The outbreak of dengue and chikungunya across India has again directed our attention to the state of the Indian health system. The media is awash with stories of overcrowded hospitals and under-prepared government authorities struggling to deal with the magnitude of the problem. The sheer economic, social and personal costs of these diseases — in terms of healthcare costs, loss of productive work days and patient-suffering — are there for all to see. However, the most unfortunate aspect of this saga is that it seems to be an annual affair for India. Each year, as the monsoon sets in, we see a spurt in the reported cases of, and deaths due to, dengue, chikungunya and malaria. This bears testimony to the state of our planning in the public and private sectors to address disease outbreaks.
To fix India’s healthcare scenario, what is most needed is “systems thinking”. For far too long, India has followed a vertical approach in its health sector, which translated into disease-specific national programmes being set up. While many of these programmes have their own value, and have proved their efficacy over the last several years, there is an urgent need to adopt an approach that strengthens health systems to deal with problems such as the annual outbreak of diseases like dengue and chikungunya, as well as to prepare for the upcoming onslaught of non-communicable diseases such as cancer and diabetes.
As per the World Health Organisation (WHO), an effective and efficient health system consists of six key building blocks — service delivery, medicines, information, health workforce, financing and governance. We all know that save for India’s ingenuity in producing cheap generic medicines, the country’s record via-a-vis the other five blocks is dubious at best. Therefore, if we are actually serious about improving the health outcomes of India’s citizens, we must look at strengthening the country’s health system in its entirety, with an equal focus on disease prevention, health promotion, and disease diagnosis and treatment.
This translates into ramping up our commitment to disease surveillance and data collection systems, better medical research, health workforce training and staff-retention programmes, public provision of quality healthcare and nutrition services, equal access to safe and efficacious medicines, increased public financing for healthcare and nutrition, and effective public and financial management of our national healthcare and nutrition service delivery programmes. This roadmap is quite simple to follow, and all it needs is a strong political will, a long-term view of planning and management, and attention to detailed implementation. This approach, of course, raises questions about the feasibility of the so-called panaceas like the mohalla clinics, which may be well-intentioned but are poorly planned. As we have seen, the mohalla clinics seem to be courting controversy at every step, with the most recent episode calling into question their commissioning norms and spotlighting allegations of inflated property rents.
Considering that India has a great opportunity to leverage its demographic dividend like no other country in the post-modern era, it is incumbent upon us, the political leadership, to do the right thing. We know that health and nutrition are inextricably linked to each other. Research has shown that good health and nutrition during the early childhood period lead to proper physical and cognitive development amongst children, which is directly related to improved productivity and earning potential when these children become adults. Therefore, our failure to improve the health and nutrition outcomes of our children is a major disservice to the future growth and progress of India.
There is an urgent need for the Central government to take the lead in ensuring health and nutrition service delivery. Unfortunately, going by the current trends, the National Democratic Alliance (NDA) government seems to be averse to the idea of leading the way in health and nutrition. A quick analysis of the 2016-17 budget allocations to the National Health Mission (NHM) and Integrated Child Development Services Scheme (ICDS Scheme), compared to the 2013-14 allocations, shows an approximate increase of six per cent and a decrease of 14 per cent, respectively.
Given that India needs more public investment to strengthen its health system in line with WHO guidance, the paltry increase in the NHM allocation and the steep reduction in the ICDS budgets are ill-conceived. They seem even more regressive when one considers the historic steps — such as the launch of the National Rural Health Mission (NRHM) — that were taken by the preceding United Progressive Alliance (UPA) government to improve the health outcomes of India’s citizens.
The government must understand that it cannot substitute the health, nutrition and overall development outcomes of Indian citizens with “efficiency gains”. It also cannot shift its responsibility of delivering health and nutrition services to non-state actors. India’s changing demographic and epidemiological profile requires us to think bigger and better. The political leadership cutting across party lines needs to come together and look at new and more efficient ways to deliver healthcare to our citizens. That certainly is not possible in the face of shrinking public investments in the social sector.
More than any other time, when India is standing right at the cusp of a potential demographic dividend, we must get it right now.