A recent study has called for a radical transformation in the architecture of India's healthcare delivery system, if the country is to achieve the government's vision of assuring health for all.
The paper, authored by Professor Vikram Patel (Public Health Foundation of India and London School of Hygiene & Tropical Medicine) and colleagues, documents India's progress on major health indicators in the past decade, but also its many deficiencies; it identifies the structural problems with the health care system, and reasserts the recommendations of previous expert groups on the need for a radical new vision for India's health care delivery system.
The most disturbing indicator of the deficiencies of the Indian health care system is the observation that health care costs are driving millions into poverty. The authors argue not only for more resources, but for an integrated national health care system, built around a strong public primary care system with a clearly defined supportive role for the private and indigenous sectors, that (i) addresses acute as well as chronic health care needs; (ii) offers choice of care that is rational, accessible, and of good quality, (iii) is cashless at the point of service delivery, and (iv) is governed by a robust regulatory framework to ensure accountability.
The paper records the considerable efforts being made in the health sector, with national and local governments investing in targeted disease control programmes and the National Health Mission focusing on maternal and child health.
Despite this, a variety of structural weaknesses have led to a situation where India's health system performance is unable to cope with the enormous demands placed on it by the country's growing population.
According to the paper, India continues to lag behind regional neighbours especially on health indicators like mortality rates for children aged under five years, with India recording 27 percent of all neonatal deaths and 21 percent of all child deaths in the world. Chronic nutrition deficiency manifesting as stunting continues to affect a third of children under five years. Compounding this burden is the large and rapidly rising burden of non-communicable and chronic conditions.
According to Vikram Patel, "The health time-bomb ticks on due to the rising burden of non-communicable diseases. Suicide is now a leading cause of death of young Indians, and an Indian is likely to suffer from a heart attack at least ten years earlier than in developed countries and yet the health care system has barely responded to these urgent health crises".
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Further,Patel notes, there are, "widespread inequities in health outcomes that are apparent in the large morbidity and mortality differentials across socioeconomic status, caste, class, sex, and geographic location."
The paper states that an important cause of this large and inequitably distributed burden of disease in India can be attributed to social determinants beyond the conventional health-care delivery sector such as urbanisation, poor access to water and sanitation, food insecurity, environmental degradation, and the pervasive caste system.
According to the authors, India's current health system needs to correct its course urgently across seven key challenges. The first involves prioritising primary care and massively strengthening the country's weak primary health system. Second is the challenge of skilled human resources, where an overall shortage was further compounded by inequitable distribution of skilled workers. Third, India needs to better harness and regulate its large private sector. Fourth, dismally low public spending on health has crippled the public sector and created large barriers in quality and access and most of this expenditure was out-of-pocket leading to catastrophic health care expenditure for millions.
Fifth is the issue of fragmented and uncoordinated health information systems, health metrics data in India are gathered by multiple agencies and surveillance systems but are often incomplete and inadequate. Sixth, curbing the irrational use, and containing the spiralling costs, of drugs and technology. And finally, to deal with the issue of weak governance and accountability.
The study appears in The Lancet.