News Release

Experts call on India to have a truly universal health-care system by 2020

Peer-Reviewed Publication

The Lancet_DELETED

India is experiencing a period of record growth, with its economy rapidly progressing to make it one of the biggest players on the world stage. But its health-care and public health systems are completely inadequate to address the needs of its population that continues to grow. In a Series of seven papers published by The Lancet, experts detail the problems faced by India's health-care system, and call on the country to establish a truly universal health-care system by 2020, with a detailed plan for the future included as a call to action in the final paper.

For links to all the papers, see the individual links beneath each part of the press release; however if you wish to provide a link for your readers to a page containing the whole Series, please use the link below but please note this link will only be live once the embargo has lifted.

http://www.thelancet.com/series/india-towards-universal-health-coverage

Highlights from the Series

Paper 1: Infectious Diseases

The first paper (T Jacob John and colleagues) describes the continuing threats faced by India from infectious diseases, while highlighting the success it has had in tackling diseases such as polio, leprosy and AIDS. Infectious diseases represent 30% of the disease burden. Longstanding attempts to control tuberculosis, malaria, and visceral leishmaniasis are not yet successful. Innumerable other diseases that are not targeted through vertical (and often donor-driven) programmes, including even cholera and typhoid fever, are neglected and poorly monitored.

India's public health-care system is overwhelmed by the infectious disease burden, driving many families to use the private sector, where the costs of treatment can be crippling. Only a functional public health infrastructure shared between central and state governments, with adequate infectious disease and epidemiology training of personnel, can prevent and control infectious diseases in order to reduce the burden on the health-care system.

For full Series paper 1, see: http://press.thelancet.com/india1.pdf

Paper 2: Reproductive health, child health, nutrition

The second paper (Vinod K Paul and colleagues) highlights that India has the highest burden of any country in the world for maternal, child and nutrition-related health. Some 1.8 million children under 5 die in India every year; 68,000 mothers die due to maternal causes; and 52 million children in the country are stunted. The Millennium Development Goals for maternal and child health will probably not be met, due to insufficient coverage of priority interventions, sub-optimum performance of established intervention packages, and inequities in access. India's weak health system is the overarching cause of all these problems, with specific problems in planning, human resources, infrastructure, governance and monitoring.

The authors of this paper say that nutrition programmes currently focus on 3 to 6-year old, rather than children aged 2 years and under. Established research has shown that the first two years are critical for preventing undernutrition and its consequences.

For full Series paper 2, see: http://press.thelancet.com/india2.pdf

Paper 3: Chronic Diseases and injuries in India

The third paper (Vikram Patel and colleagues) reveals India's rapidly ballooning chronic disease burden. Many chronic diseases are equally prevalent in rural and poor populations and often occur together. More than one in five Indians have a chronic disease, while over one in ten have more than one. Half of all deaths in India are caused by chronic diseases, while one in nine (11%) are caused by injuries. Risk factors are abundant through the population, but focused on the poor, for example one third of the poorest 25% of the population smoke daily, compared to just 11% in the richest 25%.

The authors conclude that some interventions are highly cost effective and could be implemented quickly, such as increased taxation and reduced advertising for tobacco and alcohol, reducing availability of locally brewed alcohols, bidis tobacco (unfiltered tobacco flakes), reducing salt, providing reading glasses, preventive treatment for high blood pressure, and, in the hospital setting, screening and treating breast cancer. Interventions of medium cost-effectiveness include preventing traffic injuries by enforcing speed limits and seat-belt use, depression and alcohol misuse treatment, flu vaccination, and treatment of heart problems with aspirin and statins. More expensive and thus less realistic options for the near-term include universal cycle helmet use by children, and organised, specific care for conditions such as stroke and COPD. The authors feel that India is still at an early enough stage in its chronic disease epidemic for the most cost-effective interventions to have an immediate and lasting effect. India does have policies on some of these issues, but progress is inadequate.

For full Series paper 3, see: http://press.thelancet.com/india3.pdf

Paper 4: Health care and equity in India

The fourth paper (S V Subramanian and colleagues) addresses the vital issue of equity. Massive inequalities exist, and three-quarters of the increasing burden of health-care are met through out of pocket expenses. Such expenses push a further 39 million Indians into poverty each year. Overall immunisation coverage for children under 5 years old is 44% overall, but 64% for mothers with more than 5 years of education and just 26% for mothers with no education. Life expectancy is 56 years in the state of Madhya, versus 74 years in Kerala. Only 40% of women give birth in a health facility, with those in the richest 20% six times more likely to do so than the poorest 20%.

India must substantially increase the share of Gross Domestic Product (GDP) that it spends on health—currently at just 1.1%. But projects are now running to address inequitable access, such as the National Rural Health Mission, established in 2006 to improve universal access to health-care, especially in 18 states with poor indicators. The authors give four key principles that should guide future progress: use of equity metrics; investment in health-systems research; equity-focused decision making in health-care; and redefinition of specific responsibilities of key players. The authors believe that the country's economic boom gives it a unique opportunity to provide these investments.

For full Series paper 4, see: http://press.thelancet.com/india4.pdf

Paper 5: Human resources for health in India

The dire shortage of human resources for health is discussed the fifth paper (Krishna D Rao and colleagues). The majority of healthcare workers are concentrated in urban areas, meaning the care of most rural Indians is left to unqualified providers. The country also faces a brain drain of doctors to other countries such as the USA, UK, and Australia. There is woeful underinvestment is human resources, especially nurses and paramedics.

A comprehensive training and location policy is needed to address these issues, offering appropriate monetary and non-monetary incentives. Doctors and nurses must have their training tailored to the health needs of the country, and have access to continuing education once in practice. While this training gap is closed, the authors suggest India uses the short-term measures to overcome shortages, such as task-shifting to practitioners of alternative specialists in ayurveda, yoga, and naturopathy among others; rent private sector health centres and purchase some services from private providers. The National Rural Health Mission is working hard to plug these gaps, but the road ahead is a long one—a district of 1.8 million people would need some1450 midwives/nurses and 370 doctors to hit targets; currently the average district of that size in India employs around 500 nurses and 100 doctors.

For full Series paper 5, see: http://press.thelancet.com/india5.pdf

Paper 6: Financing health care for all

The sixth paper (A K Shiva Kumar and colleagues) addresses health financing in India, and what has to be done to improve the situation. Low per person spending (around 1% of GDP, combined with inefficiencies in that limited spending in both the public and private sectors, result in very high out-of-pocket expenditures for health. Only 10% of the population have medical insurance.

To fix this, a tripling in investment, from 1% to at least 3% of GDP is called for, followed by a subsequent increase to 6% of GDP, along with sector-wide improvements in efficiency and accountability. Policies must be implemented to contain the rising costs of drugs and medical care. Availability of health-care services must be increased using both private providers of both conventional and allopathic medicine. The new strategy must increase insurance and risk pooling to provide financial protection, and introduce a predominantly tax-paid universal medical insurance plan that offers essential coverage to all citizens.

For full Series paper 6, see: http://press.thelancet.com/india6.pdf

Paper 7: Call to action to create an integrated national health system for India

India's continued economic growth will be at risk if adequate steps are not taken—quickly—to invest in the health of its citizens. The authors of the Series combine to call on India to create an integrated national health system for India by 2020. To do so, public spending on health would need to be gradually increased from 1% up to 6% of GDP< and 15% of tax revenues, including new taxes on tobacco, alcohol, and unhealthy foods, would be earmarked for health. Out of pocket spending should be no more than 20% of costs by 2020. They summarise their targets as follows:

  • We call for a radical transformation of the healthcare system to promote equity, efficiency, effectiveness, and accountability in the delivery of healthcare at all levels through the establishment of an Integrated National Health System (INHS).
  • The INHS should have three key goals: ensure the reach and quality of health services to all Indians; reduce the financial burden of healthcare on individuals; and empower people to take care of their health and hold the healthcare system accountable.
  • This call to action aims to achieve better health status of the population and reduce inequities through strengthening of the national health system in India as the primary provider of promotive, preventive and curative health services, and a well regulated integration of the private sector health care and the Indian system of medicine within the national healthcare system.
  • This call to action proposes increase in public spending on health to 6% of GDP and reduction of the proportion of out-of-pocket spending to 20% of the total health expenditure, by 2020.
  • We propose five major strategies to achieve universal health care: the provision of a universal health insurance scheme for all citizens; the establishment of autonomous councils for promoting accountable and evidence based practices and for promoting the production, distribution and utilisation of appropriate human resources for health; the restructure the governance of health with convergence of all health related ministries or departments and complete decentralization to a district based model; and the to legislate and enforce the health entitlements of Indians.

The authors note that two recent events make the timing of this call to action particularly opportune: the outlining of health priorities by the Health Minister of India, several of which match those in the call. The other is the setting up of a High Level Expert Group on Universal Healthcare by The Planning Commission of India. They conclude: "We therefore call for a national debate about these recommendations in India—government, civil society, private sector, academia, and the media—to engage in active dialogue for making universal health care a shared national goal by 2020."

They add: "The results of what happens in India will have ramifications across the world."

For full Series paper 7, see: http://press.thelancet.com/india7.pdf

The Editors of the Series, Vikram Patel, Srinath Reddy, Shiva Kumar and Vinod Paul, say in a Comment with the Series: "The final shape of a new and just health-care system in a country that is characterised by pluralism and a vibrant civil society will require much wider consultation and consensus building than we have been able to achieve. We are aware that the goals we set out are ambitious and the challenges huge, but we believe that 21st-century India can channel political commitment and resources to help realise the nation's founding vision of health for all. The time to act has come".

For full Comment from Prof Patel and colleagues, see:

http://press.thelancet.com/indiacom2.pdf

In another of the Comments, Lancet Executive Editor Pam Das and Editor Richard Horton say: "India rightly brands itself incredible. The country's remarkable political, economic, and cultural transformation over the past half century has made it a geopolitical force almost equal to that of China."

They conclude: "Children and women bear a particularly shocking and intolerable burden of death and disability…the emerging epidemic of chronic disease has barely been addressed…[there is a] perilously low density of educated health workers across the country [and] too many politicians in India do not take the health of those they claim to represent seriously enough."

For full Comment from Dr Horton and Dr Das, see: http://press.thelancet.com/indiacom1.pdf

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CONTACT DETAILS FOR SERIES AUTHORS

(Note: For a general Series overview, Prof Patel and Prof Reddy are all available on numbers below)

Paper 1: Professor T Jacob John, Christian Medical College, Vellore, Tamil Nadu, India. T) +91 416 2267 364 E) tjacobjohn@yahoo.co.in

Paper 2: Professor Vinod K Paul, All India Institute of Medical Sciences, New Delhi, India T) +91 9811042437 E) vinodkpaul@gmail.com

Paper 3: Professor Vikram Patel, Sangath Centre, Goa, India, and London School of Hygiene and Tropical Medicine, UK. T) +91-9822132038 E) Vikram.patel@lshtm.ac.uk

Paper 4: S V Subramanian, Harvard School of Public Health, Boston, MA, USA. T) +1 617 803 9936 E) svsubram@hsph.harvard.edu Alternative contact for SV Subramanian: Todd Datz, Harvard Media Relations, T) +1 617.998.8819 E) tdatz@hsph.harvard.edu

Paper 5: Dr Krishna D Rao, Public Health Foundation of India, New Delhi, India. T) +91 9818954463 E) kd.rao@phfi.org

Paper 6: Dr A K Shiva Kumar, UNICEF India, New Delhi, India. T) +91 9899453222 E) akshivakumar@gmail.com

Paper 7: Professor K Srinath Reddy, Public Health Foundation of India, New Delhi, India. T) +91-9818364844 E) ksrinath.reddy@phfi.org

Lancet Press Office. T) +44 (0) 20 7424 4949 E) tony.kirby@lancet.com


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