The healthcare moonshot
The time has come to develop a realistic roadmap to realise the idea of access to health care as a fundamental right for all citizens of India. In India, the National Digital Health Mission and Ayushman Bharat Yojana rollout by the government have sounded the intent. Also, the Lancet Citizens Commission for Reimagining India’s Health Status, which the authors serve on, will present a report to the nation in its 75th year of Independence of a path to implementing Universal Health Care in India by 2030.
The Commission’s work towards universal health care has multiple dimensions to it – financial, human resources, governance of health systems, citizen engagement, and technology. All are important, of course, and the roadmap’s success will depend on all dimensions succeeding in execution.
Historically, technology missions with ten-year horizons have fared well if disruptive and almost outlandish goals drive them:
*) Send a human to the moon;
*) Connect the world with the internet;
*) Sequence the human genome;
*) A unique ID for 1.3 billion citizens;
*) Create vaccines for novel diseases in under a year;
*) Fold proteins using high performance computing and machine learning
We call these “moonshots” in honour of the first example in modern times. So, what is the moonshot for health care?
Universal Health Care for all citizens of India by 2030 at a health expenditure of ₹1,250 a month per capita (USD 200 per annum).
This amounts to approximately ₹20 trillion per year in 2021 currency. We should recall that the 2021-22 public health budget is ₹2.2 trillion which is at 1% of the Gross Domestic Product (GDP) and there is a commitment to raise the share of public health expenditure to 2.5% of the GDP. There is also the commercial health insurance payer contributions and out-of-pocket expenditure towards health care.
The delivery of adequate services would seem an impossible goal given international experience. This is achievable only if we are willing to take a fresh look at health systems. In the rest of this note we sketch some ideas of how a technology-driven approach can make this a reality.
• Patient at the centre (sometimes with a healer) – personal health records, digital health lockers, portability across health exchanges.
• Preventative health care – population scale vaccinations, realign with our traditional knowledge. Use affordable sensor technologies and gamification for encouraging lifestyle changes.
• Diagnosis – focus on early detection, which improves outcomes across diseases. Engage with the extraordinary advances in point-of-care diagnosis, engage with Moore’s law.
• Care workflow – creating an open network of our primary, secondary and tertiary care delivery.
e) Follow-up care – a non-commercial infrastructure that makes teleconsultation affordable to all.
f) Evidence-driven health system - population scale digital health monitoring and intelligent surveillance.
The ₹20 trillion has to be spent in a completely different mix than it is today. A major focus has to be the spend on prevention and diagnosis. This will require a complete realignment of our public health economic priorities from an 80-20 focus on remedial actions on the “provider infrastructure and human resources” to an 80-20 focus on preventative care and diagnoses. Radical as it sounds, in 2016, the World Economic Forum, in agenda council deliberations on the future of health, clearly identified that misalignments among stakeholders (such as patients, regulators, pharmaceutical and device manufacturers, providers, insurers, academics, policy-makers and investors) significantly contribute to the underperformance of the healthcare sector. India has the opportunity to avoid this trap.
“Whatever you can do, or dream you can do, begin it. Boldness has genius, power, and magic in it. Begin it now." - Johann Wolfgang von Goethe
We can realise the advantages of the future only by understanding the scientific and technological trajectories today. The remarkable advances in digital technology, including Artificial Intelligence (AI), and the extraordinary advances in molecular biology give us great hope of an intelligent health system for India.
“Artificial Intelligence has enormous potential for strengthening the delivery of health care and medicine and helping all countries achieve universal health coverage. This includes improved diagnosis and clinical care, enhancing health research and drug discovery, drug development and assisting with the deployment of different public health interventions, such as disease surveillance, outbreak response, and health systems management.”
Dr. Soumya Swaminathan, chief scientist, World Health Organization
The pandemic is the trigger for rethinking the health system in India from the ground up. India needs a decentralised approach that is accountable to the citizen. New digital infrastructure can bring this to reality. We also need force-multipliers for our doctors and para health workers. A revamped approach to health data and machine-learning based approach to health knowledge (the elusive learning health system) can provide this force-multiplier in every nook and corner of the country.
Let us begin with the imagined future state and work backward to the present. Moonshot thinking requires this new paradigm. Let us embrace this approach in healthcare.
The Lancet Citizens’ Commission on Reimagining India’s Health System is a cross-sectoral endeavour to develop a citizens’ roadmap to achieving universal health coverage for the people of India in the next decade.
(The piece has been authored by Vijay Chandru and Sharad Sharma)
Vijay Chandru (firstname.lastname@example.org) is an adjunct professor at the Centre for BioSystems Science and Engineering and healthcare advisor to ARTPark at the Indian Institute of Science. Sharad Sharma (sharad@iSPIRT.in) is the co-founder of iSPIRT Foundation which has conceptualised the National Health Stack to usher in health inclusion at scale.