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

Fundamental things happening at the bottom level in Last One Year Courtsey- Shobha Warrier/Rediff.com

S.Gurumurthy rarely talks about Prime Minister Narendra Modi or the way he is administering India. In this rare and exclusive interview with Shobha Warrier/Rediff.com, Gurmurthy,, analyses the first year of Prime Minister Narendra Modi in office, how he has turned all the all the negatives to positives, and what he should do to make the economy grow.

Perhaps for the first time in India has a prime minister been scrutinised and dissected so thoroughly after one year in power. Is it because he promised ‘achche din’ during the campaign and so people expected good days to come from the very day of him assuming office?

No. The unadmitted truth is that the media hates him and they will always hate him. They were the ones who said this man was a Hitler and had killed 4000 Muslims; they later reduced it to 2000 and now it (the toll) stands at 1000. A shameless media pretending to be neutral targeted him for 12 years. Some of them went to the extent of creating the suspicion that the Godhra tragedy was enacted by Modi to justify killing Muslims! This fraudulent theory was assisted by a United Progressive Alliance-sponsored commission of inquiry which said the tragedy was an accident, not a conspiracy.

They demonised the man so much and so continuously that the foreign media began echoing the Indian media, and the foreign media xerox copying the demonisation of Modi by Indians became news here as the foreign media too was calling him a demon! It is the foreign-funded NGOs-Indian media alliance, the most deadly and immoral alliance, that started the campaign against Modi and kept targeting him for over a decade.

You mean the English media?

It is the English media that dominates and the language media is only a shadow of the English media, even though it is several times bigger. Opinions are created by the English-speaking elite media and many of them have nothing to do with the real India but these are the people who set the agenda for India and inform the world. No foreign media will quote a language media even though it might command a readership much higher than the English media. The NGO which worked in conspiracy with the Indian media proclaimed that they got the Americans to deny visa to Modi!

Every prime minister from Jawarharlal Nehru to Indira Gandhi to Rajiv Gandhi to P V Narasimha Rao to A B Vajpayee commanded goodwill in India and outside. In the case of Vajpayee, the media said the Jan Sangh was bad, the Rashtriya Swayamsevak Sangh was bad, but Vajpayee was good. But you take the case of Modi, the moment he was proclaimed as the PM candidate of the Bharatiya Janata Party, 60 members of Parliament, including communists, wrote to the president of the USA to be firm on the visa issue. The Economistmagazine wrote, ‘we cannot be persuaded to support this man’. See the kind of hatred they had generated then within India which echoed outside.

And the man comes to power! Can you imagine the deficit he had to cover? Trust deficit and legitimacy deficit of the victorious Modi transformed into national discredit of having elected a leader with such deficits. But in one year, he has completely overturned the situation. Has any newspaper written one word on this?

First, the foreign media said he would never have good relations with his neighbours. In one move, by calling all the Saarc leaders for his swearing-in, he demolished it. It was such a brilliant strategy. How many in the media appreciated this? They couldn't tolerate that he has come to power in spite of them.

Now about the kind of scrutiny he had to go through. Modi has been elected for five years, and he was supposed to do certain things in five years. But newspapers are writing editorials asking, tell us what have you done in one year? I can understand an immature person like Rahul Gandhi asking this. But to see editors calling themselves great intellectuals saying what Rahul Gandhi says, speaks of their credibility.

How do you evaluate his first year? What are the positives?

What Modi has achieved in terms of India’s strategic relationship and economic benefits from abroad is something unbelievable in 365 days. He has made America accept our nuclear liability clause. He has made Australia and Canada give 3500 tonnes of uranium. He has not only made China commit to invest $20 billion, but he has told China about setting right the negative trade deficit, implying anti-dumping duties against them. (We have over $ 400 billion in current account deficit). Manmohan Singh, who was virtually crawling before the Chinese president, allowed the nation to run up a trade deficit of $ 375 billion in 10 years. Modi got $ 35 billion investment from Japan and then from EU too. In 365 days, he has turned all the negatives into positive, from (-) 5 to (+) 7. Did any analyst write about the negative scores he had had to overcome in and outside India? They wrote as if he began writing on a clean slate.

The criticism is that he has only got promises for billions of dollars but nothing has come to India…

You mean to say they issue a cheque for $20 billion on the first day? It will come only when the projects begin to take off.

Another criticism against him is that he has been travelling all over the world, neglecting the domestic front…

I told you that he had unbelievably set right his and the country's image abroad (that was) viciously spoilt by our own media in 365 days. Without that, economic recovery in India too would be difficult in an inter-dependent world, particularly when we have been running a current account deficit and making it up through loans and investments from abroad.

On the home front, he is building a powerful foundation for the country’s economy. What are the things that have been missing till now? We were not able to reach people in terms of financial inclusion. No foreign economists or the RBI would say the person who has no money should have a bank account. That was the policy till now. Here, our need is, everybody should have a bank account, only then could we put money in his account.

The RBI agreed to have one crore bank accounts in three years. The finance ministry said, three crore bank accounts in one year. But Modi wanted 7 .5 crore bank accounts in five months. Do you know what the latest tally is? 16.5 crore bank accounts. The scaling up of the operation Jan Dhan Yojana is unthinkable.

Next, 10 crore people have been hooked into three insurance schemes. It happened because they had bank accounts, kisan credit cards and other financial inclusion mechanism

These are all fundamental things. Rajiv Gandhi had said 85 per cent (of the allocation) gets eaten away on the way. Those days are over. The money will go directly to the person. Nobody can eat it in between. Afterwards, what the beneficiary does with the money, is a different matter.

Take the gold monetisation scheme and the MUDRA refinance scheme -- a remarkably India-specific idea. All these are India-centric ideas which neither the Indian nor the foreign media will write about.

You take any measure by Narendra Modi; it is not intended for today’s results; the result will be permanent. He is planning a socio-economic structure which will be solid for the country whether Modi is the prime minister or somebody else. 

In the second and concluding part of his interview, Gurumurthy, image, below, outlines the two areas he believes the government should focus on.

Why is it that none of the economists are talking about all these issues you mentioned?

Most of the modern economists evangelised in the Western paradigm do not know about India because they have studied economic theories which worked in the West and most of them have ceased working even in the West now -- whether it is Raghuram Rajan or Arvind Panagariya or Arvind Subramaniam. 

Why then did Modi appoint them?

He needs them to deal with foreigners and various countries. The West-centric economics has nothing to do with India. There was a time when economic theories were regarded as universal. From 2005 and definitely after 2008, the West itself has distanced itself from this view. But Modi has everything to do with India. None of this -- whether it is MUDRA bank or Jan Dhan Yojna or gold or insurance schemes -- would have been approved by these foreign experts.

But what made headlines was Arun Shourie’s comments on Modi’s economic policies. He said it was directionless…

Shourie is my friend. I don’t want to comment on him.

But are the government's economic policies directionless?

What do you decipher from what I have said so far? With all my respects for him, I do not agree with the comments, but I do not want to comment on him.

But what he said became big news.

That is because the media wants it. If he had completely endorsed Modi in his interview, it wouldn't have got that publicity. Had the media not been anti-Modi, Shourie’s comments would not have got such publicity. Assume he had spoken against Sonia Gandhi, it would not have been published at all.

Back to Narendra Modi’s one year. Would you say he has done a good job?

He has recovered from minus and gone into plus. It is unthinkable in one year. I thought he would take two years to reverse the opinion of other countries about himself, but he has achieved it in one year. The man who denied a visa to Narendra Modi (US President Barack Obama) came and attended the Republic Day function! It is not a small gesture.

Image apart, do you agree with him saying it is ‘achche din’ now?

When you say good days are coming, does it mean it will come in the first year itself? But there is absolutely no doubt that the economy is in a much better shape now. You just take the coal auction. They got Rs 4,50,000 crores. From 2G auction, another one lakh crore! There is no ministerial corruption. Lobbyists have been retrenched from Delhi. A leading anti-Modi newspaper itself said so. From where have we reached here? From a completely corrupt UPA ministerial regime to a corruption-free Modi ministerial regime.

I may have serious differences with some of their approaches and there are plus points and minus points, but the entire plus points have been ignored by the media. They only say what he not done. Have they written about what he has done?

Tell me the five big things which Modi said he would do in the first year but did not do.

Some of the economists I spoke to said inflation is down, budget deficit has come down and the GDP growth is there but that’s not due to Modi’s policies but because of the fall in global oil prices. What do you have to say about this argument?

That is not correct. Oil prices have contributed only to one half of inflation reduction. GDP going up has nothing to do with oil price reduction because it became effective only by 2014 end and early 2015. That benefit is likely to be seen only in the current year because we go on forward for oil. So oil price reduction is not the sole reason for all the positives of the Modi government. Of course, it was one of the favourable factors.

Since the manufacturing sector has not seen any positive growth and in general industrial growth is also not happening, one view is that the government, with the money got from auctions, should invest in infrastructure projects so there will be buoyancy in the economy. Once the economy becomes buoyant, the promised money from other countries will also start pouring in. Do you agree?

There are two areas which the government has to focus on. One is, how to handle the stalled projects in which Rs 8 lakh crores is locked. These are power projects, steel projects, manufacturing projects but they are stalled because of environmental clearance, cost overrun, etc. There are also criminal investigations against these investments. Unless those projects are restarted, the investment cycle cannot open. Unless the investment cycle reopens, manufacturing will not start.

The money is with the bank and they are not able to lend anymore. This is a catch-22 situation. This is not the problem of this government but it is a problem created by the previous government. This is the biggest challenge for the Modi government. How soon, how effectively and how boldly he overcomes this will decide how fast we will move. Unfortunately, all the big and medium groups are caught in this. They will not start any fresh investment unless this issue is resolved.

The second thing is the land bill. Unfortunately, the government has been caught in an ‘industrialists vs agriculturists’ situation. It is not anti-agriculture at all because the government is not going to acquire agricultural land for industrialists. There is a huge wasteland of 47 million hectares and also government lands and only these lands will be used for our infrastructure and other projects. This is what they have said. But they have not been able to communicate this effectively to the people.

Why is there a communication gap?

One, because the media is not reporting truthfully, and also (due to) the inability of the BJP to communicate effectively as many of its spokespersons lack experience and also skill to vault over a biased media.

Is that the reason why Modi is asking his MPs, MLAs and party members to go and talk to the people directly?

Naturally. The media will not allow a debate on this. Rahul Gandhi does not know what the bill is but what he says makes headlines.

When the bill came with amendments, even the Swadeshi Jagran Manch opposed it. Dr Ashwani Mahajan told Rediff.com that the SJM was against the amendments.

The Swadeshi Jagran Manch has a genuine concern, that the government cannot promote industries at the cost of agriculture. I think there is little interface between the government and SJM. The projects are rural roads and national highways, railways and power projects that have as much to do with agriculture as with industry. Yet the government has allowed the detractors to turn the entire bill into a farmer vs industrialist issue -- which it is not because the government has clearly said that it would not acquire farm lands for private business. Now, the SJM seem to be discussing the bill with the government though I am not part of the discussions. Hope the government will be able to convince the SJM.

Do you feel the fringe elements have done more harm to Modi’s image than anyone else?

When there are aggressive Muslims and Christians, there will be aggressive Hindus too. They will always be there. It is foolish to ask Modi to answer when some aggressive Hindu talks.

But it’s not just any aggressive Hindu, some of his ministers also…

You can’t expect Modi to answer when a minister expresses his views in private -- in a private or party meeting. In my view a minister is also entitled to his private view. He cannot express his private view in an official meeting.

What do you think the Narendra Modi government must do in the next year?

He is addressing an area not addressed by any government, like the MUDRA Bank addressing the credit needs of six crore micro and small businesses. This he can do in the next two-three years. Since the banks are not reaching them, he has created a new mechanism to give credit to them. Once he does it, the face of the Indian economy will change. They are now borrowing by paying 60 to 120 per cent interest and if you give them funds at 12-13% interest, many of the six crore micro entrepreneurs will open two more shops and employ four more persons. Once they lend at 12 pc, the others also have to cut the rates. This was what happened at the transport finance sector. Similarly, intervention by MUDRA Bank will be very effective.

These people are also perpetually in debt due to illness and accidents and when the insurance scheme takes care of these things, their quality of life will improve. They are getting the benefits directly from the government.

These are fundamental things happening at the bottom level.

You mean to say the change will happen from the bottom up and not trickle down from the top like the economists say?

Everything is bottom upwards; even MUDRA. That is why you don’t see economic newspapers writing about this. For them, the only news is Sensex rise and FDI inflow; nothing else matters.

This way, do you expect a transformation to happen in the rural area and not in urban India?

Yes. Once you put people in touch with the financial system, change will happen. In 54 pc of the new bank accounts, money is there in the bank. That means nil balance account is coming down.

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With regards
S.Murali Dharan
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