The Indian Express | 22 hours ago | 29-03-2023 | 11:45 am
Over the years, the Indian health system has overcome seemingly insurmountable problems, long considered hopeless. At a time when we are the envy of the world for having the youngest population for more than three decades to come and if we are to redeem that advantage fully, some tough health challenges will need to be confronted.Nothing is impossible, as the recent National Family Health Survey (NFHS-5) results have shown. In 2007, national and international demographers concluded that even under the best-case scenario, India would achieve a total fertility rate of 2.1 (replacement level) only by 2041. India achieved this by 2020. Likewise, high maternal and infant mortality seemed destined to persist as late as 2010. Despite evidence showing the crying need for women to deliver in a hospital, the reaction was always the same — “sadiyon se humare dai yeh kaam karti arahi hai. Isse hum badal nahi sakte.” (For centuries, the traditional dais have delivered babies and we cannot change that.) Ten years later, the latest NFHS-5 findings show how even in the so-called BIMARU states, hospital deliveries have soared to 89 per cent.Today’s macro picture shows at least five interrelated challenges which are pervading the population. Cardiovascular diseases (CVDs), cancers, chronic respiratory diseases (CRDs) and diabetes are spiralling and they all share four behavioural risk factors — an unhealthy diet, lack of physical activity and use of tobacco and alcohol. A report, ‘India: Health of the nation’s states’, estimated that the proportion of deaths due to non-communicable diseases (NCDs) has increased from around 38 per cent in 1990 to 62 per cent in 2016. Obesity has increased from 19 per cent to 23 per cent between NFHS-4 and NFHS-5, in both urban and rural areas. Among Delhi’s citizens, 38 per cent were found to be obese, followed by Tamil Nadu and Kerala. People in Punjab, Telangana, Andhra Pradesh, and Karnataka also have large sections of the population that are obese. This increases the risk of diabetes, hypertension, and CVD. Building awareness and exhorting people to lead healthy lives will save millions from illness and decelerate premature death. Unspectacular as it sounds, governments must keep millions away from ill health — more cost-effective than eventually treating chronic medical conditions in hospitals.The state of infrastructure matters. Since 2018, governments at the Centre as well as the state have been trying to bolster primary healthcare by establishing health and wellness centres (the new incarnation of primary health centres and sub-centres.) But a 2022 report by the Centre for Community Medicine in AIIMS, which covered selected districts in 18 states, found huge variations between states. Some northeastern states like Mizoram, Arunachal Pradesh and Nagaland were found to have better arrangements followed by Gujarat and Chhattisgarh. The lowest proportions of primary health facilities with full institutional capacity were in Jharkhand, Karnataka and Uttar Pradesh. An idea announced in 2018 ought to have got more traction by now. States must step up efforts.In urban areas, the challenge is to bridge the gap in hospital services between large urban agglomerations and tier II and tier III cities. A recent Lancet publication (2023) found that the provision of core health services is far from uniform across state-run district hospitals. Just 16 per cent of the district hospitals in Tamil Nadu offered all key services. In states like Assam, Punjab, Madhya Pradesh, Mizoram and UP, it was found to be just 1 per cent. Whether it is wanted or not, people have to bank on the private sector, which owns two-thirds of the country’s hospital beds.Large hospital chains like Apollo, Fortis, Max, and Narayana Hrudayalaya account for just 4-5 per cent of the beds in the private sector. Standalone hospitals and nursing homes provide 95 per cent of private hospital beds. Though these institutions provide a much-needed service, they are unable to provide multi-specialty, leave alone tertiary and quaternary care. The gaps between services available in the metros and big cities and in districts must be bridged. Making the centrally-run hospitals (where a 40 per cent vacancy was reported only a few months ago) and the district hospitals fully functional is imperative.The other problems centre around low health insurance penetration and the very high personal outgo on healthcare. But over the past three years, more than four crore Indians have bought health insurance. From 2018, the Ayushman Bharat insurance scheme for 10 crore poor families has been undertaken to provide insurance against hospitalisation for up to Rs 5 lakh per year per family. Taken together with the state-run insurance schemes, the Employees State Insurance (ESIC), group insurance and CGHS, nearly 74 per cent of Indians are either covered or eligible for health insurance coverage, which even if it is only insurance and not healthcare, is a game changer from the pre-2018 situation.However, millions remain uninsured. Out-patient doctor consultation costs, diagnostics, and drugs account for the biggest chunk of out-of-pocket (OOP) personal expenditure. Presently this is pegged at 50 per cent of the total health expenditure. It is, therefore, essential to provide insurance for the unorganised middle class and to include identified out-patient costs.An emerging concern is the use of Artificial Intelligence (AI) and digital technology. Surgery assisted by robots, the use of genetic codes, clinical judgements based on AI, and even pandemic forecasting are already widespread and are to be welcomed. But ethical and regulatory concerns abound, which recently prompted the Indian Council of Medical Research to release guidelines foreseeing the problems of a lack of accountability for machine-made medical decisions. When medical malpractice in substandard institutions and by unqualified medical practitioners is still not regulated, a new dimension has been added making the regulation of healthcare even more compelling.India has shown how the impossible can be achieved. What is needed is out-of-the-box thinking and the resolve to steer the ship before a storm arrives.The writer is former secretary in the Ministry of Health
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