Healthcare in India- Reaching the Last Mile

 Healthcare in India has been always a critical factor hindering it’s developmental dynamics. There are multiple factors including lifestyles that influence the burden of disease. The burden of communicable diseases has been declining. The focus of the Government is to provide accessible, affordable and accountable quality healthcare facilities to all sections of society especially the marginalized sections in the country. While there are multiple challenges, the availability of Primary Health Centres, human resources, number of medical colleges and medical seats, have been improving. Public health and hospitals being a State subject, the primary responsibility to address healthcare challenges is that of State Governments.

However, under National Health Mission (NHM), financial and technical support is provided to States/UTs to strengthen their healthcare systems including support for strengthening health infrastructure, deployment of medical personnel, ASHAs, creating awareness about health issues and lifestyles, and support movement towards Universal Health Coverage. The Central Government has enacted the Clinical Establishment (Registration and Regulation) Act, 2010 and also notified Clinical Establishments Rules 2012 to provide a legislative framework for the registration and regulation of clinical establishments in the country and also seeks to improve the quality health services by prescribing minimum standards of facilities and services which may be provided.

The Government has also taken steps for strengthening and upgrading district hospitals and making available tertiary health care services in the public sector through strengthening of hospitals, establishment of AIIMS institutions in the States and up-gradation of existing Government medical colleges across the country. With regard to increasing awareness about the health issues, the Ministry of Health and Family Welfare regularly releases print advertisement and TV and radio spots in National/regional media for generating awareness among population about various Health and Family Welfare issues and programmes of Ministry of Health and Family Welfare. These include Mission Indradhanush, World Health Day, World No Tobacco Day, Yoga Day, Intensified Diarrhoea Control Fortnight, World Population Day, Breastfeeding, Tuberculosis, etc. The Government has formulated the National Health Policy 2017 which has laid emphasis on the role of the Government in regulation, governance, and quality assurance, healthcare infrastructure and in leveraging information technology. The policy also envisages raising public health expenditure to 2.5% of the GDP in a time bound manner.

Ayushman Bharat is a game-changing initiative in ongoing efforts to ensure universal healthcare in the country. Focus on areas like strengthening healthcare infrastructure, holistic and preventive healthcare, digital outreach, and risk cover is critical in achieving this objective. On March 21, 2018, the Union Cabinet chaired by Prime Minister Mr Narendra Modi made an announcement that marked a milestone in India’s healthcare journey. It approved the launch of Ayushman Bharat - National Health Protection Mission (AB-NHPM), which was announced as part of Union Budget 2018-19.

AB-NHPM will eventually become the world’s largest government-funded healthcare initiative, says Union Health Minister J P Nadda. It is humongous in both scale and reach, taking several steps ahead the vision captured in the National Health Policy, 2017. One of its twin focus areas is providing healthcare to 100 million poor families, offering them up to `5 lakh (US$ 7,723.2) per family per year for secondary and tertiary care hospitalization. The other is improving accessibility—`1,200 crore (US$ 185.36 million) has been set aside for National Health Policy, 2017, under which 150,000 health and wellness centers will be created by transforming the existing sub-centers and primary healthcare centers by 2022. WHO Director-General Tedros Adhanom’s remark reflects the robustness and inclusiveness that lie at its core— “The new National Health Protection Scheme has the potential not only to improve health, but to help lift people out of poverty… The reforms which India is embarking on are bold, and they must be.”

Rooted in the concept of cooperative federalism, Ayushman Bharat takes into account the varied needs of the different states and offers them the freedom to choose the modalities for implementation and expansion. This vision was reflected in the Prime Minister’s words at the inauguration of the first healthcare and wellness centre under the scheme in Bijapur district (Chhattisgarh) on April 14, 2018, “The Ayushman Bharat scheme is not limited to simply providing a service, but also invokes public participation so that we can create a healthy, capable, and content New India.” It is up to the states to decide whether they want to run it alongside their own insurance schemes or integrate it into existing ones.

BUILDING BLOCKS
Primary healthcare took shape as a concept in the country in 1946, following the recommendations of the Bhore Committee. Concerted efforts have since been made by successive governments towards expanding infrastructure. The year 2005 saw the launch of the National Rural Health Mission (NRHM), a strategic plan to cater to the underserved in remote areas. In 2013, the National Urban Health Mission (NUHM) was approved as one of the sub-missions (NRHM being the other) of O the National Health Mission (NHM). The progress made under NHM, as of September 2017, included accelerated decline in maternal mortality rate (MMR), infant mortality rate (IMR), under-five mortality rate (U5MR), and total fertility rate (TFR). IMR declined from 39 in 2014 to 37 in 2015, MMR from 178 during 2010-12 to 167 during 2011-13; U5MR dropped from 59 in 2010 to 43 in 2015. The number of endemic blocks with prevalence of more than one case of Kala Azar per 10,000 population was brought down from 230 in 2010 to 94 in 2016. Malaria API declined from 1.10 in 2011 to 0.84 in 2016. The Millennium Development Goal 6 of halting and reversing the incidence of Malaria, TB, and HIV/AIDS was achieved.
Recently, a proposal was cleared for continuation of NHM till March 31, 2020 with a budgetary support of `85,217 crore. During this extended span of time, the government aims to improve neo-natal mortality rate (NMR), IMR, U5MR, and TFR. There will be much emphasis on wellness through integration of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) and reducing out-of-pocket expenditure, too. In Union Budget 2018-19, an allocation of `9,752.82 crore (US$ 1.51 billion) was made for NRHM, and `1,004.67 crore (US$ 155.19 million) for the flexible pool for non-communicable diseases, injury, and trauma.
TECH EDGE
Its sprawling geographical expanse leaves India facing a huge challenge vis-à-vis healthcare delivery—one reason why technology has been adopted on a large scale. The government has been increasingly focusing on digital health and employing ICT for improving efficiency. A National Telemedicine Network (NTN) has been set up, and telemedicine nodes have been established across the country. Further, there is a National Medical College Network that brings together 50 government medical colleges for e-education and e-healthcare delivery.

ALTERNATIVE MEDICINE
The government is also harnessing the innate potential of India’s traditional streams of medicine. The setting up of the Ministry of AYUSH is ample proof of this. As of March 8, 2016, as many as 3,598 hospitals and 25,723 dispensaries across the country offer alternative medicine treatment.15 The All India Institute of Ayurveda was set up in 2017.16 AYUSH information cells have also been set up in 29 countries, and an MoU has been signed with the National Health Organization of the US for development of ayurveda and yoga.17 Yoga--the path to wellness, as the Prime Minister puts it-—is being promoted in a big way, in perfect alignment with the government’s holistic approach to health. June 21 is being celebrated as International Yoga Day since 2015. Dr K R Kohli, Director, AYUSH, says, “The two aspects that are better in allopathy compared to Ayurveda are emergency treatments and technology. But the incidence of non-communicable diseases has gone up now, for which we would not need either of these. What is required is good care, different kinds of massage, and other holistic treatments. AYUSH will dominate in terms of prevention and cure of noncommunicable diseases.” ‘Holistic’ is the essence of Ayushman Bharat too. And it is bound to have a sweeping impact across the spectrum, with its pronounced focus on preventive care and AYUSH, financial risk protection, and access to quality and affordable care which will also play a major role in poverty reduction in the country.

Presently, the Centre and the states have joined hands for a strategic mission and, together through a reinforcing cooperative federalism, they are sure to add momentum to India’s steps towards achieving universal health coverage—one of the SDGs (sustainable development goals) laid down by the UN.

By: Abhishek Sharma