This week, the UN General Assembly is debating the theme of “The Sustainable Development Goals (SDG): a universal push to transform our world”. This is a historic moment when all nations will unite around a shared vision for the future of our planet with 17 goals which countries can commit to attaining by 2030. The next challenge is to figure out how to measure progress toward achieving these goals. This is no small challenge as the SDGs, together, entail monitoring over 200 indicators. While health is just one of these goals (“to ensure healthy lives and promote well-being for all at all ages”), indicators related to health span at least 10 other goals — for example ending hunger and ensuring clean water and sanitation. Altogether, indicators pertaining to health services and health outcomes, and factors with well-established causal connections to health account for 47 of the 200 odd indicators.
The Global Burden of Disease study, headquartered at the University of Washington, and involving over 1,750 collaborators from around the world (including several from India) has extracted data for 33 of these indicators to generate a composite “SDG health index” for each country. The findings of these analyses, which include reporting the relationship of the SDG health index with an index of the socio-economic development status of the country, have been published in the Lancet journal this week. The report has two major findings relevant to India, both of which reaffirm why health is India’s most neglected development priority.
The first finding is that India ranks near the bottom of the league of nations in its overall SDG health index —143 out of 188 countries. Our score (which can range from 0 to 100) was a meagre 42, about half that of the top-ranked country (Iceland). Few working in the development sector would be surprised that India ranked behind the high-income countries or that it was also the last amongst the BRICS. But what might alarm some readers is that we were nearly 100 places below Malaysia, 60 places below Sri Lanka and, astonishingly, even behind countries like Libya and Iraq which have been shattered by war. We are also behind some of the poorest countries of the world, including Cambodia, Timor-Leste, and Myanmar. The silver lining, at least for the “nationalists” amongst us, is that we are six places ahead of Pakistan. The second finding which stands out is that India’s SDG health index is far worse than what would have been predicted on the basis of the country’s socio-economic index; in other words, we have squandered the opportunity, that most other nations have harnessed, to turn socio-economic success into better health for our citizens. In this respect, we are the worst performer in South Asia.
Neither of these findings will surprise public health activists in India or even readers of this newspaper who are assaulted on a daily basis by a litany of reports reminding us of the appalling state of our health system. In the past few weeks alone, we have been horrified by the unfolding epidemic of mosquito-borne infections in the capital of our country, shocked by the scandal of kidneys for sale in corporate hospitals, and driven to grief by the story of Dana Majhi, a tribal man who carried his wife’s dead body, riddled with tuberculosis, on his shoulders for nearly 12 km as he had no money for a hearse van and the district hospital authorities allegedly refused to arrange one. It is easy to lay the blame on successive governments for failing to address health as a fundamental right for the Indian people. But the real tragedy is that we, the people of India, have not taken our government to task for this catastrophic failure.
The solution, adopted by most countries with SDG health indices ahead of us, is a universal health care system and a strong commitment to addressing the social determinants of health, such as sanitation and hunger. While hard-nosed economists argue that we are not rich enough to afford universal health care, they ignore the fact that much poorer countries than us have attained this goal — ironically, we produce more health workers and medical products such as drugs than these countries. Those who believe that health is a commodity, on par with cars or computers, fail to grasp the basic economic lesson that health is very vulnerable to exposure to the markets, not least due to the profound asymmetries in power between the providers and consumers. These ideologues also ignore the well-documented evidence that investing in health gives one of the best returns to society: A healthy workforce is a more productive one and will ultimately contribute to economic growth. In short, investing in health is not only socially but also economically sound. This does not mean that all healthcare must be funded by the tax-payer. There are numerous options for financing universal health care. What it does mean, however, is that it is a fundamental duty of the state to ensure quality healthcare, in both private and public sectors, to all its citizens, free at the point of delivery, with a robust regulatory system to ensure that commercial or professional interests never supersede patient rights.
If this country can send a satellite to Mars at a fraction of the cost of other countries who attempted to do the same, then surely we can fix our broken healthcare system with whatever resources we have. We need the political will to do so.