Monday, October 19, 2015

Future of Health Care in India: Challenges ahead

The shifting landscape of healthcare in Asia-Pacific

Healthcare in Australia, China, India, Japan, and South Korea has seen substantial success, with life expectancy rising markedly over the past two decades in each country. In health, however, the playing field never stays constant with changing risks presenting challenges for each country. This study looks at current and likely future disease loads for these five countries as well as how healthcare systems are set to cope with them. Its key findings include:

Non-communicable diseases already dominate the current health burden in the five countries
in this study.

Traditionally, communicable diseases are associated with developing countries and non-communicable diseases (NCDs) with developed ones. Japan, Australia, and South Korea made the epidemiological transition to an NCD-dominated health burden some time ago. In recent years, China has joined them, with 85% of its mortality coming from NCDs in 2010. Even in India, a majority of deaths (53%) came from this group of diseases and the figure is likely to grow. Communicable diseases inevitably remain a potential threat to all countries, and an ongoing, widespread challenge to health systems in India and China, but the main health burden is, and increasingly will be, NCDs.

The impact of specific NCDs affecting the five countries vary greatly, with China and India now the worst affected.

A common set of risks accounts for much of the growth in the number of NCDs, including: ageing; unhealthy lifestyle choices around smoking, diet, and exercise; environmental pollution; and urbanisation. The extent of these risks, however, varies greatly between countries so that the specific NCDs affecting populations also differ markedly. Excessive salt consumption, for example, elevates the number of strokes in East Asian countries while excessive caloric intake means that heart disease is a bigger problem in Australia. Air pollution, meanwhile, is driving up chronic obstructive pulmonary disease (COPD) and lung cancer incidence in China and India.  Currently, the voluntary and involuntary risks experienced in developing countries are exacting a heavier price than those in developed ones:  according to the WHO, in South Korea, Japan, and Australia, the combined probability of dying from cancer, heart disease, diabetes, and COPD between the ages of 30 and 70 is just over 9%. In China, though, it is 19% and in India 26%.

Mental illness is too often an unrecognized part of the burden.

Mental illness is a significant NCD, but, because it is directly responsible for few deaths, mortality data tends to hide the size of its impact. In terms of total years lived with disability by a population, though, the health burden is huge—between 20% and 30% of the total. Service provision for those with these conditions is usually insufficient. Although China and India are beginning reforms in this area, health care personnel and infrastructure remain insufficient to meet patient need. Japan and Korea, meanwhile, remain wedded to care in isolated hospitals rather than the community based provision which is current best practice. Although Australia has gone furthest in the right direction, it still has a long way to go.

The NCD challenge requires patient-centred, accessible healthcare systems.

Most healthcare systems were developed for, and are still bestsuited to, acute care. At our current state of medical knowledge, though, NCDs are largely chronic conditions which require long-term management. A system capable of meeting this challenge well needs to: give appropriate attention to cost effective prevention as many NCDs are preventable; be accessible so that care will be more than sporadic and episodic; provide patient-centred care, in which healthcare providers support patients to manage their own conditions rather than dictating from above; and be integrated so that it can provide each patient with coherent, customised care—a need typically best serviced by a strong emphasis on primary care. Such a system would benefit not only those with NCDs, but describes the type of care which experts in communicable disease such as tuberculosis and HIV also advocate.



None of the healthcare systems in this study meet this ideal and several are worryingly illsuited to face their current healthcare burden.

Each of the countries covered has weaknesses:

Australia—Although it has strong assets within its healthcare system, these require integration around the patient rather than exhibiting a provider focus. Currently patients can find it difficult to navigate the complexity.
China—The country’s recent healthcare reforms have so far failed in their goal to establish integrated, patient-centred, accessible care. Instead provision typically involves episodic, very brief interaction with harried staff in hospitals. Moreover, costs remain high and frustrations have damaged patient-clinician trust to such an extent that two-thirds of Chinese do not trust doctors’ professional opinions.
India—The country’s healthcare system is still almost entirely organised around acute care to an extent that even the health ministry acknowledges that efforts against NCDs are only “nascent.” High costs also make regular care difficult for much of the population to afford. Both these factors make effective chronic care extremely difficult: one interviewee estimated that half of the country’s 62 million diabetics do not even know they have the condition.
Japan—Japanese healthcare has many strengths, but is doctor-dominated, hospital focused and has a weak role for primary care. The result is poorly integrated provision in which patients face lengthy waits for very short consultations as doctors and specialists are in short supply. It is also an open question whether the current system is financially sustainable when funding relies on a debt-strapped government.
South Korea—Despite impressive improvements in its healthcare system in recent decades, South Korea shares some of Japan’s flaws, including weak primary care, an overemphasis on hospital-based provision, and too few clinicians. The quality of care also needs more attention and provision for those with mental illness is particularly poor given the need.

Initiatives both large and small point to changes that can work.

There is no simple way to create a perfect healthcare system, but diverse initiatives in the countries in this study show that change is possible in a range of important areas:
Prevention—Effective prevention involves winning people over as well as creating conditions which make healthy choices easier. This can occur at various levels. In Seoul’s Gangdong district, health counselling centres based in the community rather than in healthcare facilities are attracting large numbers of citizens and having a measurable, positive effect on health indicators. At the national level, Australia’s anti-tobacco efforts, through decades of consistent, coherent activity combining education, regulation, and taxation have brought down smoking rates from 38% in the mid-1970s to 13% today.
Universal access—China’s healthcare reform efforts have, as noted above, substantial weaknesses but it would be wrong to overlook their successes. The widespread extension of insurance has helped allow a substantial increase in use of healthcare facilities as well as an expansion of basic provision such as vaccinations and ante-natal care.
Patient-centricity—The Flinders Chronic Condition Management Programme in Australia has created self-management support processes that involve true partnership between patient and clinician, putting into practice the oftespoused wish for patient-centric, integrated care. Early studies indicate that it is improving healthcare outcomes as well.
Technology—Information and communication technology have important innovations to offer medical care. Japanese surgeons and diabetologists are using big data to shape understanding of best practice. Cardiac surgeons, who were pioneers in the effort, have seen more than a decade of improved outcomes. IT is not limited to well-off countries. In India, the Swasthya Slate is a point-of-care device that allows healthcare workers to conduct 33 different tests on the spot and feed the data to more senior clinicians if appropriate.
Reshaping care—If doctor-delivered, hospital based care is too expensive for dealing with an NCD-based disease load, what alternatives might exist? Long Term Care Insurance in South Korea has for several years been providing subsidised social care for the elderly and has shown the potential for reducing levels of social hospitalisation—the long-term housing of the elderly in hospitals for lack of a better alternative. In India, meanwhile, the Accredited Social Health Activist programme has helped train 900,000 community health workers in rural areas. Maternal and child care have especially benefitted.

Courtsey- The Economist Intelligence Unit Limited 2015