It's time to wage war against diseases: Preetha Reddy

The first two weeks of December 2015 were as grim a time as I have seen in Chennai. The heaviest rainfall in a hundred years left the city ravaged with destruction and desperation. For days on end, over five million citizens grappled with inundation in their homes and work places, power outages, telecom blackouts and traffic gridlocks. The city was rightly declared a disaster zone. It was also in the face of this adversity that I witnessed the force of collective will. Individuals and organisations from across the country opened their hearts and homes to the people of Chennai.

In retrospect, however, I fail to fathom the dichotomy of the Indian mindset. The same Indians who found a deep reservoir of empathy and catalysed such momentum have shown a high degree of apathy to a far more widespread and insidious enemy—I speak of the great devastation being unleashed, every single day, by non-communicable diseases (NCDs). 

According to the World Health Organization, NCDs are estimated to account for 60 percent of deaths in India. It is said that the probability of an Indian, in the age group of 30 to 70 years, dying from one of the four main non-communicable diseases—diabetes, cancer, stroke and respiratory problems—is 26 percent, currently.

 

There are over 62.8 million diabetics in the country and about 80 million are pre-diabetic. Over 600,000 people in India die each year due to cancer and almost 70 percent are in the 30 to 70 age group. More than half the cancers are associated with lifestyle choices, ranging from obesity to tobacco use. One woman dies every 10 minutes of breast cancer. As many as seven out of 10 cancer patients die in the first year of illness in India, due to late detection of the disease.

 

These statistics clearly indicate that Indians have to commit to making healthy living a habit, and good health should be a personal goal. It is estimated that NCDs will cost India $6 trillion by 2030. The brunt of NCDs is borne by most individuals in their most productive years and it has a domino effect on their families, companies and the nation at large. Yet, Indians are indifferent to these non-communicable diseases.

Hence, harnessing the collective will to wage war against NCDs is at the top of my hope list for health care in 2016.

The collective will to embrace wellness, undergoing regular health screening and making healthy lifestyle choices can bring forth a sea change in the country. NCDs are prevalent across rural and urban geographies and the immediate priority should be to wage a war against this threat, one that transcends geographical and political boundaries.

The historic agreement signed at the recently concluded Conference of the Parties (COP21) in Paris is cause for optimism. It is an example of how collective will across countries have paved the way for what is perhaps a prescription for a greener, healthier and more sustainable planet. 

This is an opportune time to bring global health to the foreground too; the challenge of lifestyle diseases is as severe as the one that climate change poses. The results are as catastrophic from a social and economic standpoint. Unfortunately, health care is yet to find the same degree of resonance and mind space that climate change has received; I hope that 2016 sees a change in this tide. 

The need for speed in achieving health care goals is even more pronounced in India. Just as we are making a firm commitment to increase our tree cover and reduce emissions by as much as 30 to 35 percent, we need an unwavering determination to fight disease. A public health focus on clean water, sanitation, large-scale immunisation programmes for prevention and increased awareness on the part of individuals are needed to reduce risk factors. Also, making trained talent available at the grass root level will enable multidisciplinary primary care.

Creating a technology and health IT backbone that enables data integration and continuous engagement will also lead to coordinated care across different points of delivery. A shift towards prevention is needed, with outpatient services covered by insurance and with rewards for behaviour that prioritises prevention and wellness.

 

A few years ago, China made health screening at pre-determined intervals mandatory and that’s helping the populous nation. Collective resolve, augmented with regulatory will, could be the trigger for India to realise its potential. Moreover, it is unfortunate that we spend 10 times as much in treating these diseases, compared to investing in research to prevent them, particularly in India where most of the 1.28 billion people pay out of their pockets for medical expenses.

A recent National Sample Survey Organisation (NSSO) report reveals that almost one in every four households in the country take a loan to pay medical bills. The situation in urban India is marginally better, where one in every five households borrows money to meet medical expenses. It is a scary fact that high debt forces 0.8 percent of rural and 0.4 percent of urban households to sell their assets to pay medical bills. 

According to the NSSO 2014 report, the existing public health care setup lacks basic infrastructure. India spends hardly one percent of its gross domestic product (GDP) on health compared with 8.3 percent in the US. Access to quality health care, be it financial or geographical, is not a privilege, but a fundamental right of every citizen. So, No. 2 on my hope list for health care is unhindered access to quality health care for every Indian.

 

India should aspire to provide universal insurance coverage for essential care with low out-of-pocket spending. The government should focus on its role as a payer and regulator and drive provision of health care in under-served areas, across the care continuum. Moreover, as a payer, its reimbursement model should be viable and inspiring. A healthy situation would be one in which the total spending on health care reaches 6 percent of GDP with out-of-pocket spending at less than 30 percent. Public spending on health care should increase to 3 percent of GDP and account for around half of overall health expenditure, driven by greater government prioritisation of health care. 

And as a regulator, the government has to be contemporary and in sync with the dynamics of the new world order. While regulatory systems have been partially defined, a holistic regulatory framework is required. A well-functioning and effective system is required to manage the large and diverse set of service providers in India.

 

A lot of change can be achieved through innovative public private partnerships (PPPs) or even PPPPs (i.e. including people in the partnership). The private sector should lead the provision of care and enable expansion of insurance coverage to urban India. In addition, the government should take the lead in facilitating public health through a focus on awareness, education, sanitation, immunisation and implementation of public health initiatives. 

Young entrepreneurs are exploring new ground with telemedicine, e-consults, m-health and many apps to make health a lot more accessible. The government should incentivise this acumen, and harness their collective energy to make technology a game changer rather than a mere enabler.

We do, however, need to bear in mind that all the technology in the world can never replace the human interface in medicine—the doctors, nurses, paramedics and the actual infrastructure. Therefore, No. 3 on my hope list for health care is a talent revolution.

The WHO has set the doctor-to-population benchmark at 2.5 doctors per 1,000 as a basic parameter for a healthy ecosystem. India falls well short of this mark; we are currently struggling at 0.65 doctors per 1,000 population. The irony of the situation is that while we have the second largest pool of doctors in the world, we have a shortfall of doctors and nurses, which runs into millions.

The resource gap in health care is more pronounced when we get to the heart of India: Our villages. Grass root level health care is severely weakened due to the lack of an efficient and effective staff. The number of primary health care centres (PHCs) is inadequate; 8 percent of them do not have doctors or medical staff, 39 percent do not have lab technicians and 18 percent of PHCs do not even have a pharmacist. It is the sector’s immediate imperative to spark off a surge in the number of health care professionals. This has to be a long-term and sustained programme, built on the bedrock of robust infrastructure and powerful vision.

A key requirement is to reinvent and revitalise medical education in India. Old rules and regulations regarding the basic criterion to set up medical colleges have become outdated; I hope to see an overhaul of the policies that govern the establishment of medical institutes in India. I believe a lot can be done without compromising on the quality of health care professionals we produce. We can take immediate and positive strides in relaxing the regulations regarding the minimum land requirements and faculty ratios to augment the current system. The private sector needs to be harnessed and incentivised to make medical education a priority.

 

Some of India’s finest medical talent goes overseas, either to pursue higher education or to practice abroad. I find it extremely disturbing that the problem of brain drain still persists in India. 

The first part of a solution to this is to nurture an ecosystem where our young doctors see no need to move to greener pastures. Better education, better infrastructure and a proud culture of clinical excellence will go a long way in this mission. 

The other aspect is to draw talented doctors from the Indian diaspora back to the country. This, too, is a viable vision. A concerted effort is required to ease the regulatory issues to draw them back, as well as instill the confidence in them that the Indian health care ecosystem is at par with the very best in the world. From personal experience, I know this works. In the coming year, I hope to see several concrete steps to reverse the brain drain.

The total skill gap is approximately 97.9 percent across various health workforce categories, according to the findings in a study by The Public Health Foundation of India. An investment in increasing the medical manpower in India, and nurturing a skill revolution that permeates to the core of the system will drive huge benefits of our country—not only will we have better health coverage, but we will definitely multiply our GDP with more employment and better productivity. 

Indian health care is at a crucial crossroad. Positive steps now will see the fruition of a vision—where every Indian is healthy and India is stronger and prouder than ever. I truly believe this is a great time for health care. Let us sow the seeds in 2016; soon we can change India and the world.