Dr Vivek Sharma
He who has health, has hope; and he who has hope, has everything – Thomas Carlyle
Ever have a doubt about the relevance of health? Ask a person who has arthritis, cancer or even a simple fever. Their answer would reflect the immense significance held by a healthy body and mind. Health permeates our ability to learn, work, connect and live a complete life. India with a population of over 140 crores has entered ‘Amrit Kaal’ with a vision to achieve affordable and quality health care. A well thought out approach is required in meeting the needs of its huge population and utilise this ocean of human capital for its greatest growth story. Charting the path for future requires a look at the current state of health care and course correction wherever needed.
According to the National health account estimates, Government’s expenditure on health was at meagre 1.3% of GDP in FY 19. Such a low spending leads to a high Out of pocket expenditure (OOPE) which was at 47% as of April 2023 despite improvement from 62% in 2014-15. A World Health Organization (WHO) study published in March 2022 noted that high OOPE on health impoverishes 55 million Indians, annually. Doctor population ratio is better than WHO standards of 1:1000, if we take AYUSH practitioners into account as well. But there are large regional variations with poor availability of doctors and paramedics in rural and remote areas. ASHA workers, an important factor in primary healthcare, are not paid well. There is an inadequate infrastructure reflected in non availability of beds at times and even ventilators during a life threatening state. This infra and health professional problem is alarming in peripheral areas. Our preventive health care is far from working at optimal level despite being a crucial aspect of healthcare. Poor infra in primary health, road connecivity and less availability of health professionals make primary health care even more precarious. Poor primary and secondary health care put pressure and immeasurable burden on tertiary health care. Doctor-patient relation has gone through troubling times with the issue of sensitivity towards patients which may be either due to paucity of time or rising role of money in healthcare. On the other hand, the tolerance and respect among patients and attendents towards doctors and staff have gone down to new lows which is reflected in repeated mental torturing of doctors by attendants through wattsapp or google university information, threats of political interference or even taking to violence which sometimes lead to grievous injuries or even the death of a doctor. This may be because of mistakes on the part of doctor, the hospital, the governance structure as a whole or even the lacklustre attitude of patient and attendants in reaching a healthcare facility in time. Too much burden on healthcare providers with long working hours impact both their personal and professional life and by default their mental health. What is even more disturbing is the prevalance of a toxic culture in the health and medical education where junior doctors and students often have to face mental trauma at the hands of senior doctors. This causes a huge impact on their confidence, dignity and mental health. Inspite of these troubling scenes, there are a plenty of positive signs reflecting hope for a brighter future. Government’s spending on health care has improved from 2014-15 levels which was at 1.13% , and also OOPE is on a rapid decline. Health Infrastructure is improving with establishment of new medical colleges and AIIMS across india.
There is an increase in work force as reflected by an increase in PG seats, bulk recruitment in newly established Govt. Medical Colleges and AIIMS, mushrooming of nursing colleges across states and integration of AYUSH with allopathy. Healthcare access in remote and peripheral areas is improving with the better availability of doctors and paramedics compared to the situation that existed earlier. ASHA workers, a key figure in primary health care, were recently acclaimed by WHO for their remarkable role during CoViD19. Government has taken some important steps like Ayushman Bharat, Genome India project and Pradhan Mantri Swasthya Suraksha Yojna(PMSSY) to name a few. Ayushman Bharat Digital Mission (ABDM) enables maintaining patient’s record in digital format and ensures data privacy. It also improves effectiveness of the next follow up, unlike earlier. Life expectancy has improved. Super-speciality service is now available at District level.
Inspite of this, we are still far from reaching a reasonable health care level. To achieve a world class health care, we need to understand what went into the development of quality healthcare in advanced economies. 1) They focussed on innovations and inventions by promoting R&D. 2) They didn’t have a lopsided growth. Growth in other sectors supplemented health sector and greatly reduced its burden. 3) Prevalence of a progressive and analytical educational system allowed people to participate, stay informed, updated and careful about their health. 4). High per capita income provided decent standards of living and made healthcare accessible and affordable. 5). Adequacy of infrastructure along with exemplary uptake of technology formed an important part of their success story. 6) Their nutrition levels are good that reduces the need of many health interventions like consultations, malnourishment induced immunocompromised states and anemia etc. 7) They also attracted the best talent from abroad while we lost our best brains to deplorable state of healthcare in India. 8) Even the west had not faced a tremendous population pressure with its large unrealised potential. 9) Public and private sector work closely and supplement each other.
Envisaging our journey through Amrit Kaal :
Government’s health spending should go to higher levels of at least 2.5% by 2025 as suggested by National health policy 2017. Adequate infrastructure with state of art equipments and use of disruptive technologies like digital health and AI for consultation, performing procedures and dispatching medicines via drones can entirely change the health care landscape. A holistic development reduces burden on healthcare as the growth in one sector supports the other and so on. Practicality also demands the securing of an adequate space for dealing with exigencies like COVID 19. Medical tourism which has witnessed a rise over the years, would be strengthened with a comprehensive health care. With regard to mental health, we need a broad based approach which involves ending the toxic culture prevalent in the health and medical education, reduction in the volume of patients and attendants, ending the stigma about mental health in our larger society and ensuring everyone’s privacy and dignity along with the availability and accessibility of a sufficient number of psychiatrists and clinical psychologists. These can bring a sea change in the mental health scenario. The Government’s initiative of tele-MANAS and e-Sanjeevani are steps in the right direction.
A complete overhaul of health care requires measures ranging from infra and referral to awareness among citizens to not bypass primary health care and later over load tertiary health care. Primary healthcare is the back bone of a health care and there is urgent need to work on the prevailing gaps. Health and Wellness centres and Mohalla clinics of Delhi Government are important initiatives. Expansion of Ayushman Bharat to provide Universal health coverage like J&K’s SEHAT or Delhi Government’s health model can be a forward looking approach. Advance procedures, availability and affordability of medical devices, and leaps in gene therapy are some of the areas that need extra emphasis. India has earned the title of ‘pharmacy of the world’ and now, it is the time to capitalise on it and move up the ladder of research and development to develop newer class of drugs. To sustain this tag, we require strict adherence to guidelines and quality regulations to prevent incidences of adverse drug reaction as happened in some African countries with drugs supplied by Indian Pharmaceutical companies. Further, there is a need to ensure higher levels of sanitation and hygiene and caution in drug usage, disposal and treatment facilities to prevent rising infections and antimicrobial resistance. Health care needs to be accessible to all citizens irrespective of gender, disability, region, culture or socioeconomic status. A high quality of care with the usage of advanced tech and adequate availability of trained healthcare professionals to meet international standards is the need of hour. This would also help with a channelised learning, rather than learning in a battle like scenerio with less guidance especially during emergency duties. For a personalised care, it is necessary to have community engagement in decision making so that the policies are in line with local needs and aspirations.
Adding to this, a R&D driven economy can significantly improve health care outcomes by bringing innovative solutions and reducing import burden thereby creating more space for health spending. Transformations like fit india and raising awareness hold the promise of reducing burden of non communicable diseases like diabetes and hypertension. A vicious cycle of malnutrition and infection creates heavy burden on health care and therefore, needs to be broken with active interventions. As there is higher prevalence of anaemia and hunger in the country, there is a need to rethink about the efficacy of programmes like anemia mukht bharat and make course corrections for better outcomes. The issue of menstrual hygiene that causes disabilities like dropping out of school, taboo, discrimination, genital infections and even infertility in some cases requires a holistic approach with behavioural change, awareness, accessibility and affordability of sanitary pads. There is also a question of work ethics and expectation of being well paid for exceptional services. If Cornwallis could increase the salaries of civil servants more than 200 years ago, why can’t we increase the salaries of doctors with more non practice allowance when the Government is looking to curb private practice?
As we have set the goal of becoming a developed nation by 2047, it is imperative to have a world class health care. It encompasses medical interventions, accessibility, affordability, and a patient-centered approach. Our quest to achieve SDG 3 ( Good health and well being) requires effort from both public and private sector. As we navigate the complexities of healthcare systems, it becomes imperative to advocate for policies that prioritize excellence, inclusivity, and continuous improvement. Collaboration among healthcare providers, policymakers, and the community would pave the way for a future where everyone, regardless of background or circumstance, can access and benefit from quality healthcare services. Quality healthcare is not just a necessity; it is a shared responsibility that reflects our commitment to the dignity and vitality of every individual. The greatness of a nation lies in the way it sees its health care and deals with the underlying problems. We have an opportunity to realise the dream of 1.4 billion people – a dream of a healthy nation, where we can set a remarkable example of standing tall in healthcare in the 21st century and beyond.
(The author is an alumnus of Government Medical College Jammu)
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