London School of Hygiene & Tropical Medicine

A radical transformation in India's healthcare delivery system is needed to achieve the government's vision of assuring health for all, according to a new report published in The Lancet.

The report, led by the London School of Hygiene & Tropical Medicine and Public Health Foundation of India, acknowledges the progress seen in the health sector in India, including the elimination of polio from the country in 2014. 

However, it demonstrates that the extremely high cost of health care is forcing millions into poverty, while the weak structure of the health care system means that the country is struggling to cope with public health demand of its expanding population. The report reviews the current situation in India, and suggests a drastic plan of improvement.

India continues to lag behind regional neighbours in population health, reporting 27% of all neonatal deaths and 21% of all child deaths in the world in 2015. Stunting caused by chronic nutrition deficiency continues to affect a third of children under five years, and the country accounted for 20% of the global burden of disease in 2013, with high levels of communicable diseases including tuberculosis, diarrhoeal diseases, malaria, and typhoid.

Meanwhile, there is a large and rapidly rising burden of non-communicable and chronic conditions: 1 million deaths in India are attributed to tobacco consumption each year, 65 million people have been diagnosed with diabetes, and suicide rates are among the highest in the world.

Lead author Vikram Patel, Professor of International Mental Health at the London School of Hygiene & Tropical Medicine, said: "The health time-bomb ticks on due to the rising burden of non-communicable diseases. Suicide is now a leading cause of death of young Indians, and an Indian is likely to suffer from a heart attack at least ten years earlier than in developed countries and yet the health care system has barely responded to these urgent health crises."

The paper states that an important cause of this large and inequitably distributed burden of disease in India can be attributed to social determinants beyond the conventional health-care delivery sector such as urbanisation, poor access to water and sanitation, food insecurity, environmental degradation, and the pervasive caste system.

Low public spending on health in India has crippled the public sector and caused large barriers in the quality of and access to care, with catastrophic health care costs for millions of people. India spends as little 0.1% of its Gross Domestic Product (GDP) on publicly funded drugs, and in 2014, more than 70% of outpatient care and 60% of inpatient care was provided in the private sector. Meanwhile, lack of regulation in the private sector has led to widespread corruption, with consequent poor quality of care and impoverishment of patients.

Prof Patel notes that there are "widespread inequities in health outcomes that are apparent in the large morbidity and mortality differentials across socioeconomic status, caste, class, sex, and geographic location."

The report argues that urgent measures must be taken to improve primary care facilities, address a widespread shortage of skilled medical professionals particularly in rural areas, and prevent the spiralling costs and irrational use of drugs and technology. Meanwhile, the country must regulate its private sector to prevent corruption, and, most importantly, work towards a nationally integrated health care system with strong governance from the state.

The researchers suggest that political will is crucial to implement a drastic plan of action, as only a radical restructuring of India's health care system will assure health care for all Indians. The country must work to prioritise health services for the whole population based on their vulnerability and risk, expand health coverage of high-priority services to everyone, and eliminate out-of-pocket payments to ensure that health care is cashless at the point of service delivery, they state.

Vikram Patel is supported by a Wellcome Trust Principal Research Fellowship in Clinical Science.

Publication

Vikram Patel, Rachana Parikh, Sunil Nandraj, Priya Balasubramaniam, Kavita Narayan, Vinod K Paul, A K Shiva Kumar, Mirai Chatterjee, K Srinath Reddy. Assuring health coverage for all in India. The Lancet. DOI: 10.1016/S0140-6736(15)00955-1