(The Gist of Kurukshetra) HEALTH SYSTEM: TOWARDS A NEW INDIA [JANUARY-2020]

HEALTH SYSTEM: TOWARDS A NEW INDIA

Introduction:

India has made noteworthy strides on health and nutrition over the last two decades. Polio guinea worm disease, yaws as well as maternal and neonatal tetanus have been eliminated.
The Total Fertility Rate has reduced sharply from 2.7 in 2005-06 to 2.2 in 2015-16 and for the first time the birth cohort has fallen below 25 million. Contrary to expectations, we were able to achieve the Millennium Development Goals in respect of the Maternal Mortality Ratio (MMR level of 130 against a target of 139) as well the Under-5 child mortality target (U5 MR level of 43 against a target of 42).
Infant Mortality Rate has also reduced from 57 per 1000 live births in 2005-06 (National Family Health Survey-3) to 41 per 1000 live births in 2015-2016 (NFHS-4). Given the size, complexity and diversity of our country, the importance of these improvements in the health and nutrition status of the population cannot be underestimated.

Challenges:

India's health system is still facing multiple challenges. There are significant inter and intra-state disparities in outcomes and socio-economically disadvantaged groups are especially vulnerable to gaps in healthcare access. Additionally, while the burden of non-communicable diseases is rising, there is also a substantial unfinished agenda with respect to communicable diseases as well as maternal and child health.
The health system is fragmented at multiple levels: payers and modes of financing, providers of healthcare services and the digital backbone. Currently the government (Union and States combined) spends approximately 1.13 per cent of GDP on health. As a consequence, households finance 62 per cent of the healthcare spending through out-of-pocket expenditure at the point of care. Risk pooling is low, with less than 35 percent of the population participating in any risk pooling scheme and less than 10 per cent being covered by a functioning risk-pooling mechanism which provides effective protection against catastrophic health events.
Delivery of health services is also fragmented into small sub-scale entities with 95 per cent of the care being delivered by providers employing less than 10 workers each, adversely affecting the quality and efficiency of service delivery.
The digital systems used in these health care entities, if at all used, are also siloed in the absence of mandatory adherence to any data standard. The result is that the patient health records lie buried in manual systems or disparate IT systems with little standardization and almost no possibility of interoperability. This limits the availability of information that could potentially guide policy making.
While there is no doubt that building a well-functioning system is a work of decades, the the government has initiated systematic efforts over the last few years by taking a comprehensive view of the health system and impacting its multiple determinants.

Public and Primary Health:

Over 2.55 crore children and 70 lakh pregnant women were immunized over a period of two years under Mission Indradhanush. The programme has emerged as a global best practice in public health. Further, Rotavirus and Pneumonia vaccines were introduced in an effort to counter pneumonia and diarrhoea in children less than 2 years of age. For the first time, a comprehensive effort is being made for incorporating traditional medicine within the overall framework for promoting health and well-being through the National AYUSH Mission.
In 2017, the first-ever All India Institute of Ayurveda was launched along the lines of AIIMS, New Delhi, for creating synergies between the traditional wisdom of Ayurveda and modern technologies. Cleanliness is crucial for preventing diseases. Following the implementation of the Swachh Bharat Abhiyan, nearly 100 per cent of households in rural India now have access to a toilet, compared to merely 29.1per cent in 2005-06.
The battle against Tuberculosis (TB) has also been escalated through the launch of a new National Strategic Plan in 2017. The thrice weekly treatment regimen has been changed to a daily fixed-dose drug regimen and a sum of Rs. 600 crore has been allocated for providing nutritional support to TB patients in the Union Budget 2018-19. Going forward, the establishment of dedicated public health cadres by States needs to be prioritised with training imparted on critical skills such as the ability to integrate health with its social determinants, carry out community surveillance, analyse data and enable public participation, disseminate health promotion information and effect behaviour change.
To build a robust primary healthcare system, the government has announced the setting up of 150,000 Health and Wellness Centres (HWCs) between 2018 and 2022 under the Ayushman Bharat initiative. Currently, over 27,000 HWCs are operational across the country. Historically, only a selective package of services has been provided at the primary care level in India, however, the HWCs will deliver a comprehensive package of diagnostic, curative, rehabilitative and palliative services for communicable as well as non-communicable diseases. Moreover, the Centres will provide diagnostics and drugs free of cost which will have a direct impact on controlling out-of-pocket expenditures. Currently, over 55 per cent of India's out-of-pocket expenditure is on outpatient care, of which drugs constitute the biggest component.

Secondary and Tertiary Healthcare:

The second pillar of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojana (PM-JAY) which will provide 10 crore of the poorest and most vulnerable families in the country an annual cover of Rs. 5 lakh per annum for hospitalization related expenses.
By consolidating multiple health insurance schemes under PM-JAY, the government is taking a major step towards 'One Nation One Scheme' which will ultimately ensure that all citizens can access a common package of secondary and tertiary health services regardless of the State in which they reside. Thus far, 19,624 hospitals have been empanelled under PM-JAY and over 70 lakh patients have been admitted.

Human Resources for Health:

We cannot build a world-class health system without first investing in a world-class medical education system. Earlier this year, the government enacted the landmark National Medical Council Act 2019 for overhauling medical education in India. Central and State government medical colleges are being upgraded to add 10,000 undergraduate and 8,058 postgraduate seats by 2020-21, ensuring the presence of at least one medical college for every 3-5 Parliamentary Constituencies and at least one in every State.
Similar efforts are also underway for producing the requisite number of skilled nursing professionals through the setting up of 112 Auxiliary Nursing and Midwifery schools and 136 General Nursing Midwifery schools in underserved districts of the country. Further, minimum qualifications for teachers in medical institutions have been rationalized for the Diplomate of National Board. This is expected to expand the pool of candidates eligible for appointment as faculty by 3700 a year.

Medicines and Devices:

More than 5,500 Jan Aushadhi stores have been opened for providing quality drugs at affordable prices and the government plans to expand the number of stores to 7,500 by 2020. It is estimated that these stores serve between 10-15 lakh people across India on a daily basis.
To make medicines affordable for all citizens, the government has also fixed the ceiling prices of nearly 850 drugs. Further, the prices of Drug Releasing Stents which are used for treating blocked arteries were also lowered from INR 30,180 to INR 27,890. This is a significant step because an estimated 5 lakh patients undergo the stent procedure every year.
Recognizing the vital role played by medical devices in ensuring a well-functioning health system, the Medical Devices Rules were notified by the government in 2017. Previously, only 15 categories of devices had been subject to regulation, that too under the umbrella of drugs. India also finalized its first National Essential Diagnostics List earlier this year to guide decision making with respect to the different kinds of diagnostic tests required by healthcare facilities across the country. Moreover, to boost indigenous production the government is supporting the establishment of medical device parks in India.

Health Technology and Data Systems:

Tools such as telehealth, mobile health and Artificial Intelligence (Al) are helping to lower barriers between hospitals and patients, thereby improving access to care, especially in Tier-2 and Tier-3 cities.
India has made considerable progress in leveraging Information Communication Technology (ICT) for enhancing the coverage and quality of maternal and child health services. For example, the Auxiliary Nurse Midwives Online or ANMOL application has been developed to equip public health workers to register pregnant women, encourage institutional birthing and monitor immunisation programmes for newborns.
In the area of digital health, the National Health Stack proposed by NITI Aayog in 2018 is an important step. It is designed to offer a suite of advanced technologies which can be incorporated into overall digital health implementation in India. The availability of these "plug-in" modules will simplify and accelerate progress in implementing digital health in facilities and for health payers.
It will also facilitate collection of comprehensive healthcare data across the country. The focus of this work will allow policymakers to experiment with policies, detect fraud in health insurance, measure outcomes and move towards smart policy making.
In 2019, the National Digital Health Blueprint was released by the government. The key features of the blueprint include a Federated Architecture, a set of architectural principles, a 5-layered system of architectural building blocks, Unique Health ID (UHID), privacy and consent management, national portability and Electronic Health Records (EHRs) among others.
Operationalizing EHRs for every citizen will be the key to optimizing health information systems. A system-wide EHR will enable monitoring of diseases, expenditures and performance to deliver financial and health outcomes.
AI solutions can provide doctors with an unbiased second opinion on diagnosis, treatment options, potential risks and predicted outcomes. For doctors working under considerable time pressure, AI can prove to be an important supportive tool by collating test reports of patients, studying their medical records and suggestion treatments.
Crucially, AI can enable healthcare personnel to detect the dormant signs of diseases, thereby ensuring prevention or treatment at an early stage. Cancer screening and treatment is one area where AI provides tremendous scope for targeted large scale interventions. Indian witnesses an incidence of more than 1million new cases of cancer every year, a number that is likely to increase given the ageing Indian population and lifestyle changes. NITI Aayog is in advanced stages of launching a programme to develop a national repository of annotated and curated pathology images for cancer screening and treatment.

Nutrition:

A critical determinant of ill health is malnutrition. Even though governments have launched multiple schemes over the years, a robust convergence mechanism has been absent, resulting in persistent high levels of malnutrition in the country.
To tackle this challenge comprehensively, the POSHAN Abhiyaan was launched to provide an appropriate governance structure reflecting the many overlapping factors like access to sanitation and health services that affect the nutritional status of an individual or household.
The Abhiyaan is targeting a reduction in stunting, under-nutrition, anaemia and low birth weight by at least 2 per cent, 2 percent, 3 per cent and 2 per cent per annum respectively.
The POSHAN Abhiyaan. focuses on engaging all stakeholders to make nutrition a Jan Andolan. Rashtriya POSHAN Mah has been celebrated in the month of September for the last two years. In 2018, it reached out to over 25 crore people with messages on crucial practices like antenatal care, optimal breastfeeding, anaemia, growth monitoring, delaying age at marriage for girls and hygiene, among others.
Rashtriya POSHAN Mah, 2019 focused on creating awareness about essential health and nutrition interventions during the first 1000 days of a child's life, prevention of diarrhoea, Anaemia Mukt Bharat, complementary feeding practices as well as the importance of clean water, sanitation and hygiene.

Way forward:

A challenge that will need to be addressed going forward is the prevalence of Overweight Obesity which is one of the most important risk factors for non-communicable diseases.
While it currently affects the affluent sections of society disproportionately, the transition of the risk factor will progressively impact all population groups including poorer households.
To address the Overweight-Obesity burden in the country, a lifecycle approach that focuses on ensuring the availability and consumption of adequate quantities of nutritionally balanced food at every stage of life is required. Surveillance mechanisms for monitoring overweight-obesity prevalence in the population must be established and scaled-up. Physical and wellness activities like Yoga also need to be promoted in every age group.
In its Three-Year Action Agenda, NITI Aayog called for a new wave of institution building with a strong and a pro-active stewardship role by the government to overcome the persistent challenges while also leveraging the potential of a mixed health system. The government has launched several reform initiatives over the last few years which need to be rigorously implemented.
Additionally, the key enablers of health system reform such as financing, organisation and provision of service delivery as well as digital health need to be strengthened as highlighted in the book Health System for a New India: Building Blocks released by NITI Aayog earlier this year.