Strengthening India’s Health System: Closing the Gaps

A recent World Bank report highlights a decline in public health spending in low- and middle-income countries, including India, reversing pre-pandemic progress. A study covering 63 nations shows growth in health expenditure slowing from 2.4% before the pandemic to just 0.9% between 2019-2023. In India and 34 other nations, health budgets have dropped as a percentage of national expenditure, falling to 6.5% in 2023. Projections from the IMF suggest further cuts through 2029, jeopardizing universal health coverage and SDG health targets.

Key Emerging Health Challenges in India

1. Climate Change and Health Impacts
   • Heat-related and Respiratory Illnesses: Rising temperatures and extreme weather events, such as heatwaves, have caused a significant uptick in heat-related illnesses and respiratory diseases. In 2022, India saw a 54% increase in labor hours lost to heat exposure compared to the late 1990s.
   • Vector-Borne Diseases: Extreme weather conditions are also fueling the rise of diseases like dengue and malaria.
   • Waterborne Diseases: Floods, which are occurring more frequently, lead to the contamination of water supplies, causing outbreaks of cholera, dysentery, and typhoid.
   • Extreme Weather Deaths: The death toll from extreme weather events rose by 18% in just three years, exacerbating the health crisis.
2. Antimicrobial Resistance (AMR)
   • Widespread Misuse of Antibiotics: India faces a growing challenge with antimicrobial resistance due to overuse and misuse of antibiotics. A study found that nearly 47% of antibiotics in India’s private sector lacked approval from the Central Drug Regulator, contributing to unnecessary prescriptions.
   • Increased Drug-Resistant Infections: Multi-drug resistant infections are on the rise in Indian hospitals, with resistant strains of bacteria like E. coli and Klebsiella pneumoniae being increasingly found in ICUs.
3. Mental Health Crisis
   • Post-Pandemic Surge in Mental Health Issues: The Covid-19 pandemic has led to a 25% global increase in anxiety and depression, with India witnessing a dramatic rise in mental health disorders.
   • Limited Mental Health Resources: India’s mental health infrastructure is severely underdeveloped, with only 0.75 psychiatrists per 100,000 people. This, combined with social stigma and lack of affordable care, leaves millions without adequate support.
   • Growing Need for Mental Health Interventions: The National Mental Health Survey highlights that 150 million Indians need mental health care, yet services remain inadequate.
4. Rise of Non-Communicable Diseases (NCDs)
   • Increased Burden of NCDs: India is witnessing a sharp rise in NCDs, such as diabetes, heart disease, and cancers, particularly among younger populations.
   • Lifestyle Changes Contributing to NCDs: Rapid urbanization, sedentary lifestyles, and unhealthy diets are major contributors to this trend.
   • Impact on Healthcare: NCDs now account for 63% of all deaths in India, and the number of people with diabetes has surged from 70 million in 2019 to over 101 million.
5. Double Burden of Diseases
   • Ongoing Challenge of Infectious Diseases: India continues to battle infectious diseases such as tuberculosis, malaria, and dengue, particularly in rural areas.
   • Emerging and Re-emerging Threats: The country also faces new health threats, including zoonotic diseases and the resurgence of diseases like H3N2 influenza and Mpox, with 2023 seeing over 3,000 H3N2 cases and 30 Mpox cases reported.
   • Simultaneous Burden of NCDs: While communicable diseases remain a significant concern, the rising prevalence of NCDs like hypertension and cancer further strains the healthcare system, which is ill-equipped to handle this dual burden.
   • Healthcare Resource Strain: Managing both acute infectious diseases and chronic conditions necessitates long-term care and puts immense pressure on India's already overwhelmed healthcare infrastructure.

Why India Faces Challenges in Maintaining Effective Healthcare

1. Fragmented Governance Structure
   • Inconsistent Policy Execution: India’s healthcare system suffers from a fragmented governance model across central, state, and local authorities, leading to uneven policy enforcement and resource allocation.
   • Regional Disparities: States like Kerala have developed strong healthcare systems, resulting in better health outcomes, while others such as Bihar still face significant challenges.
   • Implementation of Standards: Though the Clinical Establishments Act of 2010 aims to create uniformity in healthcare services, its inconsistent implementation across states results in varying standards and regulatory enforcement.
2. Insufficient Healthcare Funding
   • Low Public Health Expenditure: Despite numerous healthcare schemes, India’s public health spending remains among the lowest globally, at just 1.9% of GDP, as noted in the Economic Survey 2023-24.
   • Reliance on Private Spending: India’s healthcare financing is heavily reliant on out-of-pocket expenses, which make up about 62.6% of the total health expenditure, one of the highest in the world.
3. Infrastructure Gaps and Unequal Distribution
   • Urban-Rural Divide: There is a significant gap in healthcare infrastructure between urban and rural areas, with rural areas often lacking essential medical facilities and equipment.
   • Non-compliance with Health Standards: A report reveals that only a small fraction of healthcare centers meet the Indian Public Health Standards (IPHS), with only 11% of sub-centers, 13% of primary health centers (PHCs), and 16% of community health centers (CHCs) meeting these standards.
   • Disproportionate Resource Allocation: Around 65% of hospital beds cater to just 50% of the population, highlighting a severe imbalance in healthcare resource distribution.
4. Workforce Shortages and Migration Issues
   • Inadequate Medical Professionals: India faces a severe shortage of healthcare workers, including doctors, nurses, and specialists, particularly in rural areas.
   • Brain Drain: The migration of skilled healthcare professionals abroad continues to exacerbate this shortage.
   • Uneven Distribution of Healthcare Workers: Even with increasing medical education capacities, rural areas struggle to attract and retain qualified professionals, with a shortfall of over 80% of needed surgeons and pediatricians in many community health centers.
5. Weak Data Integration and Monitoring Systems
   • Lack of Integrated Health Data: Although there are digital health initiatives, India’s health data management systems remain fragmented, hindering informed decision-making and resource allocation.
   • Delayed Disease Response: The absence of real-time health monitoring systems affects the country’s ability to respond promptly to disease outbreaks and health emergencies.
   • Privacy and Infrastructure Barriers: Privacy concerns and inadequate infrastructure further slow the adoption of digital health technologies, with only 30% of the private sector participating in the Ayushman Bharat Digital Mission.
6. Underdeveloped Focus on Preventive Healthcare
   • Prioritization of Curative Over Preventive Care: India’s healthcare policies largely focus on treating illnesses rather than preventing them. Preventive healthcare initiatives, such as health education and environmental health programs, receive minimal attention and funding.
   • Limited Investment in Public Health: Only 13.55% of the total health expenditure goes toward preventive measures, leading to missed opportunities in reducing the burden of diseases before they occur.
7. Inefficiencies in Pharmaceutical and Supply Chain Management
   • Frequent Stockouts and Inefficient Supply Chains: India struggles with frequent shortages of essential medicines and medical equipment, disrupting patient care.
   • Dependency on Imports: A large percentage of pharmaceutical ingredients, particularly from China, makes the supply chain vulnerable to external disruptions. This dependence drives up costs and poses risks to drug security.
   • Challenges in Generic Medicine Distribution: The country’s generic medicine programs face issues such as implementation gaps and public perception problems related to quality, despite their critical role in providing affordable healthcare options.

Key Measures for Strengthening India's Healthcare System

1. Developing an Integrated Digital Health Ecosystem
   • Unified Health Data Platform: India should prioritize the rapid implementation of a centralized digital health infrastructure, connecting primary health centers to specialized hospitals. This platform should include standardized Electronic Health Records (EHRs), telehealth systems, and real-time surveillance tools for disease tracking.
   • Data Privacy and Security: Ensure robust security measures for patient data and ensure smooth information sharing across public and private healthcare providers.
   • Expanding Telemedicine Services: Platforms like E-Sanjeevani should be scaled, taking inspiration from Tamil Nadu's success in expanding online consultations.
2. Reinforcing Primary Healthcare
   • Transforming Health and Wellness Centers (HWCs): Upgrade HWCs to offer a range of services, including diagnostic tests, telemedicine, and health screenings. Focus on preventive care, vaccinations, and early disease detection.
   • Community Engagement: Strengthen the role of community health workers like ASHAs to raise awareness and educate the population on preventive health.
   • Incentivizing Healthcare Workers: Implement performance-based incentives to improve quality and retain medical professionals in underserved areas.
3. Public-Private Partnership (PPP) Reforms
   • Equitable Access through PPPs: Develop new models of public-private collaboration to enhance healthcare access while ensuring that quality standards are met.
   • Regulatory Oversight and Accountability: Establish clear frameworks, with defined performance metrics and independent monitoring systems, to evaluate PPP outcomes.
   • Technology and Capacity Building: Encourage technology transfer and professional development as part of PPP arrangements to enhance healthcare delivery.
4. Healthcare Financing Reforms
   • Increase Public Health Investment: Raise public health spending gradually to 2.5% of GDP, through targeted health cess and optimized resource allocation.
   • Strengthen Health Insurance: Expand the Ayushman Bharat scheme, simplifying claim procedures and increasing coverage, including the recent addition of senior citizens aged 70 and above.
   • Sustainable Health Financing Models: Implement a hybrid financing model that combines robust public investment with universal insurance coverage to ensure long-term sustainability.
5. Medical Education and Workforce Development
   • Modernizing Medical Curriculum: Incorporate practical skills, digital health, and emerging technologies into medical education.
   • Rural Healthcare Workforce Initiatives: Introduce mandatory rural postings for medical professionals, complemented by attractive incentives and clear career progression paths.
   • Expanding Education and Training Centers: Establish medical education hubs in underserved areas, focusing on region-specific healthcare needs and community health education.
   • Continuous Medical Education (CME): Create a system for ongoing education to keep healthcare professionals updated with the latest medical advancements and technologies.
6. Strengthening Pharmaceutical and Medical Device Manufacturing
   • Enhance Domestic Production: Accelerate the development of domestic manufacturing capabilities for critical medicines and medical devices using Production Linked Incentives (PLI) schemes.
   • Reduce Import Dependence: Build API parks with shared infrastructure to minimize reliance on imports for essential ingredients.
   • Improve Generic Medicine Quality: Implement stringent quality control measures and standardize generic medicine production to build trust and ensure accessibility.
   • Expand Jan Aushadhi Network: Enhance supply chain management to ensure the availability and accessibility of affordable medicines across the country.
7. Establishing Robust Emergency Preparedness
   • Regional Emergency Centers: Develop a network of emergency response centers equipped with surge capacity and essential medical supplies.
   • Real-Time Disease Monitoring: Implement early-warning systems for disease outbreaks and set up real-time monitoring mechanisms for quicker response.
   • Strategic Reserves: Create stockpiles of essential medicines and equipment, ensuring regular rotation and replenishment to maintain readiness.
8. Focus on Preventive Healthcare
   • Comprehensive Health Screening: Implement nationwide screening programs for all age groups at Health and Wellness Centers (HWCs) to detect diseases early.
   • Promote Holistic Health Approaches: Integrate traditional medicine systems (such as AYUSH) with modern healthcare for a comprehensive wellness model.
   • Lifestyle and Wellness Campaigns: Actively promote initiatives like "Eat Right India" and "Fit India" to encourage healthier lifestyles, focusing on nutrition, exercise, and mental well-being.
   • School and Workplace Health Programs: Introduce health interventions tailored to lifestyle diseases in educational institutions and workplaces.
9. Regulatory Framework Overhaul
   • Unified Health Regulation: Establish a national regulatory authority with clear guidelines for quality control, standardization, and accreditation of healthcare facilities.
   • Transparent Pricing Systems: Implement transparent pricing for medical services, procedures, and drugs to ensure fairness and accessibility across the population.
   • Regular Audits and Accountability: Set up regular audits for healthcare facilities to ensure compliance with national standards and improve service quality.
10. Implementing the One Health Approach

• Integrated Health Systems: Fast-track the implementation of the "One Health" approach, linking human, animal, and environmental health to tackle the rise of zoonotic diseases.
• Strengthen Surveillance Networks: Develop systems for monitoring and early detection of diseases at the human-animal-environment interface, preventing future outbreaks.
• Collaborative Action Across Sectors: Promote collaboration among healthcare, veterinary, and environmental sectors to create a cohesive approach to disease prevention and health promotion.

Key Takeaways
To tackle India's growing healthcare issues, a comprehensive strategy is crucial, centered on digital transformation, prioritizing preventive measures, and fostering strong public-private collaborations. Enhancing primary healthcare and focusing on proactive health strategies will alleviate pressure on advanced healthcare systems. Through synchronized reforms, India can better manage health emergencies and make significant progress toward achieving universal health coverage and the Sustainable Development Goals (SDGs).