India is currently suffering from a multi faceted burden of disease — the unfinished agenda of infectious diseases; the challenge of non communicable diseases (NCDs), linked with lifestyle changes; and the emergence of new pathogens causing epidemics and pandemics. NCDs and injuries together have overtaken infectious and childhood diseases in terms of disease burden in every state of the country, posing a new challenge to public health.
NCDs today account for 61.8% of all deaths in India, followed by communicable diseases (27.5%) and injuries (10.7%). While infectious and associated diseases made up majority of disease burden in most of the Indian states in 1990, this was less than half in all states in 2016. The health system of India is largely geared to address only acute disease as of now, and there is a need to change this tendency to include the rising pattern of non-communicable diseases.
This was said by experts in public health assembled at the two-day International Public Health Conference held at the Amrita Institute of Medical Sciences during November 02 -03, 2018. The event has brought together dozens of experts from the government, NGOs, global health bodies and the corporate world to discuss the challenges facing public health in India, including universal health coverage, cancer, cardiovascular disorders, dengue, snake bites, oral health, diabetes, and mental health.
Said Dr Vijaykumar, Chief of Public Health and Community Medicine, Amrita Hospital “India’s public health situation is problematic, with underfunded and overcrowded hospitals and inadequate rural coverage. This is despite increasing demand due to the growing incidence of age and lifestyle-related chronic diseases. The Indian healthcare sector today witnesses 50% spending on inpatient beds only for lifestyle diseases. In addition, the country has 65 million diabetes patients, among the highest in the world. This has resulted in the rapid development of super-specialty hospitals to combat lifestyle diseases. The rapid growth of the private health sector has come at a time when India’s public spending on health at 0.9% of GDP is ahead of only five other countries in the world – Burundi, Myanmar, Pakistan, Sudan and Cambodia. Only 33% of Indian healthcare expenditure in 2012 came from government sources. Of the remaining private spending, as much as 86% was out-of-pocket. Over 40% of all patients admitted in Indian hospitals have to borrow money or sell assets to cover their medical expenses, and 25% of all farmer patients are driven below the poverty line by catastrophic healthcare costs.”
Talking about the most pressing diseases impacting public health in India he added: “While the biggest killer of Indians in 1990 was diarrheal disease followed by ischemic heart disease, today this order has got reversed. Lung diseases have also grown rapidly among the Indian population. Chronic obstructive pulmonary disease (a group of lung conditions that cause breathing difficulties) has climbed the charts to become the second deadliest killer of Indians today, up from number 5 in 1990. Diarrheal diseases, cerebrovascular disease, lower respiratory infections and tuberculosis, in that order, remain the other four leading causes of death of Indians today. While the per person disease burden dropped in the country by 36% from 1990 to 2016, major inequalities remain among the states, with the burden varying almost two-fold between them. Child and maternal under-nutrition is still the single largest risk factor in India, responsible for 15% of the total disease burden in 2016.”
The experts recounted the enormous challenges in improving the overall public health in India. Dr Prem Nair, Medical Director, Amrita Hospital opines: “India is presently in a state of transition – economically, demographically, and epidemiologically – in terms of health. Apart from the high disease burden, other challenges in improving public health include low government expenditure on health, the shortage of human capital in the healthcare industry, lack of private-public partnership, absence of an organized health system, inefficient public health workforce, non-usage of modern technology by public health system, and lack of access to marginalized populations.
The experts also deliberated upon the ways to meeting these challenges. Said Dr Ashwathy, NCD expert, “Investing more in health as well as disease prevention and health promotion should be the topmost priority. The government expenditure on health should increase to at least 2.5% of GDP by 2025. The existing government healthcare infrastructure needs strengthening to improve the process of service delivery. The emerging epidemic of non-communicable diseases needs to be addressed. India has one of the lowest densities of health workforce in the world, including physicians (7 per 10,000 population) and nurses (17.1 per 10,000 population), as against the global average of 13.9 and 28.6, respectively.”
The experts said that while Ayushman Bharat Yojana is a big step in public health and a harbinger of change, the road to universal health coverage will not easy in a country like India. It depends on how fast and how well can the government evolve this scheme with the changing and emerging healthcare needs of Indians.
Said Dr Vijayakumar: “Ayushman Bharat signals a shift of focus of the government from particular diseases and reproductive and child health to comprehensive primary healthcare. There is heavy involvement of the private sector in this scheme. Yet, several issues remain. The program is being launched without much preparation and there is lack of focus on reform of the broader healthcare system. Package rates under Ayushman Bharat for various procedures and interventions are deemed too low by private hospitals. It caters to only inpatient expenditure, while outpatients and medicines are not included in the program. Without effective and comprehensive primary healthcare, pouring money into hospitalization at the secondary and tertiary level will only lead to an increase in overall health expenditure.”