Pivoting India’s Public Healthcare Programme to Fuel Development

We are all, by now, very familiar with the video published by Bill Gates in 2015, where he predicted that the next global catastrophe killing millions would most likely be a highly infectious virus. Four years on, in their annual report on global preparedness for health emergencies, the Global Preparedness Monitoring Board in September 2019 specifically warned of a very real threat in the near future of a rapidly moving, highly lethal pandemic of a respiratory pathogen, killing anywhere between 50 to 80 million people and wiping out nearly 5% of the world’s economy.¹ The GPMB also stated that the trend of largescale viral outbreaks, on the rise for several years now, is likely to continue. Why then have global leaders, governments, and regulatory watchdogs including the WHO, all who ignored warning signs and done very little until the catastrophe called COVID-19 was at our doorstep?

Closer home, India’s Universal Immunization Programme is renowned as one of the largest public health interventions in the world, successfully bringing under control many communicable diseases. We were hailed for our success in eradicating smallpox and polio through targeted public intervention. March 2014 was a watershed moment in the history of the Indian public healthcare system when India was declared polio free by the WHO – the fourth region globally to have achieved this feat – only after America, Western Pacific and Europe. However, public healthcare in India has been a low priority over the last decade with little or no focus on boosting our healthcare infrastructure. Until early this year, our public health expenditure was just 1.29% of the country’s GDP in 2019-20, far lower than the global average of 6%. In 2018, we were behind even our BRIC peers in the area of public health investments. In fact, India’s public expenditure on health as a percentage of the GDP has been far lower than some of the “poorest” countries in the world, as admitted by the Union Ministry of Health and Family Welfare.²

COVID-19 has firmly put the spotlight back on the importance of a strong healthcare infrastructure, irrespective of the size and health of the economy. The Indian Union Budget’s highly reactive and long overdue fillip to healthcare in the current fiscal year has proposed an outlay of INR 2.23 lakh crore, increasing spending on healthcare by a whopping 137%. The budget has also proposed a dedicated outlay of rupees 35,000 crores towards COVID-19 vaccination, increased outlay on drinking water and sanitation, the PM’s Atmanirbhar Swasth Bharat Scheme and the six-year phased plan to develop primary, secondary, tertiary sectors are all well-intended and welcome. This revamped budgetary allocation has been a long time coming. While many may argue that this was a face-saving act on the part of the government, the proposed outlay includes promising initiatives including the establishment of health and wellness centres and integrated public health labs in every district that can potentially be a game-changer for healthcare in a developing country like India, albeit very late.

However, for these initiatives to succeed, we need to back up central policies with robust planning, strong coordination between the central and state governments, good execution muscle and effective implementation – which have been the Achilles’ heel of India’s healthcare delivery system. Ours is a unique dilemma with policies enforced by the centre and execution accountability resting with the states. The pandemic has been a clarion call for a synchronized disaster management and revamped healthcare delivery programme that needs to be implemented at the regional level to ensure this nightmare doesn’t repeat.

What do we need to focus on to ensure effective implementation of healthcare policies?

Things brings us to the question: What do we need to focus on to ensure effective implementation? Health equity in India grapples with myriad challenges. For instance, there has been significant progress in healthcare technologies and care provision, but these benefits are highly skewed in favor of the urban elite in our metros. Effective implementation of healthcare policies across the country to appropriately respond to the needs of the disadvantaged has been slow. The framework needs to be reworked to adequately address inequities in socioeconomic-cultural and geographic factors, in order to drive true equity in healthcare. I believe an overhaul of these five foundational pillars can help accelerate our vision of universal and equitable healthcare access to all.

Establish a proactive and dedicated disaster management programme:

COVID-19 has shown us the mirror on how ill-equipped and under-prepared we are to manage large scale healthcare disasters. We must identify disaster care management as being unique and separate from routine care from a policy perspective. Consider this. World Bank data puts India’s bed availability at an abysmal 0.5 beds per 1,000 people³ and 0.9 physicians per 1000 people, as per 2017 and 2018 figures respectively.⁴ This is inadequate at best, even during normal circumstances. So, imagine the pressure on the country’s caregivers during times such as the pandemic. We need provision for a dedicated, long-term programme on healthcare disaster management including setting up disaster management wings across zonal healthcare centres in rural and semi-urban areas. Focus must be on stepping up availability of hospital beds, physicians and trained support staff and necessary medical equipment. Medical students must be mandatorily trained and certified on emergency and disaster management protocols and caregiving best practices. Priority must be given to step up preventive research funding in biological and medical sciences, and encourage homegrown pharmaceutical and med-tech companies. This must also include provisioning for healthcare infrastructure, emergency supplies, PPE and medical equipment. Detailed and routine collaboration programmes between public sector healthcare institutions and private sector hospitals to encourage knowledge and knowhow exchange, and training on the latest best practices will help equalize the healthcare system across and reduce the burden on our metros and tier-I cities.

Increase focus on preventive healthcare and fortify the public healthcare system:

Medical science in India has a long and rich history. We are the land of Ayurveda or the ‘Science of Life’, the ancient Indian system of natural, personalised and holistic medicine. We are also home to two of the most famous medical treatises ever written and have produced many renowned names in medical history. In more recent times, we have successfully stemmed the rampant growth of TB, Hepatitis, HIV, and other deadly diseases, while providing timely intervention care in curing others such as cancer. However, with our burgeoning population and changing lifestyles, we are today struggling to cope with the healthcare requirements of the country’s masses. Diabetes, hypertension, obesity and other lifestylerelated diseases are nothing short of raging epidemics in the country. Our decadent lifestyles, unhealthy eating habits, sedentary routines, lack of hygiene and abuse of alcohol, tobacco and drugs, combined with lack of awareness has led to the creation of what McKinlay refers to as “illness factories”. These illness factories are impacting the lives and health of the populace at large, slowly pushing people down the stream into recuperative care at our healthcare facilities or into “intervene and repair” mode.⁵ The growing number of people requiring medical intervention is putting relentless pressure on the healthcare system, the hospitals and public healthcare agencies who are hard pressed for time, investments and trained resources in successfully treating people.

In a developing country like ours, intervention must be the last resort. What will help us scale to effectively address the medical needs of our people is to prioritize educating and raising awareness among people about the importance of living healthy lifestyles. There is a dire need to recast our individual lifestyles, healthcare policies, research and infrastructure to shift gears to primordial prevention practices and preventive research and stem the cascading effect of illnesses on our ecosystem. Training and upskilling our Community Healthcare Professionals (CHPs) and medical professionals across rural areas in educating the masses, increasing awareness and identifying symptoms early on is key to providing better healthcare access, alongside setting up adequate infrastructure.

Invest in electronic health records (EHR) and technology integration for equitable and efficient healthcare access:

Ensuring adequate medical coverage and access to care in a country as geographically and economically diverse as ours is a mammoth challenge. This is where the benefits of the internet of things (IOT), artificial intelligence (AI), the cloud and the new connected digital world can provide an impetus to achieving better healthcare provision for all. We are a country known for our technological capabilities and skilled tech pool that service the very best of global clients and mega corporations across industries. And yet, our public healthcare system remains mired in disparate, disconnected, inefficient and legacy technology and infrastructure. Rehauling the technology enabling our public health system is critical to effectively scale. Another key area of concern is the level of manual effort the CHPs and public healthcare workers invest in maintaining public health records which are dispersed and poorly maintained.

Technology can be a key fulcrum in reshaping the future of public healthcare in India. We must leverage technology to provide better care and this starts with digitizing our public health records. A simple, robust, well-integrated low-code electronic health records (EHR) platform designed to function on low bandwidth in remote areas will help address many challenges in healthcare implementation at once. It will create a central, ready and live repository that will provide us a single pane of view into the health of the nation. From monitoring immunization charts of children to maternal health of women in rural areas, to tracking the spread of infectious diseases and the spike in chronic ailments, EHRs can pave the way for a strategic overhaul of the country’s public healthcare approach. This will enable integrated care practices and proactive follow-up with all of the patient’s health history accessible at the click of a button. An effective EHR system will also reduce the burden on our healthcare providers by helping us analyze and prioritize the more urgent cases requiring immediate attention, reduce errors in manual patient data entry and transcription. EHRs will also immensely improve productivity, reducing effort and time spent on collecting and collating data, and improve flexibility of rotation of healthcare workers. Reduced overall costs and increased ability to make informed decisions are other significant macro level benefits that will aid the economy well. Technology integrations and backward linkages to effectively and continually monitor, assess and respond in a cohesive manner to disasters are key to effective patient care and monitoring.

Increase accountability in healthcare implementation at the state level:

While public health is a state subject, the centre has played a pivotal role in designing robust health programmes. However, lack of technical expertise alongside lack of governance of public health infrastructure at the state level has resulted in poor implementation of most of these programmes. States constantly struggle with effective last-mile delivery in healthcare. The solution may lie in enforcing greater accountability in healthcare delivery at the state level. This must be ably supported through the establishment of state or regional-level advisory bodies that include representation from local entrepreneurs and management expertise from private corporations, research and educational representatives, and experts in public health for adequate guidance and support. We must also push for greater co-ordination and region-wise implementation support from the country’s policy making authorities such as the Indian Council for Medical Research (ICMR) and others.

India has some stellar privately owned and managed healthcare institutions with excellent treatment, research and hospital management experience. The government can explore avenues to formally involve private sector organizations to help train, upskill, improve processes, know-how and technology across India’s primary and secondary healthcare centres. Policies mandating minimum budgetary, infrastructure and resource allocation by private sector healthcare organizations towards upliftment of rural areas might be welcome. Encouraging large corporations to work with the state government by allocating a certain percentage of their CSR funds towards primary healthcare for the underprivileged and partner with local healthcare authorities in effective implementation by offering managerial and operational expertise is another option worth exploring. In fact, the government must actively encourage public-private partnerships to overhaul the healthcare system, a model that has done wonders for us in areas such as infrastructure and power.

Democratise medical education:

While we have encouraged and embraced globalisation and industry involvement in engineering sciences and business management, the medical education system, bound by regulatory restrictions, has remained stagnant for decades. Syllabi have remained largely unchanged despite the advancements in practice methodology, teaching methodologies have seen little progress, and a highly theoretical approach to medical studies with little practical exposure and experience has left our students challenged and less than prepared for practice. Policy makers need to take a hard look at rehauling the medical education system, with greater focus on academiaindustry collaborations to bridge the glaring knowledge gap. We need to forge a paradigm shift in medicine to encourage an integrated learning experience. We can affect this by democratising medical education to encourage international collaborations, exchange programmes and partnerships, with a focus on enabling empirical problem solving and hands-on exposure for medical students on the latest in medical science. In fact, the government recently decided to introduce engineering courses in select regional languages across shortlisted institutes, in an attempt to overcome language barriers and provide better opportunities to students from regional areas.⁶ This model, if emulated in medical education, will help the medical fraternity better connect with the under privileged and less informed local populace. It can significantly improve preventive healthcare practices, improve general public awareness on health issues and boost our healthcare delivery model. Global exposure and best practices integrated with local implementation can spur our public healthcare system into the future with great results.

Future-proofing the public healthcare system for economic development

Access to quality healthcare must be a fundamental right. Successfully pivoting India’s healthcare infrastructure and approach will be crucial to not just building a healthy nation but also a healthy economy. Government bodies, policy makers and even global watchdogs such as the WHO need to rise beyond mere policy making and arbitration to ensure effective planning, governance, regulation, and implementation of appropriate healthcare measures and provide necessary leadership and support to countries globally. If the pandemic has shown anything, it is this. Humans cannot exist or thrive in isolation. We are all connected, intertwined and interdependent. The health and progress of one impacts the health and progress of all. As the African saying of ‘Ubuntu’ goes, “I am, because, you are.” And it is providing this equity that we must focus on as a nation, in order to march ahead. The onus of ensuring this lies on us professionals as much as it does on the system. It is my ardent hope that together, the academia, policy makers and professionals in this noble field of medicine will be harbingers of change and help in effectively bridging the gap between the haves and the have-nots in medical care in this country.