While releasing India’s progress report on the Millennium Development Goals (MDGs) on July 7, Niti Aayog member Bibek Debroy remarked that the country had lagged behind on health goals like maternal and infant mortality as well as basic sanitation, despite having achieved substantial success in poverty reduction. India’s economic progress has clearly not been matched by improvements in health.
Tellingly, India lags behind Sri Lanka, Bangladesh and Nepal in indicators like infant mortality rate, child immunisation rate and even total life expectancy. Even as private urban tertiary care centres vie for global medical tourism, the stark failure of basic public health services profiles the paradox of India’s health system. While India has become the global pharmacy for inexpensive generic drugs, the draft National Health Policy put out in January tells us that over 63 million Indians face the threat of poverty each year due to unaffordable health care expenditure. Huge inter-state disparities in health indicators testify to the widely varying quality of health services across India.
The 2015 deadline for meeting the MDG targets turned the spotlight on our poorly performing health system. The Sustainable Development Goals (SDGs) will replace the MDGs this September at the United Nations (UN). Can we resolutely revamp our health system to make it capable of delivering the targets set by the new health goal? As Toni Morrison writes in the Song of Solomon, ‘if we do not create the future, the present extends itself’.
The lone but lofty health SDG calls on all countries to “ensure healthy lives and promote wellbeing for all at all ages”. Tagged on are specific targets to be achieved by 2030: reduce maternal mortality to less than 70 per 100,000 live births (we are at 178 now); end preventable deaths of newborns and under-five children; end the epidemics of HIV, TB, malaria and neglected tropical diseases; reduce by one-third premature mortality from non-communicable diseases (deaths before 70 years from cardiovascular and chronic respiratory diseases, cancers and diabetes); halve deaths and injuries from road traffic accidents; provide universal health coverage, including financial risk protection, and access to essential medicines and vaccines to all; universal access to sexual and reproductive health services; substantially reduce harm from hazardous chemicals and pollution of air, water and soil.
This ambitious but essential agenda recognises health as pivotal to development. Even as our aspirational draft national health policy document of 2015 awaits an uncertain fate, with health remaining at the fringe of budgetary priorities, the SDG for health provides a road map of what a caring society must aim to achieve for its people.
Can we do it? What about the challenge of poor health financing, with states now being asked mostly to fend for themselves? Where will we get the skilled human resources to fill the critical gaps that exist at various levels in our health services? In our mixed health system, how will we get the best out of the public, private and voluntary health care providers, to secure assured and affordable access to quality health services for all Indians?
We can do it, with the right mix of investment, innovation and integrity. Public financing of health must rise, in central and state budgets, to invigorate primary health services, strengthen district hospitals and expand the health work force. Essential health services, drugs and diagnostics must be provided without financial burden, through a system of universal coverage. Different streams of health financing must be channelled into a single payer system that procures quality care as a cashless service from a mix of providers. Several successful models exist across the world to show that a fine balance of economy, efficiency and equity can be achieved by health systems which are configured for universal health coverage. The broad framework has to be common across states, with enough room for context-specific modifications. No Indian should be denied needed health care wherever he or she may reside, work or travel in the country.
Innovation, in the face of physician non-availability in many rural areas and disorganised urban primary health services, calls for technology-enabled nurse practitioners and community health workers to provide frontline services and chronic continuous care in community settings. Auxiliary nurse midwives, armed with android tablets configured with an array of diagnostic tests and decision support systems, are now working in six districts of Jammu and Kashmir to transform maternal and child health services. Mobile phones have become powerful tools in the home management of diabetes and hypertension. Telemedicine and mobile medical units are bridging distance to improve access. As the role of allied health professionals is expanded, millions of young persons, especially women, can be gainfully employed, invigorating both health and the economy. Indian systems of healing too can help to reduce unmet health care needs.
This action agenda requires political commitment to a vision that values health as a societal imperative for accelerated, sustainable and equitable development. It also calls for integrity in delivering that vision through good governance which optimally utilises health system resources. This involves rational and transparent priority setting, corruption free procurement processes, standard management guidelines, robust regulatory systems and timely monitoring and evaluation. The malaise of purchased seats in medical colleges and the dubious role of councils that regulate health professional education has been debated for long, even before Vyapam shocked the nation. It calls for grit and guts on the part of policymakers to clean these Augean stables.
As India celebrates another Independence Day, can we hope that health will move to the centre stage of our development agenda and become the talisman of good governance? Even if SDGs are adopted at the UN, the health of our people is one that we must Make In India!
K Srinath Reddy is president, Public Health Foundation of India. The views expressed are personal.