with the objective of ensuring access to quality diagnosis and care for all TB patients. Several notable activities were implemented under this programme in 2012 to improve its efficacy. These included notification of TB; case-based, web-based recording and reporting system (NIKSHAY); standards of TB care in India; Composite indicator for monitoring programme performance; scaling up of the programmatic management of drug resistant TB services etc. NIKSHAY, the web based reporting for TB programme has enabled capture and transfer of individual patient data from the remotest health centres of the country.
National AIDS Control Programme: Launched by the National AIDS Control Organization, Ministry of Health and Family Welfare from December, 1999, it encouraged and enabled the states to take the onus of responding to the epidemic and promoted growing partnerships between government, NGOs and the civil society. The AIDS – II project of the National AIDS Control Programme also includes a scheme with 100 per cent financial assistance from the central government to state AIDS Control Societies and select Municipal Corporations. Concerted efforts through this programme ensured significant reduction in the number of HIV infections across the country. As per National AIDS Control Organisation data, India demonstrated an overall reduction of 57 percent in estimated annual new HIV infections (among adult population) from 0.274 million in 2000 to 0.116 million in 2011, and the estimated number of people living with HIV was 2.08 million in 2011.
National Programme for Prevention and Control of NCDs: The NPCDCS’ objective is to integrate the non-communicable diseases (NCDs) interventions in the NRHM framework in abid to optimise scarce resources and make provisions to ensure long term sustainability of these interventions. The NCD cell implements and supervises activities connected to health promotion, early diagnosis, treatment and referral, thereby facilitating partnership with labs for early diagnosis in the private sector. It also seeks to create and sustain a fortified monitoring and evaluation system for public health through convergence with the ongoing interventions of National Rural Health Mission (NRHM), National Tobacco Control Programme (NTCP) and National Programme for Health Care of Elderly (NPHCE).
Mission Indradhanush: Launched by the Ministry of Health and Family Welfare (MOHFW) in 2014, Mission Indradhanush’s objective is to ensure full immunisation of all children under the age of two years as well as pregnant women against seven preventable diseases namely:
- Diphtheria
- Pertussis (Whooping Cough)
- Tetanus
- Tuberculosis
- Polio
- Hepatitis B
- Measles
Recently, the vaccines for Japanese Encephalitis (JE) and Haemophilus influenzae type B (HIB) are also being provided in selected states, under this programme.
The way foward
These programmes have significantly contributed to the betterment of public health in India and ensure health access to the rural and remote parts of the country. However, there are several gaps that need to be plugged to improve and optimise their impact. Challenges to be tackled include inadequate funds or delay in releasing them, lack of coordination between the stakeholders, insufficient capacity of well-trained, motivated health workers etc.
It is of utmost importance to address these challenges and thereby enhance the impact of such programmes as it would help India achieve the goal of ‘Health for All’.
Launching the National Health Mission
15 years back, India’s healthcare system suffered from several systemic deficiencies. These included lack of a holistic approach, absence of linkages with collateral health determinants, gross shortage of infrastructure and human resources, lack of community ownership and accountability, non-integration of vertical disease control programmess, non-responsiveness and lack of financial resources. On April 12, 2005, the Government of India launched a major welfare initiative, the National Rural Health Mission (NRHM) in 18 states (including eight Empowered Action Group (EAG) states, the North-Eastem states, Jammu & Kashmir as well as Himachal Pradesh) with weak public health indicators and infrastructure. Eventually, it was extended across the entire country.
The Mission aimed at making the public health delivery system fully functional and accountable to the community, human resources management, community involvement, decentralisation, rigorous monitoring and evaluation against standards, convergence of health and related programmes form village level upwards, innovations and flexible financing and also interventions for improving the health indicators.
One of the success stories being attributed to NRHM is a huge increase in institutional deliveries. ASHAs (around 7.5 lakhs in number) at the grassroot level have mobilised women from valuable community to come to institutions (the number of beneficiaries under JSY had increased from seven lakhs in 2005-2006 to over 86 lakhs in 2008-2009). However, it is critical to ensure that there is corresponding increase in inputs available at the facilities, so that health outcomes for mother and baby are ensured. There definitely have been gains as shown by statistics – infant mortality rate has come down to 53/ 1000 live births, maternal mortality rate has come down to 254/1000 live births and total fertility rate is now 2.7.
In the year 2013, the UPA government, as part of the 12th five year plan, extended the provision of the this mission to the urban poor as well and launched the National Health Mission that included the NHRM and National Urban Health Mission (NUHM). Under the NHM, efforts were taken to consolidate the gains and build on the successes of the NHRM to provide accessible, affordable and quality universal healthcare, both preventive and curative, which would include all aspects of a clearly defined set of healthcare entitlements including preventive, primary and secondary health services.
As reducing maternal and child mortality are the foremost goals of the National Health Mission it has significantly fostered plans for child health in a decentralised manner up-to district level. Steady progress in curbing child deaths has been achieved. India’s under five mortality rate declined from 126 per 1,000 live births in 1990 to 49 per 1,000 live births in 2013.
In 2014, Mission Indradhanush was launched under the NHM to fill the gaps in immunisation. Further on, the ministry has called for the participation and partnership of the private sector in providing accessible, affordable and cost effective healthcare services in the country to complement the efforts of the NHM. It is one of the major initiatives undertaken by the Indian government. However, to ensure its success, it is vital to ensure transparency in its implementation.
Renewed Focus on Sanitation
Sanitation and healthcare very closely interlinked. Hence, in a bid to improve public health in India, several sanitation programmes have been introduced in the country over the years. Central Rural Sanitation Programme, started in 1986, was one of independent India’s initial efforts to provide safe sanitation in rural areas. It focussed on providing subsidies to construct sanitation facilities. Later, it was restructured and renamed as the Nirmal Bharat Abhiyan. The scheme’s revised target was to achieve total sanitation by 2022. Its goal was not only universal toilet coverage by 2022, but also improving health and providing privacy and dignity to women, with the overall goal of improving the quality of life among the rural population.
Sanitation again came into the limelight when in 2014, Narendra Modi, the Prime Minister of India launched the Swachh Bharat Mission. Nearly 95 lakh toilets have been constructed in the rural areas during the first year of the Swachh Bharat Mission.
Advent of Technology
Technology has changed the way we lead our lives, be it the way we shop communicate, work or the way we travel. In the last two decades, advent of technology has also been transforming healthcare delivery. Whether, it is patient interaction, treatment, diagnostics or research, technological innovations have given medical providers new tools to look at the disease and treat the patients more effectively.
Information technology has made patient care more efficient and safer. The Internet has changed everything and its effect is evident on healthcare. From sharing knowledge to bringing doctors and patients closer, the Internet is impacting healthcare in a big way. While electronic health records (EHR) have already created big strides in the centralisation and efficiency of patient information, it can also be used as a data and population health tool for the future. Mobile health is freeing healthcare devices of wires and cords and enabling physicians and patients alike to check on healthcare processes on-the-go. Telemedicine and remote monitoring tools have changed the way healthcare is delivered in India. It has also aided in addressing the industry’s two biggest problems: accessibility and lack of manpower. Several telemedicine centres in smaller towns are connecting patients to specialists in metro cities.
Genomic sequencing has turned the healthcare industry upside down. Personalised medicine is no longer a dream and is being practised in India. With the rapid development in next generation sequencing techniques we are now able to detect defective genes that can be targeted for therapeutic response.
However, the most unmistakable way technology has changed healthcare is by providing new machines, medicines, and treatments that save lives and improve the chance of recovery for billions.
From robotic surgical tools to radio-surgery techniques, and sophisticated imaging techniques to digital microscopes, technology has penetrated every aspect of healthcare
delivery.
Lowering Drug Prices
Despite being a leading exporter of pharma products, India faces a serious crunch when it comes to ensuring access to medicines to its own populace. The majority of the Indian population pays for their healthcare expenses from their own pockets. Reportedly, medications and health services comprise 60 – 90 per cent of this expenditure. Hence, the government over the past two decades has undertaken several measures to regulate the drug market in India and ensure quality and affordability alongwith availability of medicines.
Setting up the National Pharmaceutical Pricing Authority (NPPA), in 1997, under the Ministry of Chemicals and Fertilizers was a major step to make medicines more affordable to its population.
The Pharmaceutical Policy 2002 also furthered the cause of ensuring quality drugs at reasonable prices, encouraging indigenous production of medicines for cost-effectiveness, curbing trade barriers and giving an impetus to in-house R&D efforts of domestic pharma players.
In 2003, the Mashelkar Committee conducted a comprehensive study on the growing presence of spurious and sub-standard drugs in the country and recommended several stringent measures at Central and state levels. The Commitee’s efforts brought to light that the country had only 17 quality-testing laboratories, of which only seven laboratories were fully functional. This highlighted the need for more effective measures to improve the quality of drugs.
The National Pharmaceuticals Policy 2006, also recommended several steps to increase the number of bulk drugs under regulation, regulate trade margins and establish a new framework for drug price negotiations to make drugs more affordable.
In May 2013, the NPPA was authorised by the Ministry of Chemical and Fertilizers (Department of Pharmaceuticals) to regulate the availability and pricing of all the drugs mentioned in National List of Essential Medicines (NLEM), 2011. This led to a dramatic reduction in the prices of 348 essential medicines and the public could avail them at low cost.
An year later, in May 2014, a Drug Price Control Order (DPCO) authorised the NPPA to control prices 108 life-saving drugs that were not mentioned in the NLEM originally. This move also led to significant reduction of several life-saving drugs for diseases such as cancer, HIV/ AIDS, tuberculosis, cardiovascular diseases, diabetes, etc. However, in September 2014, the Department of Pharmaceuticals, Ministry of Chemical and Fertilizers, Government of India issued a notification by which 108 drugs under price control policy were withdrawn with immediate effect.
Thus, several measures have been taken from time to time to improve the availability of quality drugs, yet the verdict on their impact remains mixed. Several times, these steps for drug regulation have come under scrutiny and criticism. The need of the hour is to revamp the system and put better measures in place for further progress.
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