Healthcare in india

2014CHL291

[Healthcare in india]The major diseases and which India is facing along with the changes which have happened in the last year are discussed in this report. Along with this we also look into the scenario in 2025 and provide the possible solutions which India should follow for a positive change.

Ankit AwasthiTop diseases leading to loss of life in India and its comparison with developed countriesDiseases claiming maximum life in India

Coronary Heart Disease

Ref : http://www.worldlifeexpectancy.com/cause-of-death/coronary-heart-disease/by-countryCountryMortality rate(per 100000)India165.8United States80.5United Kingdom68.8Australia60.3

CAUSESSmokingHigh levels of certain fats and cholesterol in the bloodHigh blood pressureHigh levels of sugar in the blood due to insulin resistance or diabetesBlood vessel inflammationDiabetes Mellitus

CountryMortality rate(per 100000)India23.8United States15.2United Kingdom5.0Australia9.9

CausesGenetic Susceptibility TCF7L2Obesity and Physical InactivityAbnormal Glucose Production by the Liver Metabolic Syndromehigher than normal blood glucose levelshigh blood pressure abnormal levels of cholesterol and triglycerides in the bloodincreased waist size due to excess abdominal fatInfluenza and pneumonia

CountryMortality rate(per 100000)India68.0United States9.7United Kingdom23.7Australia7.0

Stroke

Diarrhoeal Disease

Cancer

CountryMortality rate(per 100000)India75United States123.8United Kingdom137Australia118.8

Akshat RajDual Burden of Infectious and Chronic DiseasesAs discussed above, we can see that thebiggest challengefor India is thedual fightof containing a developing countrys health concerns while a range of developed world disorders are at its doorstep. On one hand India is combating basic health concerns such as malnutrition, low immunization rates, hygiene, sanitation, and infectious diseases. On the other hand, environmental pollution and lifestyle choices such as alcohol consumption, smoking, and high fat diet are set to increase the incidence rates of hypertension/high blood pressure, cardiovascular disease, diabetes and cancer to almost epidemic levels.What is Healthcare System?Before we look into the changes in Indias healthcare system, it is necessary to understand what we mean by the term healthcare system.World Health Organisation (WHO) defines a health system as one which consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health.Changes in our Healthcare System in the Last decadeIn the last decade, Indias health system developed well in a few areas. Public sector efforts gained momentum with the adoption of the Millennium Development Goals (MDGs), as the government set targets to reduce the MMR by three quarters between 1990 and 2015; to halt the spread of HIV/AIDS, malaria and other major diseases; and to reverse their spread by 2015.The Eleventh Five-Year Plan brought about long-awaited healthcare reforms. These led to greater intensity and some changes in the direction of public sector initiatives. Within the private sector, healthcare facilities grew rapidly and insurance coverage increased. The past decade also witnessed several pilots of public-private partnerships, particularly in hospitals and diagnostic services.Rise of the Private Health Care SectorOver the past decade or so the increase in the expenditure by private companies in the health care sector has been huge, as can be witnessed from the Figure A. Also, in the last decade the private sector added about 70% of the total hospital beds (Figure B).Figure A Percentage of Private and Public spending as a part of total health care spendingFigure B Beds added by Private and public sector, 2002-2010 (Source McKinsey)

Indias Public health care expenditure is alarmingly low, and amounts to around only 1% of its total GDP while in comparison to Russia (~3%), USA (~15%) and UK (8.5%).Another thing of concern has been the increasing OOP outlays (70%), i.e. Out-of-pocket spending on health facilities by people, of this 50% is on drugs.The reasons for Private sector to pick so much have been both the positive stimulus for private companies and hospitals and the negative stimulus to public sector. Poor public healthcare facilities i.e. unavailability of attendants, poor infrastructure, etc. increased the market for private health care and also many external drivers of private sector growth like Medical Tourism have also come up.But High Involvement of Private Sector is undesirable because of various externalities and also because of the problem of informational asymmetry (Doctors have more information about the disease than the patient, and may potentially exploit patients).

Figure C Healthcare system spending (Source McKinsey)

Pharmaceutical SectorIndia has emerged as a major supplier of several bulk drugs, producing these at lower prices compared to formulation producers worldwide. (Exports US $13 Billion/Year) which is 3rd Largest in World, in terms of Volume. And it is growing at the rate of 15-20%, annually. Indian Pharmaceutical Industry has helped the world in a very positive way by bringing to people many generic drugs at much cheaper rates.The last decade saw the advent of Product Patent Regime (January 2005), which brought a considerable change in the policies of the Indian Pharma companies. Now many bigger of the Indian firms, have increased their investments in R&D to sustain themselves. Also, now many Multinational firms are now targeting high end patients while some Indian firms have chosen to target semi-urban and rural populations.It is important for Indian Pharmaceutical companies to reinvent themselves to sustain themselves.Changes in Government PoliciesIn light of the MDGs (Millennium Development Goals) that were established following the Millennium Summit of the United Nations in 2000, the Indian government has taken long strides in the right direction. As part of the Eleventh Five Year plan the government has been increasing the Share of public spending in healthcare since 2005 steadily.Also, Various Public-Private-Partnerships (PPPs) have been setup to undertake/solve many issues as soon as possible.Apart from the above the major government schemes/programs which saw the light of the day in the last decade are National Rural Health Mission (NRHM) (2005) Rashtriya Swasthya Bima Yojana (RSBY) (2008) Jan Aushadhi Initiative (2008)Others Medical Tourism is now one of the major external drivers of growth of the Indian healthcare sector, seeing an exponential growth in the last decade.No. of Medical Tourists: 2005 -150, 000; 2011 850,000. (Source: Confederation of Indian Industry & ASSOCHAM)It is so because the treatment and medicines in India are much cheaper as compared to many developed countries while the quality of services is at par. India was declared Polio Free on March 27, 2014. Similar success is also needed for diseases like TB, etc. Clinical Trials India has become a more attractive market for clinical trials, because of various policy changes it took, which has made its policies similar to those around the world. Telemedicine Providing access to diagnostics and Treatments through Video Conferencing.

Challenges in Indian Health Care SystemVinita KumariIndias health care system is overburdened by increasing population. India faces the twin epidemic of continuing/emerging infectious diseases related to poor implementation of the public health programs as well as chronic degenerative diseases which is the result of demographic transition with increase in life expectancy. About 40 per cent of all deaths in India are due to infections. The majority of the remainder are mainly due to non-communicable conditions such as cardiovascular diseases (heart attacks and associated conditions, including strokes, are alone responsible for a quarter of all mortality), chronic respiratory disorders and cancers. Indias government spending on health care is less than 2% of GDP, among the lowest worldwide. Even though Indias private health insurance industry grew its business volumes by 35% annually in recent years, 85% of the population remains uninsured. About 65% of Indians that incur expenditures on major health problems become indebted for life. Economic deprivation in a large segment of population results in poor access to health care. Poor educational status leads to non-utilization of scanty health services and increase in risk factors. While India has emerged as a destination for drug development, a key obstacle moving forward is matching the priorities of the drug developer with those of the physician and the patient in clinical trials. The major challenges that India face in the health care industry are: Low investment by government in health care sector: Health cares spend is not growing as same pace as countrys GDP. Indias healthcare spending as a percentage of GDP has reduced from 4.4 percent in 2000 to 4 percent in 2010. Lack of infrastructure: Infrastructure gaps are substantial and underutilization of existing resources further adds to the problem of meager infrastructure. Public sector hospitals are not well maintained and their utilization remains low. In rural areas there are very few hospitals and health care centres and villagers have to cover miles to access health care services. Lack of health workforce: The total number of doctors and nurses in the country lags the WHO benchmark of 2.5 doctors per 1000 people at 2.2 per 1000 people. Despite the scarcity of medical personnel the problem of underutilization exists. Many registered medical practitioners, nurses are not actively involved in the formal sector, density of practicing workforce falls to 1.9 per 1000. High cost of health care services: Indias healthcare costs may be among the lowest in the world but they are still out of the reach of a vast majority of its citizens. Most people cant even afford conventional treatments at subsidised prices in public hospitals. Access to affordable and quality health care is still a dream for most rural Indians. Government hospitals can hardly fill the gap and therefore, most rural Indians are left with no choice but to rely on costly private hospitals. On a day-to-day basis many people experience outlays on drugs (which to varying degrees also encompass professional and institutional fees, as well as taxes) as the dominant element in the out-of-pocket expenditures they believe are needed to protect their health. Many sources suggest that a half of total health care outlays are spent on purchasing drugs. Each year, 39 million people are pushed into poverty by out-of-pocket payments for healthcare, with households on average devoting 5.8% of their expenditures to medical care.

Major diseases in India and their economic burdens on Indians:

CancerCancer is one of the leading causes of death in India, with about 2.5 million cancer patients, 1 million new cases added every year and with a chance of the disease rising five-fold by 2025.This is owing to the poor availability of prevention, diagnosis and treatment of the disease. All types of cancers have been reported in Indian population including the cancers of skin, lungs, breast, rectum, stomach, liver, cervix, esophagus, bladder, blood, mouth etc. Cancers of lung and mouth in men and cervix and breast in women are the biggest killers. Ignorance among public, delayed diagnosis and lack of adequate medical facilities has given cancer the dubious distinction of being a killer disease.As per a Boston Consulting Group study, 70-80% of cancer patients are diagnosed late when treatment is less efficient and 60% of them do not have access to quality cancer treatment. Out of 300+ cancer centres in India, 40% are not adequately equipped with advanced cancer care equipment.High treatment costs are one of the main reasons why cancer care is out of reach for millions of Indians. If detected early, treatment is effective and cheaper. However, if detected late, it is more expensive (can even lead to bankruptcy) and also reduces chances of survival. An average cancer patient bears an economic burden of Rs 36,812 for the entire cancer therapy at an institution like the All India Institute of Medical Sciences (AIIMS) where services are free or highly subsidized. Chemotherapy and hormonal drug therapy can cost from Rs10,000 to Rs 4 lakhs depending on the drugs used and duration of treatment. Some breast cancer patients, for example, need targeted treatment drugs, such as Herceptin or Herclon, made by global major Roche, which cost around Rs 75,000 for a course; a patient could need up to 17 courses. Similarly, a drug called Avastin - used to treat colon, kidney, lung and gall bladder cancer - can add around Rs 8 lakh to a patient's bill at around Rs 1 lakh a cycle. India has a population of approximately 1,200 million with a requirement of more than 1,200 Radiation Therapy (RT) machines. At present, there are just 400 RT machines that are available for cancer treatment. Access to cancer detection technologies -- quality pathology labs, imaging equipment, especially PET/CT or molecular imaging that can detect cancer at least 5 years earlier than any other technology -- needs to be improved.

DiabetesAt present, India is considered as the diabetic capital of the world. In India, 63 million people have diabetes as of 2012, and the number is estimated to increase to 101 million by 2030. Diabetes is a metabolic disease in which a person has high blood glucose, either because the body does not produce enough insulin, or their cells do not respond to the insulin produced. People with diabetes develop further health complications as a result of inadequate blood sugar control, a condition that can lead to heart disease and stroke, as well as damage to kidneys, nerves and retina.Because of its chronic nature, the severity of its complications and the means required to control them, diabetes is a costly disease. Diabetes consumes between 5% and 25% of the income of an average Indian family, which translates to USD 2.2 billion a year on diabetes care and treatment. Many patients are unaware of treatment expenses and are not able to plan the budget. Direct costs to individuals and their families include medical care, drugs, insulin and other supplies. Since it is a chronic disease it requires prolonged treatment like regular doses of insulin injection, regular intake of tablets to maintain metabolism of body.In India, more than half of patients have poor glycaemic control and have vascular complications. Therefore, there is an urgent need to develop novel therapeutic agents of diabetes without the development and progression of complications or compromising on safety.

Tuberculosis (TB)Tuberculosis (TB) is one of the major public health problems in India with a significant impact on the health and economy of the country. India is the highest tuberculosis (TB) burden country in the world, accounting for nearly one-fifth of the global incidence. Annually more than 250,000 people die of TB. This is most unfortunate as TB is a curable disease if treated appropriately and adequately. Almost 70% of TB patients are aged between 15 and 54 years. The disease is more common amongst the poorest and the marginalized sections of the community. Whilst two-thirds of cases are male, TB takes a disproportionately larger toll among young females, with more than 50% of cases occurring amongst females less than 34 years of age. The most reliable test for diagnosis of TB is smear microscopy which is widely used under the RNTCP(revised national tuberculosis control programme). However, the private sector does not prefer this simple and reliable test; instead a number of antibody based blood tests (serological tests) which are nonspecific are being widely used for diagnosing TB. Patients are therefore often falsely diagnosed based on these unreliable tests and unnecessarily treated for a disease they are not suffering from while incurring unwarranted out of pocket expenditure. It is estimated that over 1.5 million of such unreliable serological tests are performed in India annually primarily by private laboratories. A cause for concern is the potential threat of extensively drug-resistant tuberculosis in India, with unregulated availability and injudicious use of the second-line drugs and no system to ensure adherence to standardized regimens and treatment for multidrug-resistant tuberculosis. Multidrug-Resistant TB (MDR-TB) is the resistance to the two most effective first line drugs isoniazid and rifampicin. When these first-line drugs fail, second-line drugs are used for treatment. The cost of these drugs is staggering, as much as 1400 times that of regular treatment, with severe side effects and prolonged duration of treatment over 2 years.India needs an enhanced model for the control of tuberculosis. District public health ocers are needed to receive reports about all cases that are diagnosed in all health-care clinics in the district.

ConclusionIndias health care industry needs managers with knowledge about the reality at the ground level to help grapple with the above challenges.Most people in India buy healthcare from the private sector, a compulsion that accounts for a high proportion of healthcare-related expenditure. To reduce the burden of healthcare costs, the government must improve availability and affordability of generic and essential medicines in the market. Government needs to understand the scope of Indias health care gaps, work to build infrastructure to reach rural pockets, and to create innovative financing to deliver health care to the underprivileged. Creating incentives for local companies, roping in support from global players and putting in place public-private partnerships are the main areas for the improvement of Indian health care services industry. Rishi YadavMajor Programmes by Ministry of Health and Family welfare Communicable Diseases Non-Communicable Diseases, Injury & Trauma Pradhan Mantri Swasthya Suraksha Yojana - PMSSY Poor Patients-Financial Support Other National Health Programmes National Health MissionCommunicable Diseases Human Immunodeficiency Virus Infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) - Department of AIDS Control State AIDS Prevention and Control Societies Revised National TB Control Programme (RNTCP)Second largest DOTS (Directly Observed Treatment, Short course) programme in the world. However, India's DOTS programme is the fastest expanding programme, and the largest in the world in terms of patients initiated on treatment, placing more than 100,000 patients on treatment every month. National Vector Borne Disease Control Programme (NVBDCP)Central nodal agency for the prevention and control of vector borne diseases i.e. Malaria, Dengue, Lymphatic Filariasis, Kala-azar, Japanese Encephalitis and Chikungunya in India. Integrated Disease Surveillance Project (IDSP)Integrated Disease Surveillance Project (IDSP) was launched with World Bank assistance in November 2004 to detect and respond to disease outbreaks quickly. National Leprosy Eradication Programme(NLEP)The National Leprosy Eradication Programme is a centrally sponsored Health Scheme of the Ministry of Health and Family Welfare, Govt. of India.Non-Communicable Diseases, Injury & Trauma National Mental Health Programme (NMHP) National Programme for Prevention and Control of Deafness (NPPCD) National Programme for Control of Blindness(NPCB) Pulse Polio Programme Universal Immunization Programme (UIP)Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) Aims at correcting the imbalances in the availability of affordable healthcare facilities in the different parts of the country in general, and augmenting facilities for quality medical education in the under-served States in particular. The scheme was approved in March 2006. The first phase in the PMSSY has two components -setting up of six institutions in the line of AIIMS; and upgradation of 13 existing Government medical college institutions. In the second phase of PMSSY, the Government has approved thesetting up of two more AIIMS-like institutions, one each in the States of West Bengal and Uttar Pradesh andupgradation of six medical college institutionsnamely Government Medical College. The estimated cost for each AIIMS-like institution is Rs. 823 crore. For upgradation of medical college institutions, Central Government will contribute Rs. 125 crore each. In thethird phase of PMSSY, it is proposed to upgrade the following existing medical college institutions namely Government Medical College, Jhansi, Uttar Pradesh; Government Medical College, Rewa, Madhya Pradesh; Government Medical College, Gorakhpur, Uttar Pradesh; Government Medical College, Dharbanga, Bihar; Government Medical College, Kozhikode, Kerala; Vijaynagar Institute of Medical Sciences, Bellary, Karnataka and Government Medical College, Muzaffarpur, Bihar. The project cost for upgradation of each medical college institution is Rs. 150 crores per institution. Central Government will contribute Rs. 125 crores.State Government will contribute Rs. 25 crores.Poor Patients-Financial Support Rashtriya Arogya Nidhi (RAN)The Scheme provides for financial assistance to patients, living below poverty line who is suffering from major life threatening diseases, to receive medical treatment at any of the super specialty Govt. hospitals / institutes or other Govt. hospitals .The financial assistance to such patients is released in the form of one time grants to the Medical Superintendent of the hospital in which the treatment is being received. RAN (Health Ministers Cancer Patient Fund)Financial assistance to BPL Patients suffering from Cancer, to receive medical treatment at any of the super specialty Govt. hospitals / institutes or other Govt. hospitals .The financial assistance to such patients is released in the form of one time grants to the Medical Superintendent of the hospital in which the treatment is being received. Health Ministers Discretionary Grant (HMDG)Financial Assistance up to a maximum of Rs. 1,00,000/- is available from 01.01.13 to the poor indigent patients from the Health Ministers Discretionary Grant to defray a part of the expenditure on Hospitalization/treatment in Government Hospitals in cases where free medical facilities are not available.

Other National Health Programmes Medical & Para-Medical Institution in North EastNorth Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, ShillongRegional Institute of Medical Sciences, Imphal Regional Institute of Paramedical and Nursing Sciences National Programme for Health Care of the Elderly(NPHCE)An articulation of the International and national commitments of the Government as envisaged under the UN Convention on the Rights of Persons with Disabilities (UNCRPD), National Policy on Older Persons (NPOP) adopted by the Government of India in 1999 and Section 20 of The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 dealing with provisions for medical care of Senior Citizen. Department of AyushDepartment of Indian Systems of Medicine and Homoeopathy (ISM&H) was created in March,1995 and re-named as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November, 2003 with a view to providing focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. Central Government Health Scheme (CGHS)The Central Government Health Scheme (CGHS) provides comprehensive health care facilities for the Central Govt. employeesand pensionersand their dependents residing in CGHS covered cities.National Health Mission National Rural Health MissionNRHM The National Rural Health Mission (NRHM) was launched by the Honble Prime Minister on 12th April 2005 National Urban Health MissionNUHM The National Urban Health Mission (NUHM) as a sub-mission of National Health Mission (NHM) has been approved by the Cabinet on 1st May 2013. Mother and Child Tracking System (MCTS)Ministry of Health and Family Welfarelaunched the Mother and Child Tracking System (MCTS)in December 2009. The focus in MCTS is on the Beneficiary Based Monitoring of the delivery of services to ensure that all pregnant women and all new born receivefullmaternal and child health services. Accredited Social Health Activists (ASHAs)Community Health volunteers called Accredited Social Health Activists (ASHAs) Janani-Shishu Suraksha KaryakramJSSK launched on 1st of June, 2011 is and initiative to assure free services to all pregnant women and sick neonates accessing public healthinstitutions. In order to reduce the maternal and infant mortality, National Mobile Medical Units (NMMUs) District Hospital and Knowledge Center (DHKC) National Iron+ Initiative Anmol SarrafWhat are the major successes that we have achieved in the last decade?Polio free statusIndia as well as WHO's Southeast Asia region was certified polio-free in March this year by an independent commission under the WHO (World Health Organization) certification process.

Polio eradication is one of the biggest public health successes of India. From being one of the top three countries reporting polio, there hasn't been a single polio case in the country for the last three years.Several conditions must be satisfied before a region can be certified polio-free at least three years of zero confirmed cases due to indigenous wild poliovirus; excellent laboratory-based surveillance for poliovirus; demonstrated capacity to detect, report, and respond to imported cases of poliomyelitis; and assurance of safe containment of polioviruses in laboratories (introduced since 2000).In 1998, India had a high of nearly 2,000 cases of paralytic polio from the wild poliovirus, and as recently as 2009, it still was home to most of the worlds polio cases. By 2011, it had wiped out wild polio cases, and now it has maintained that status for three years.Reduction in prevalence of HIV/AIDS, MalariaSince the focus shifted from eradication to control, the programme was renamed as National Anti-Malaria Programme (NAMP) during year 1999. It is important to note that the Directorate responsible for prevention and control of malaria at central level was also made responsible for prevention and control of filariasis, Kala-azar, Japanese Encephalitis, Dengue and Chikungunya. With the convergence of prevention and control of other vector borne diseases, the Directorate of NAMP was renamed as Directorate of National Vector Borne Disease Control Programme (NVBDCP) in 2003. The NVBDCP is presently one of the most comprehensive and multi-faceted public health programmes in the country. The NVBDCP became an integral part of the NRHM launched in 2005. The special focus of the NVBDCP is on resource challenged settings and vulnerable groups. The incidence of malaria in the country started halting and sustaining reversal of cases for last one decade. The malaria cases were brought down from 2,031,790 cases in 2000 to 1,816,569 cases in 2005 and further brought down to 1,067,824 cases in 2012. The Country is heading towards achieving target of 50% reduction in incidence of malaria cases against the baseline. The annual incidence rate (cases of malaria/1000 population) of Malaria has come down from 2.57 per thousand in 1990 to 1.10 per thousand in 2011, and to 0.88 cases (provisional) per 1000 population in 2012. The malaria death rate in the country was 0.09 deaths per lakh population in 2000 which has come down to 0.04 deaths per lakh population in 2012. The total positive cases of Malaria and deaths due to Malaria have shown declining trend from 2011 and 2010 respectively. The indicators Annual Parasite Incidence (API) per 1000 population and Deaths due to Malaria are showing declining trend in the recent past and the challenge is to sustain that trend.

(http://mospi.nic.in/Mospi_New/upload/mdg_2014_28jan14.pdf)HIV infections have declined by 56 per cent during the last decade from 2.7 lakh in 2000 to 1.2 lakh in 2009 in our country, Indian Health and Family Welfare Minister Ghulam Nabi Azad said in the national capital. This has been possible due to political support at the highest levels to the various interventions under National AIDS Control ProgrammeMore than one third of all measles deaths worldwide (around 56 000 in 2011) are among children in India. With support from WHO, in November 2010, India launched a massive polio-style measles vaccination project in 14 high-burden states, in a three-phase campaign.With two phases of the measles vaccination campaign completed, and the third phase ongoing, more than 102 million children in 344 districts have been vaccinated, achieving between 87% and 90% coverage. (Improving measles control in India, April 2013, WHO)Mortality of children below five years of age is declining...Indicator: Under Five Mortality RateThe Under-Five Mortality Rate (U5MR) is the probability (expressed as a rate per 1000 live births) of a child born in a specified year dying before reaching the age of five if subjected to current age specific mortality rates. In India, U5MR has declined from an estimated level of 125 in 1990 to 52 in 2012.

Indicator: Infant Mortality RateInfant Mortality Rate (IMR) is defined as the number of deaths of infants of age less than one year per thousand live births. In India, the Infant Mortality has reduced by nearly 50% during 1990- 2012 and the present status is at 42 per 1000 live births.

As per the historical trend, the IMR is likely to reach 40 deaths per 1000 live births, missing the MDG target of 27 with a considerable margin. However, as IMR is declining at a sharper rate in the recent years, the gap between the likely achievement and MDG target 2015 is set to reduce.Indicator: Proportion of one year old children immunised against measles. The national level coverage of the proportion of one-year old (12-23 months) children immunised against measles has registered an increase from 42.2% in 1992-93 to 74.1% in 2009 (UNICEF &GOI-Coverage Evaluation Survey 2009). At the historical rate of increase, India is expected cover about 89% children in the age group 12-23 months for immunisation against measles by 2015. Thus India is likely to fall short of universal immunisation of one-year olds against measles by about 11 percentage points in 2015.Maternal Mortality Ratio is declining faster....Indicator: Maternal Mortality RatioThe Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births.

The problem in estimating MMR is due to the comparative rarity of the event, necessitating a large sample size. However, even with this constraint, Sample Registration System (SRS) data indicates India has recorded a deep decline of 45.6%in MMR from 327 in 1999-2001 to 178 in 2010-12 and a fall of about 30% happened during 2006-12.

In addition to Maternal Mortality Ratio (MMR), the Maternal Mortality Rate (MMRate - Number of maternal deaths in a given period per 100000 women of reproductive age during the same time period) and Adult lifetime risk of maternal death (The probability that a 15-year-old women will die eventually from a maternal cause) are important statistical measures of maternal mortality.The maternal mortality rate at all India level has come down from 20.7 in 2004-05 to 12.4 in 2010 -12. At all India level, lifetime risk declined from 0.7% in 2004-06 to 0.4% 2010-12 and all the major States have shown decline during this period.Indicator: Proportion of births attended by skilled health personnelThe institutional deliveries in India increased from 40.9% in 2002-04(District level Household Survey) to 72.9% in 2009 (Coverage Evaluation Survey). As per Coverage Evaluation Survey (CES), 2009, delivery attended by skilled personnel is 76.2% which was 47.6% as per District level Household Survey (DLHS-2002-04).Sustaining the declining trend in prevalence of HIV/ AIDs...The HIV epidemic in India continues to decline at the national level with an overall reduction in adult HIV prevalence, HIV incidence (new infections) and AIDS-related mortality in the country. The latest HIV estimates provide sound evidence on the current trend of the epidemic. The adult (1549 years) HIV prevalence has decreased from 0.45% in 2002 to 0.27% in 2011. India has demonstrated an overall reduction of 57% in estimated annual new HIV infections among adult population from 2.74 lakhs in 2000 to 1.16 lakhs in 2011. The trend of annual AIDS deaths is also showing a steady decline since the roll out of free Anti-Retroviral Treatment (ART) programme in India in 2004.

India has demonstrated an overall reduction in the estimated annual new HIV infections (in all age-groups) from 2.96 lakhs in 2000 to 1.30 lakhs in 2011. The estimated annual new HIV infections among adult (15+ years) population has declined steadily over the past decade by about 57% from 2.74 lakhs in 2000 to 1.16 lakhs in 2011. Males account for approximately 61% of total new annual HV infections in 2011 whilst women account for an estimated 39% of total new HIV infections.Total number of annual AIDS related deaths in India is declining over the past years. It is estimated that about 1.48 lakh (1.14 lakhs-1.78 lakhs) people died of AIDS related causes in 2011 in India. In comparison with the 2.06 lakhs (1.67 lakhs-2.45 lakhs) AIDS related deaths estimated in 2007, this marks a near 29% reduction in estimated number of AIDS related deaths during 200711. Deaths among HIV infected children account for 7% of all AIDS-related deaths.It is estimated that the scale up of free ART since 2004 has saved cumulatively over 1.5 lakh lives in the country till 2011by averting deaths due to AIDS-related causes. With the current scale up of ART services, it is estimated to avert around 50,00060,000 deaths annually in the next five years.Wider access to Antiretroviral Therapy (ART) has led to 29% reduction in estimated annual AIDS-related deaths during NACP-III period (2007-2011). (http://mospi.nic.in/Mospi_New/upload/mdg_2014_28jan14.pdf)Improved Life-ExpectancyStatistics released by the Union ministry of health and family welfare show that life expectancy in India has gone up by five years, from 62.3 years for males and 63.9 years for females in 2001-2005 to 67.3 years and 69.6 years respectively in 2011-2015. Experts attribute this jump higher than that in the previous decade to better immunization and nutrition, coupled with prevention and treatment of infectious diseases. The World Health Organization defines life expectancy as "the average number of years a person is expected to live on the basis of the current mortality rates and prevalence distribution of health states in a population". In India, average life expectancy which used to be around 42 in 1960, steadily climbed to around 48 in 1980, 58.5 in 1990 and around 62s in 2000.Accredited Social Health ActivistAccredited social health activists (ASHAs) are community health workers instituted by the government of India's Ministry of Health and Family Welfare (MoHFW) as part of the National Rural Health Mission (NRHM). The mission began in 2005; full implementation was targeted for 2012. Once fully implemented, there is to be "an ASHA in every village" in India, a target that translates into 250,000 ASHAs in 10 states. The grand total number of Ashas in India was reported in January 2013 to be 863,506.ASHAs are local women trained to act as health educators and promoters in their communities. The Indian MoHFW describes them as: ...health activist(s) in the community who will create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services.Their tasks include motivating women to give birth in hospitals, bringing children to immunization clinics, encouraging family planning (e.g., surgical sterilization), treating basic illness and injury with first aid, keeping demographic records, and improving village sanitation.[5] ASHAs are also meant to serve as a key communication mechanism between the healthcare system and rural populations.One of the success stories being attributed to NRHM is a huge increase in institutional deliveries. ASHAs (around 7.5 lakh in number) at grass root level have done a phenomenal job in mobilizing women from valuable community to come to institutions (the number of beneficiaries under JSY had increased from 7 lakhs in 2005-2006 to over 86 lakhs in 2008-2009). It is critical to ensure that there is corresponding increase in inputs available at the facilities, so that health outcomes for mother and baby are ensured. There definitely have been gains as shown by statistics - infant mortality rate has come down to 53/1000 live births, maternal mortality rate has come down to 254/1000 live births and total fertility rate is now 2.7.Mohit SoniHEALTHCARE IN INDIA - 2025At the turn of this century, health outcomes in India and the quality of health system in India significantly lagged those of peer nations and WHO standards. The progress made in the last decade has been mixed. While substantial ground has been covered, a lot is still left to be achieved. The government, recognizing the need for reforms, introduced the 11th and 12th Five - Year - Plan. The private sector has also played an important role in improving quality and access to healthcare facilities in India in the last decade.The situation today is complicated by rising inequality in healthcare access across states and demographic sections within the population. It is evident, that a Status Quo approach will be inadequate to tackle this challenging situation. Indias healthcare reform will need to operate at a scale never seen before. Almost all health indicators in India, today, will not meet the objectives of WHO Millennium Development Goals (MDG) - 2015.Spend of healthcare by the government will have to increase, infrastructure gaps will need to be closed, workforce scarcity and utilisation will have to be addressed. Policies will have to be defined to begin on this path of inclusive healthcare and Universal Health Coverage. This will demand active collaboration between the private and the public sector, with the government taking the initiative. The journey, started in the last decade, now needs to pick up momentum to meet the huge demand for affordable yet quality healthcare. 12th Five Year PlanThis plan, drafted by the Planning Commission, defines the governments long term strategy for Healthcare based on the vision of UNIVERSAL HEALTH COVERAGE.It envisions assured access to a defined essential treatment and medicines to a large percentage of the population. While Universal Health Coverage mist be the primary focus, secondary focus has to be on the efficiency and quality of healthcare.PROBLEMS FACED BY INDIAN HEALTHCARE SECTOR Shifting Disease Patterns High Costs Infrastructure Gaps Inadequate Workforce and underutilization of existing workforce. Inequitable Insurance Cover Rural and Urban Inequity in terms of facilities available. Lack of holistic regulatory environment. Childcare and Low Rates of ImmunizationSTATUS QUO - CANNOT BE MAINTAINEDA status quo approach will be rendered ineffective due to epidemiological pressures, burgeoning healthcare demand, existing and growing inequities in access and delivery and unregulated growth of the sector.1. Gap in Healthcare Spending: If the current trajectory of spending growth were to continue, the total healthcare expenditure ll intact drop from the current 4% GDP to 3.65%GDP by 2022.1. Gap in Healthcare Infrastructure: At current growth rates, infrastructure will be unable to keep pace with the demand. India may end up with a bed density of 1.7 - 1.9 per 1000 people.1. Gap in Healthcare workforce: As per the Twelfth Five - Year plan, the physician and nurse density is expected to reach around 0.7 and 1.7 per 1000 people respectively by 2022. Of these, if current utilization numbers were to be maintained, the active workforce would only be 0.5 and 0.8 per 1000 people respectively.

PROJECTIONS FOR 2025

1. BRIDGING RURAL - URBAN DIVIDE:

Fig 1: Rural India accounts for 50 - 70% of NCDs.In order to understand the inequity, its magnitude and manifestation across rural - urban divide and income segments and its alarming trajectory, we analyse six segments of the population - Urban Rich, Urban Middle Class, Urban Poor, Rural Rich, Rural Middle Class and Rural Poor.Rural India also accounts for 70 % of the communicable diseases.The number of hospital beds in Urban India is twice as much as those in Rural India.Healthcare in India also has a vast regional inequity. (Eg: There were 533 people per government bed in Arunachal Pradesh in 2008. The same figure for Jharkhand was 5494 people per government bed.)In order to bridge this growing inequity and meet WHO Bed Density standards, India must target a bed density of 1-1.2 per 1000 people by 2022. Rural Medical Practitioners and AYUSH [1] workers should be drafted into mainstream healthcare sector. Programs like NRHM / ASHA / Janani Suraksha Yojana [2] must be scaled up and promoted. 2. MUCH IMPROVED FINANCIAL ACCESSS:At least 75 % of the population should be insured.(Assuming 100 % coverage for poor population and 60 % coverage for the middle class). The remaining should receive free healthcare through government schemes and public provisioning like RSBY [3].

3.OVERCOMING WORKFORCE SHORTAGE:By 2022, India should aim for for a doctor and nurse density of 0.7 and 1.7 per 1000 people. For this to happen unto 90% of the registered practitioners will need to practise.4. INFRASTRUCTURE GAPS TO BE FILLED:Infrastructure would need to scale up with increased utilisation reaching an overall bed density around 2.1 per 1000 people including 1 -1.2 beds per 1000 people in rural areas and 3.8 - 4.2 beds per 1000 people in urban areas.Fig 2: Infrastructure requirement by 2022 - Bed Density

5.REDUCING OUT OF POCKET(OOP) EXPENDITURE AND INCREASING EXPENDITURE ON HEALTHCARE:In order to achieve the desired financial access and build the desired level of infrastructure, total spending will need to be at 5.5% of the GDP, up from the current 4%. OOP spend will also need to come down from the current 61% to 23%. This would require 17,00,000 to 21,00,000 crores investment by 2022.

Fig 3: Total Healthcare Expenditure (THE) and OOP share by 2022.6. CATERING TO A HIGHER DEMAND:Hospitalizations are expected to rise from the current 4.8 per 100 people to 6.5 per 100 people. The healthcare facilities need to be scaled up with this in mind.7. BETTER HEALTH INDICATORS:The Infant Mortality Rate (IMR)[4] and Maternal Mortality Rate (MMR)[5] have to be reduced to 25 and 100 respectively, in order to meet the MDG. Along with this, India has to aim for universal immunization.Apart from the above-mentioned points, quality of healthcare needs to be in focus, enabled by an effective regulatory system. This framework will need to include legislation for standardisation of treatment practices, clinical establishments and malpractice mitigation. Diagnostics, trauma care and emergency care also need to be scaled up to meet the increasing demand. Diagnosis of chronic and Non Communicable Diseases (NCD) will have to be more in line with that of developed countries. An effective awareness and health education program can also reduce the NCD burden. SOME CHANGES TAKING PLACE Electronic Health Records (EHR) : Hospitals and patients are maintaining EHR, which can be stored and analysed for trends. This is helping improve integration of primary and tertiary healthcare services (eg : referrals from one hospital to another)

Tele Medicine and Next Gen Diagnostics:To combat the low density of primary healthcare centers and doctors in rural and remote areas, small community centers are being set up. Patients and doctors can interact via Video Conference.There is an increased demand for home based diagnostic and monitoring devices. These devices can measure Blood Glucose Levels, ECG, etc and transmit the results to the physician. This is reducing the cost of diagnostics and making facilities available in remote areas.The government will need to play the lead role to drive Indias healthcare transformation journey. It will need to make an important choice with regards to its primary role - as a provider or payor. India can learn immensely from the healthcare reforms of peer countries like Thailand, Brazil and South Korea over the last 4 decades.A few areas, highlighted earlier, will merit joint action by the government and the private sector. The reform journey, initiated in the last 10 years, now needs to gain momentum. What peer nations achieved across 3-4 decades needs to be achieved in much lesser time. Therein lies the importance of the next decade.

Chinmay JoshiRecommendationsFor any country, healthcare facilities play an extremely important role in the development of the country. In modern Human Development Index, health is considered to be an extremely important factor. In case of developing countries, the role of government in the provision of the medical and healthcare facilities is all the more important as the large concentration of poor may be exploited by the private sector.A look at Indian healthcare related data tells you about the dismal state that public health services are in India. We start by looking at the vulnerabilities in the Indian public health system which need to be targeted for significant improvement.Important Targets Lack of Government Expenditure Historically, Indian governments expenditure in health sector has been abysmally low. This results in high OOP (Out of Pocket) expenditure by the people which forces millions of people below poverty line. A stable public health structure is a necessity of a developing nation and poor medical services can cripple the nation economically. The government expenditure will have to increase significantly in the right direction to improve the current affairs of the system. Lack of Primary Care There are huge number of cases, especially in rural India where there are large number of deaths due to female foeticide and infanticide as well as inadequate nutrition for mother and newborn child. The situation is not improving much and infant & maternal mortality has been huge in India. This has a lot of causes which are lack of education, resources in the rural areas, improper government expenditure but more importantly, healthcare facilities for women & children have to improve. Lack of Sanitation facilities The lack of sanitation facilities is a widely recognized problem in our country which has several times led to epidemics in some parts. There is severe scarcity of clear drinking water and many diseases like diarrhea, typhoid, cholera etc. These are basic amenities which have to be provided and any kind of action that is supposed to be taken in public health has to focus on this aspect. Lack of Human Resources Again, this is a widely recognized problem in our country that in rural areas, there is a severe lack of human resources in the medical sector. Despite being one of the countries with premier medical institutes, India has been unable to cater to the demand of its humongous population. A large number of doctors, nurses and medical professionals are added to the workforce but the numbers are highly unevenly distributed and there is a domino effect of medical professionals moving to urban India.The above mentioned vulnerabilities can be viewed as problems but importantly, we must realize that these problems are not the causes of the terrible state of Indias public health but the results or rather more of indicators and the solutions should be aimed at improving these indicators.

Suggested Solutions While we try to look for solutions and actions to improve the present condition of Indias healthcare facilities, we must realize that any true solution that provides significant improvement will take a large amount of time and expenditure. We, therefore, try to look out for both long-term as well as short-term solutions.Long Term Action - Concerted & Integrated Public Healthcare and Medical Service Program If we compare Indian public healthcare system to other developing countries, we realize that India is doing considerably bad. A closer look at the Indian system reveals that major cause of such a poor state is the original ideology of the Indian government with which it has tried to implement health programs. The central government has, generally, mixed up public health care and medical services and focused heavily on single-issue health programs. Although, this intermingling of medical and health services was intended to improve coordination between various different services, it ended up marginalizing public health services. The program that had intended to eradicate polio was extremely successful and the government of India boasts of complete eradication of polio as a disease. Unfortunately, the examples of such successful programs arent many and this focus on single-issue programs has led to concentration of resources on some important diseases and disallowed the development of an integrated public health care system that proactively delivers wide range of services including medical services as well as implementation of sanitary regulations. Instead, with the single-issue programs doctors several times end up treating patients who should not have been ill at the first place.Many countries like Bangladesh and Thailand have such robust and strong health care programs which continue to deliver medical goods to their public. In India, Tamil Nadu has a strong public health and medical structure and we analyze that.In the state health department, there are three separate directorates under the health secretary namely, the Directorate of Public Health, of Medical services, and of Medical Education. This is the cornerstone of the structure as the separate directorates enjoy the freedom of planning and policy making in their respective departments. The directorates have separate and significant budgets which enable them to all the activities related to the implementation of their policies. Also, the separate budget helps them in maintaining a trained, experienced and dedicated taskforce which includes not only managerial and grassroots level workers but also, a range of technical staff. This healthcare structure is legalized by the legislative assembly in the state. This gives considerable power to the health officers in the state so that they can act to any kind of complaint regarding to any activity that threatens to jeopardize the environment. In our country, we badly need such a structure of health system that proactively caters to the demand of the public. Such a system will not only provide stable medical services, but also provide healthcare services such as vaccinations, regular check-up camps, health awareness campaigns etc. This kind of a system will require dedicated funding and sincere efforts, and no doubt this will take time to build but only such a system can truly provide to improve the level of health of a nation.Short Term Solutions It will some amount of dedicated efforts to build the above mentioned system and more importantly, it will require significant amount of time. Therefore, to tackle immediate problems there would be a pressing need for efficient and available short term solutions.Health Insurance Schemes Health Insurance schemes are ingenious in providing security cover to the people. The objective, in this case, would be reduce the OOP expenditure and provide security in terms of healthcare. People, especially in Urban Areas, are opting for private insurance schemes which provide them security cover from various diseases. Indian government has launched its own health insurance scheme, namely, RSBY (Rashtriya Swasthya Bima Yojna) which has successfully provided cover to around 11 crore BPL people. This program has won accolades from WB as well as WHO and can be extended to provide some kind of subsidized health insurance to the people.Public-Private Partnership Public-Private Partnerships (PPP) are contract-based joint ventures where the private party provides for the services and the cost is borne out by the government. In health sector, PPPs can be used extremely efficiently as short term measures. While the private sector should be able to provide excellent quality and best modern practices for patients, the government can also use it as an opportunity to monitor and regulate the practices in the medical services provided by the private sector. This would not only provide efficient service to the patient but also, widen the reach of such facilities. It should be noted that the key objective again is to reduce the out of pocket expense and provide good quality medical facilities.The above mentioned short term solutions have been in place for some time now and are developing on the way. They have their own importance because of the time frame. But we need to realize that the long-term solution is of primary importance and if we keep taking the shorter route, there will not be significant improvement in the health status of the nation.

References Public Private Partnerships for Healthcare in India, B. Birla, U. Taneja, The Internet Journal of World Health and Societal Politics, 2008 Volume 7 Public-Private Partnership in Health Care: Contexts, Models and Lessons, A. Venkat Raman, Faculty of Management Studies, University of Delhi, http://www.who.int/global_health_histories/seminars/Raman_presentation.pdf The Early Success of Indias Health Insurance for the poor, RSBY, Victoria Fan, 6/10/13, Center for Global Development The state of healthcare in India is dismal: Amartya Sen, Nirmalya Dutta, The Health Site, http://health.india.com/healthcare/the-state-of-healthcare-in-india-is-dismal-amartya-sen/ Five Ways to Improve Indian Healthcare, Tripti Lahiri, 19/12/2011, The Wall Street Journal How to Improve Public Health Systems Lessons from Tamil Nadu, Monica Das Gupta, B. R. Desikachari, T.V. Somnathan, P. Padmanaban, The World Bank, Development Research Group HealthCare Financing Reforms in India, M. Govinda Rao, Mita Choudhury, March 2012, National Institute of Public Finance and Policy[1]:http://en.wikipedia.org/wiki/Department_of_Ayurveda,_Yoga_and_Naturopathy,_Unani,_Siddha_and_Homoeopathy[2] : http://en.wikipedia.org/wiki/Janani_Suraksha_Yojana_(India)http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/janani-suraksha-yojana/background.html[3 : http://en.wikipedia.org/wiki/Rashtriya_Swasthya_Bima_Yojana[4]: http://en.wikipedia.org/wiki/Infant_mortality[5]: http://en.wikipedia.org/wiki/Maternal_death McKinsey and Company, India - India Healthcare Inspiring Possibilities and Challenging Journey India - An uncertain Glory - Jean Drze and Amartya Sen WHO World Health Statistics, 2012 http://timesofindia.indiatimes.com/india/India-WHOs-SE-Asia-now-polio-free/articleshow/32790183.cmshttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/From_India_Achievement_Lessons_Learned_and_Hope(Sharp drop in HIV cases in India, Xinhua, 16th August, 2012, The Hndu)http://www.dailymail.co.uk/indiahome/indianews/article-2425853/Indian-scientists-make-dengue-vaccine-breakthrough-early-trials-creates-robust-immunity.htmlhttp://indiatoday.intoday.in/story/scientists-at-icgeb-develop-dengue-vaccine-from-pichia-pastoris-yeast/1/310642.htmlhttp://www.thehindu.com/sci-tech/health/medicine-and-research/india-unveils-first-indigenous-rotavirus-vaccine/article4714757.ecehttp://timesofindia.indiatimes.com/india/Now-a-desi-rotavirus-vaccine/articleshow/20058187.cmswww.dnaindia.com/world/report-indian-scientists-develop-japanese-encephalitis-vaccine-1898431http://www.thehindu.com/news/national/india-launches-vaccine-to-prevent-japanese-encephalitis/article5201813.ecehttp://world.time.com/2013/01/13/how-india-fought-polio-and-won/http://pib.nic.in/newsite/erelease.aspx?relid=99873http://www.un.org/millenniumgoals/http://www.healthissuesindia.com/infectious-diseases/https://www.icicilombard.com/health_insurance_info/Knowing-top-10-killer-death-diseases-in-India.htmlhttp://indiatoday.intoday.in/story/India%27s+no.1+killer:+Heart+disease/1/92422.htmlhttp://www.worldlifeexpectancy.com/news/india-vs-china-top-10-causes-of-deathhttp://timesofindia.indiatimes.com/india/Life-expectancy-in-India-goes-up-by-5-years-in-a-decade/articleshow/29513964.cmshttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/keyword/poliohttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/The_Road_to_Conquering_Polio_A_Major_Milestonehttp://www.indexmundi.com/facts/india/mortality-rate Jennifer G. ,Taylo D., Health and Health Care in India, UCL school of Pharmacy Jacob J. T., Dandona L.,Sharma P. V., Kakkar M.,India: Towards Universal Health Coverage: Continuing challenge of infectious diseases in India, Lancet 2011, Gudwani A.,Mitra P.,Puri A. Vaidya M., India Healthcare: Inspiring Possibilities, Challenging Journey ,McKinsey & Company ,December 2012 Tuberculosis Challenges for India, Policy brief series: No.12: 2011 February-March, http://www.clraindia.org/include/TBbriefnew.pdf Innovating Around Indias Health Care Challenges, Health Economics, 29 July 2010, http://knowledge.wharton.upenn.edu/article/innovating-around-indias-health-care-challenges/ Kapur A., Economic analysis of diabetes care, March 2007, http://icmr.nic.in/ijmr/2007/march/0319.pdf India and the fight against cancer, http://www.moneycontrol.com/gestepahead/article.php?id=965373 Price Water House Coopers (PWC), Health care in India Emerging Market Report, 2007. Jennifer G. ,Taylor D., Health and Health Care in India, UCL school of Pharmacy. Balarajan Y,Selvaraj S & Subramanian SV (2011) Healthcare and equity in India. The Lancet 377, 505-15. McKinsey & Company, India Healthcare: Inspiring Possibilities, Challenging Journey, Healthcare Systems and Services, December 2012. Kannan, R. (2013, July 30). More People opting for Private Healthcare. The Hindu. KPMG, The Indian Pharmaceutical Industry Collaboration for Growth, 2006.

.