1947 to present: A remarkable journey
Healthcare in India has come a long way over the past 75 years. Core health indicators then and now tell us the journey India has made thus far. Life expectancy rose to ~70 years from 33 years; Infant mortality dropped from ~200 per 1000 to 27 per 1000; maternal mortality that was nearly 2000 per 100,000 came down to ~100 per 100,000. Institutional births rose to 89% from 39% in the last 15 years. Eradication of smallpox and polio stands out as the single greatest achievement. Doctors increased from ~60,000 in the 1950s to ~18 lakhs (~13 lakhs allopathic and ~5 lakh AYUSH doctors); nurses increased from 16,500 to 35 lakhs during the same period. Nearly 13 lakh ASHA workers connect communities to primary health care services across rural India.
Waiting times to access healthcare services are much shorter in India than in many advanced countries despite the lower health workforce or beds to population ratio. Indian pharma and vaccine industry not only meet the domestic needs but accounts for supplies in many countries. The remarkable turnaround in supplies of personal protection equipment, ventilators, PCR, and rapid antigen tests and vaccines during COIVD-19 is a testimony to the resilience of India’s healthcare industry.
A lag in progress compared to other countries
Despite the progress, India ranks lower in many health indicators compared to countries that gained independence at the same time. We have wide disparities between states, between genders, between rural and urban people, between castes, between the educated and the uneducated, and between formal and informal labor. We account for 15% of global maternal deaths and ~27% of global tuberculosis cases. 43 percent of our children continue to be undernourished and ~20% continue to be vulnerable to diseases because of no or incomplete vaccination. The sex ratio at 935 females to 1000 males places us at 192nd position in country rankings. Our public health expenditure at ~1.2% of GDP is one of the lowest in the world. Though out-of-pocket expenditure as a percentage of total health expenditure has declined from 62.4% in 2014 to 48.8% as per a recent study, it continues to cause financial hardships to many low- and middle-income families. Despite the progress, our health workforce and health infrastructure are grossly inadequate to meet the healthcare needs of people as per the growing disease burden.
India’s resilience in the face of the devastating COVID-19 pandemic
Despite weak and fragile health systems, we, as a nation, displayed courage and resilience in absorbing the health shock imposed by the pandemic. The innovative and entrepreneurial spirit of India was evident in the way we ramped up the production of personal protection equipment and COVID testing infrastructure, the way we developed, produced, and administered our own vaccines, and the way we even supported other countries in accessing essential drugs and disposables, the way we used telemedicine to reach people, the way community health workers connected with rural people, and the way people had access to enough food to eat. The rapid recovery of our economy is a testimony to our ability to absorb shocks and recover from them.
The need to make our health systems stronger and more resilient
We still do not know how many excess deaths India really had over the last two and half years, how many children missed their vaccines, how many people missed their dialysis, how many with cancer, tuberculosis, HIV, etc., missed their drugs, how many people suffered heart and brain strokes at home, how many could not deliver in the institutions, how many lost their jobs, and how many were pushed into debts and poverty. We should know and face the truth so that we introspect sincerely to understand our strengths and weaknesses, learn from our mistakes, and build back our fragile health systems into stronger and more resilient ones.
Will our current health missions move us towards the goal of ‘Swasth Bharat’ and ‘Ayushman Bharat’?
The National Health Policy 2017 has outlined a road map towards transforming India into a healthy nation with long lives. The establishment of the National Medical Council to drive reforms in medical education, passing of the bill on allied health professionals, setting up of AIIMS in each state, and a medical college in each district, and common entrance and exit examinations to improve transparency and quality are some of the measures at strengthening human resources for health.
Programs launched under the Ayushman Bharat mission are aimed at improving financial protection for nearly 500 million people under Pradhan Mantri Jan Arogya Yojana (PM-JAY), strengthening comprehensive primary health care by upgrading subcenters and PHCs into 150,000 health and wellness clinics, building a unique national digital health architecture to drive transformation across health systems under Ayushman Bharat Digital Mission (ABDM), and strengthening healthcare and public health infrastructure to face future health shocks under Ayushman Bharat Health Infrastructure Mission (ABHIM).
There are many vertical programs directed at child nutrition; mother, neonate, child, and adolescent health; communicable diseases like tuberculosis, leprosy, HIV, vector-borne diseases, hepatitis, antimicrobial resistance, etc.; vaccination; non-communicable diseases like cardiovascular, respiratory, neurological, renal diseases and cancers; mental health, elder care, palliative care. While these programs have achieved significant gains, there is still potential to make them more efficient, integrated, and effective.
Initiatives to improve economic and social development and welfare have a significant impact on the health status of populations. Programs that aim to deliver clean drinking water to every household (Jal Shakti), clean cooking gas to prevent indoor pollution (Ujjwala), improve general sanitation and hygiene (Swatch Bharat), portable ration card system to access subsidized food items, clean energy to reduce environmental pollution, financial inclusivity through Jan Dhan accounts to receive social benefits, digital inclusivity under Digital India mission, improving wellness through Fit India and Eat Healthy India program, etc., have a significant impact on health status and longevity of people. The so-called social determinants of health account for three-fourths of the increase in longevity of life.
We can definitely advance in our journey towards the goals of Swasth Bharat and Ayushman Bharat If India can implement all above-mentioned programs inefficient, coordinated, and effective ways. It needs the participation of all the health system stakeholders – governments, non-government, private industry, civil society organizations, and people in a collaborative spirit towards a shared purpose of “Health for All”.
Where do we want to be by 2047 – 100th anniversary of our precious independence?
1. We want people to live long, healthy lives
2. We want to control our population disease burden and eliminate preventable premature deaths
3. We want everyone, irrespective of age, gender, caste, religion, education, employment, or place of living to access safe and effective care when they want, where they want, and how they want.
4. We want to ensure that no one should face financial hardships in accessing healthcare
5. We want to secure people against future health shocks from infections, wars, climate changes, financial recessions & depressions, bioterrorism, biohazard etc.
Dr. Krishna Reddy Nallamalla,
Regional Director, South Asia, ACCESS Health International
(With input from Stuti Shukla, ACCESS Health International)