K. Srinath Reddy
TRANSFORMING HEALTH CARE
IN THE SONG of Solomon, Nobel laureate Toni Morrison wrote, “If we do not create the future, the present extends itself.” As we envision India’s health in 2047, we must take stock of our present health status, evaluate the progress made since independence, anticipate the changes in population health needs and health system capabilities over the next quarter century and draw upon the distillate of that analysis to design a path to the future we seek.
India is now the most populous country. The demographic dividend of a young population, available for the next 25 years, demands investments to keep the population healthy and productive as it ages. The United Nations Population Fund forecasts that the number of persons aged over 60 years will grow from 153 million now to 347 million by 2050. Can we ensure healthy ageing, where people will remain fit and functioning rather than frail and feeble? Otherwise, we will have a cascade of chronic non-communicable diseases and mental health disorders.
Health threats posed by climate change, environmental pollution and loss of biodiversity will escalate over the next quarter century. Our health system has to withstand this fusillade. Future pandemics are high probability events. Microbial surveillance must now extend across several species. New vaccines and drugs must be developed within the country owing to the fragility of global supply chains during public health emergencies.
There will be remarkable advances in science and technology, which will transform many aspects of health care. Artificial intelligence is just beginning to demonstrate its immense potential, from drug discovery to diagnostic and treatment algorithms. Molecular biology is opening up the human cell for engineered interventions. We must develop health system capability to critically evaluate and appropriately adopt such innovations. Besides advancing multidisciplinary research for discovery and development, we need an efficient health system to effectively deliver those interventions to intended beneficiaries. Our health information systems will have to provide accurate, representative and timely data.
WHERE ARE WE?
Many of our key health indicators have improved since independence. Maternal mortality ratio has fallen from 2,000 per lakh live births to 97 in 2022. Similarly, infant mortality rate has declined from 145 per 10,000 live births to 27. Total fertility rate has now fallen to 2 from 6 in 1950. Hidden behind these aggregate national indicators lie marked inter-state disparities and wide variations between different social groups. IMR was four in Kerala and 47 in Madhya Pradesh in 2020. Such disparities within India need to be bridged.
India’s life expectancy at birth grew impressively from 32 years in 1947 to 70.4 years in 2022. However, three caveats limit the scope of celebration. First, our life expectancy is currently lower than that of Sri Lanka, Bangladesh and Nepal, despite those countries achieving less rapid economic growth and also experiencing considerable civil unrest in recent decades. India did not achieve health gains commensurate with our rising GDP. Second, our healthy life expectancy (HLE) is much shorter at 67.7 years in 2022. There are several years of life where disease and disability detract from full enjoyment of a healthy and productive life. Third, there is a huge disparity in key health indicators across different states, between urban and rural areas as well as across income, education, gender, religion and caste categories.
India aspires to attain the status of a fully ‘developed country’ by 2047. Along the way, we have to achieve the health and wellbeing targets set by the Sustainable Development Goals (SDGs) of 2030. We did overcome the Covid-19 challenge through a concerted national effort. But attention to the health agenda has subsequently drifted, as evidenced by the Union budget of 2024 and scant reference to people’s health as a policy priority and public duty in the campaigns for state and national elections which preceded it.
How should we measure development? It is now widely agreed that gross domestic product is a poor measure of assured and equitable human development. It is also clear that wide-ranging income inequalities are a formidable barrier to achieving good health. Social disharmony hampers efforts to foster health. As we chart the path for a developed and healthy nation by 2047, we must create a more equal society based on commitment to social justice and active engagement of informed communities.
As health is the best summative indicator of success across all SDGs, we should identify HLE as the prime measure of national development, adding equity as a defining feature. A median HLE of 75 years by 2047, with the range of disparities between different socio-demographic groups no wider than 10 years, is a goal we can set ourselves for experiencing pride as a developed nation.
We have committed to achieve universal health coverage by 2030. This has two measures: financial coverage and service coverage. Financial protection is assessed by three indicators: out-of-pocket expenditure on needed health care, catastrophic health expenditure (usually precipitated by a serious health event) and percentage of population impoverished by health care expenditure. Service coverage measures access to needed health services across a variety of health conditions. India has much ground to cover in both these areas.
CREATING THE FUTURE
Political commitment to building a healthy nation must be demonstrated by higher public financing for health system strengthening and provision of needed health services. Public financing of health has stagnated close to 1 per cent of the GDP for several decades, despite policymaker assertions that the goal is 2.5 per cent. Out-of-pocket expenditure remained above 60 per cent for many years. While recent estimates show it has come down to 45 per cent to 50 per cent, both the World Health Organization and World Bank state that, for universal health coverage to be achieved, out-of-pocket expenditure should not exceed 20 per cent of the total health expenditure. Higher levels of public financing on health are needed from Central and state governments. Between 2024 and 2047, we must chart a progressive rise in public financing for health alongside a progressive decline in out-of-pocket expenditure. An early impact on out-of-pocket expenditure can come from reducing the cost of drugs and diagnostics, which account for a large fraction. Essential drugs and diagnostics should be available free at all government facilities. A pooled procurement system can become the norm for both public and private sectors for markedly reducing the cost of medicines.
We need to enhance efficiency gains for the money we spend on health by prioritising where we spend and the way we spend. Primary health care is the foundational basis of a well-functioning health system. Both rural and urban primary health care systems must be strengthened to provide at home or close-to-home services that are comprehensive, continuous, combine acute and chronic care components, are connected bidirectionally to higher levels of health care and draw on active community engagement. To provide advanced care for serious health conditions, district hospitals and medical college hospitals need to be strengthened. Private sector may be engaged to support and supplement public health care services, as per need and availability, through well-defined and clearly accountable pathways of partnership.
The biggest challenge to the delivery of needed health services comes from across-the-board shortages in skilled health workforce. WHO says that a health worker density of 44.5 doctors, nurses and midwives per 10,000 people is essential for achieving the health targets of SDGs, especially the service coverage component of the universal health coverage. From laboratory technicians in primary care centres to specialists in district hospitals, shortages are many. They are particularly severe in central, north and northeastern states. Doctor-population ratio ranges from 42 per 10,000 in Kerala to 4 per 10,000 in Jharkhand.
Prioritising primary care, we must train and deploy higher numbers of technology-enabled ASHA workers, nurses and mid-level community health officers. District hospitals should be upgraded to become training centres for undergraduate and postgraduate medical and nursing students as well as various categories of allied health professions.
All of these initiatives will have to be designed and delivered, while respecting the federal structure wherein our Constitution has assigned complementary roles to Central and state governments. There has to be energetic engagement of a well-informed community in each area. India@100 should celebrate freedom and good health in a democratised health system, which features people-partnered public health and digitally enabled decentralised decision-making at district level.
K. Srinath Reddy, former president of Public Health Foundation of India