India is at the crossroads of its journey to provide healthcare to its 1.3 billion people. While major achievements in the past decade include big reductions in maternal and under-5 mortality, elimination of polio, maternal and neonatal tetanus and guinea worm disease and significant expansion of community-based health services, several challenges remain. The most pressing one is dealing with the growing number of people with non-communicable diseases, like hypertension, diabetes, cardiovascular diseases, stroke, cancer and chronic lung disease. These conditions now account for more than 60 percent of the disease burden and premature deaths. Worryingly, diabetes and hypertension are no longer diseases of the elderly. They also strike the young, affecting productivity and economic growth of the country.
The world has pledged to achieve universal health coverage by 2030. This includes not only treatment of diseases, but preventive and promotive health services, as well as palliative care and rehabilitation. The World Health Organization (WHO) report on Making Fair Choices on the Way to Universal Health Coverage says that to achieve universal health coverage (UHC), countries must advance in at least three dimensions: expand priority services; include more people; and reduce out-of-pocket payments. In each of these dimensions, countries are faced with a critical choice: Which services to expand first, whom to include first, and how to shift from out-of-pocket payment toward prepayment? A commitment to fairness — and the overlapping concern for equity — and a commitment to respecting individuals’ rights to healthcare must guide countries in making these decisions.
A good example of targeted essential services is the Janani Suraksha Yojana that provides free maternity care and cash incentives to poor women to deliver in government health centers. The next steps are to improve quality of care; detect complicated pregnancies earlier and ensure prompt referral; provide for emergency Caesarean section and blood bank facilities in district hospitals; and expand the coverage to include deliveries in accredited private and not-for-profit hospitals.
Further, many states have launched their own health insurance schemes. These mainly provide coverage for tertiary care services. However, the bulk of out-of-pocket expenditure occurs on outpatient visits and on diagnostic tests and drugs.
India’s dilemma is to expand the coverage of essential or high-priority health services to the entire population on the one hand, and also to meet the demands of various patient groups who legitimately want the best treatment available for their medical conditions.
When setting national priorities, reasonable decisions and their enforcement can be facilitated by robust public accountability and participation mechanisms. While the available evidence may not be perfect, one cannot always wait for this to be generated; decisions need to be based on the impartial scrutiny of available data. These mechanisms should be institutionalised, for example, through a standing national committee on priority setting.
The department of health research set up the health technology assessment program in 2016, with a national board to vet various proposals and make recommendations to the government. The board looks not only at efficacy and cost-effectiveness, but also sees through the lens of population health impact, equity and ethics while making recommendations. This type of evidence synthesis will provide a robust basis for the government to make policy decisions, while keeping various vested interests at bay. It will also help engage private service providers for fee for services rendered, providing a strong accountability framework within which they can operate. Further, a strong system for monitoring and evaluation is needed to promote accountability and participation and is indispensable for effectively pursuing UHC.
India’s vast network of pharmaceutical manufacturers and biotech companies provide opportunities to manufacture biosimilars and novel treatments at reasonable cost. Similar to the Hepatitis C story, in which big pharma giants voluntarily licensed their patents and transferred technology to several Indian generic companies and brought down the cost of treatment to less than 0.5 percent of what it had been, it should be possible to do this for many more therapies. Not only would Indian patients benefit, but this could be a game changer for patients living (and currently dying) with these diseases in many low- and middle-income countries. The government will need to enter into a discussion with the holders of intellectual property for these life-saving products and work out models of benefit sharing. Access to good quality, affordable medicines is an important aspect of UHC.
Finally, an upgrade of the skills of healthcare workers will be necessary. Health staff at sub-centers (now to be called health and wellness centers) should be able to treat simple diseases, refer those with serious symptoms as well as provide preventive and promotive healthcare.
These are a few steps which are needed to achieve the goals, which are clearly enunciated in the National Health Policy 2017. One hopes that in 2018, health truly finds its way into all policies — whether they are made by the ministry of food processing, agriculture, environment, road transport, housing or commerce. A good healthcare system can only provide solutions to problems. Their prevention, however, depends on determinants (air, water, nutrition, sanitation, personal habits) that are outside the health ministry. Soumya Swaminathan is deputy director-general, World Health OrganizationThe views expressed are personal - Hindustan Times