Healthcare 2019: How Did India's Health Systems Fare?
From a continued decline in infant and maternal mortality to inadequate funding for healthcare, from poor nutrition to an acute encephalitis syndrome outbreak, and from success in malaria prevention to below-par performance on leprosy control and tuberculosis elimination, here’s a look at 2019’s biggest health stories.
Decrease in Maternal Mortality, Infant Mortality
Fewer mothers died during childbirth as India’s maternal mortality ratio (MMR)--maternal deaths per 100,000 live births—fell 27% from 167 in 2011-13 to 122 in 2015-17, according to the Sample Registration System bulletin.
However, India is still a long way from the Sustainable Development Goal for MMR: a target of 70 deaths per 100,000 live births by 2030. Three Indian states have already achieved this--Maharashtra, Tamil Nadu and Kerala.
India’s infant mortality rate—deaths per 1,000 live births— also fell from 42 in 2012 to 33 in 2017, as IndiaSpend reported in June 2019. This rate is higher than the global average (29) and India’s neighbours Nepal (28), Bangladesh (27), Bhutan (26), Sri Lanka (8) and China (8), but better than that of Pakistan (61) and Myanmar (30).
While these reductions are great, a narrow focus on these indicators without tackling the social causes of these problems is pointless, said Rakhal Gaitonde, professor at the Achutha Menon Centre for Health Science Studies in Thiruvananthapuram. “We are too fixated on technical and technological fixes while ignoring basic underlying issues of poverty, hunger, livelihood and childcare which are important,” he said.
This may be the reason why five of India’s poorest states—Bihar, Uttar Pradesh, Uttarakhand, Odisha and Madhya Pradesh—were among nine states that saw their overall health performance decline in 2019, according to government think-tank NITI Aayog’s health index, IndiaSpend reported in June 2019.
Health Budget Increases, Ayushman Bharat Completes a Year
The Centre has been increasing its allocation to the health ministry, and this year’s budget of Rs 62,659 crore—2.25% of total expenditure—was the highest till date, as IndiaSpend reported in July 2019.
This figure, combined with the states’ health funding, came to 1.4% of gross domestic product (GDP)--much below the 2.5% of GDP goal set by the National Health Policy of 2017, and even the 2010 target of 2% of GDP, as IndiaSpend reported in April 2017.
Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)— the National Health Protection Scheme— completed a year of operation. By December 20, 2019, it had covered more than 6.9 million hospitalisations and issued more than 69.4 million e-cards, according to data from its website. Its target is to insure 100 million Indian families for a sum of Rs 5 lakh.
While the system to implement AB-PMJAY is agile and is improving on the go, the one challenge the scheme is facing is delays in the payment to the health provider, said Oommen Kurian, senior fellow and head of health initiative at Observer Research Foundation, a think-tank. “One already sees the Centre and states blaming each other for delayed disbursements,” he said.
Regular engagement with data, including evaluation studies and a willingness to recognise that there are issues initially—from inequity to fraud—as also an attempt to think through how to resolve them, is a welcome change, said Avani Kapur, director of Accountability Initiative, Centre for Policy Research, a research think-tank. “Portability, I think, was an excellent move to ensure ease of access,” she said.
Meanwhile, the beneficiary database is “very old” and the government has to “clean it up and exactly identify the people still left out and how to make them part of the scheme”, Indu Bhushan, chief executive officer of AB-PMJAY, told IndiaSpend in December 2019.
Already, over half of hospitalisations in India (51.9% in rural and 61.4% in urban) are in private hospitals, showed the latest National Statistical Office report on consumption in health, as we reported in December 2019. The average medical expenditure per hospitalisation in a private hospital (Rs 31,845) is seven times that in a government hospital (Rs 4,452), the report said.
However, less than 10% of the poorest have any kind of health insurance, forcing them to spend out of pocket for healthcare expenses, our analysis showed.
The focus should also move to the expansion of health and wellness centres--another aspect of the Ayushman Bharat scheme that improves the existing sub-centres to provide comprehensive primary care--both Kapur of Accountability Initiative and Kurian of ORF said. “There should be serious focus and [investment of] resources on strengthening the health and wellness centres,” said Kapur.
Litchis, Malnutrition, or Heat and Humidity?
In one of the worst outbreaks of acute encephalitis syndrome (AES) in the state since 2014, 162 children died in Bihar (till July 2, 2019). Characterised by high fever, vomiting and convulsions, the condition affects children under 15 years. There are several agents causing AES such as bacteria, fungi and viruses. The most common causes are Japanese encephalitis, Scrub typhus, dengue, measles and even Zika virus.
The cause of the outbreak this time was linked to consumption of litchi, Minister of State for Health and Family Welfare Ashwini Choubey told the Rajya Sabha on July 2, 2019. When malnourished children eat litchis (readily available in local orchards), it triggers hypoglycaemia and leads to seizures or AES, Choubey said. This was based on a 2014 study conducted by virologist T Jacob John and a 2017 study by the Centers for Disease Control and Prevention, USA.
Not all experts agreed that litchis were the only factor. High daytime temperatures (38-40 degrees Celsius) and high humidity (50-60%) at night during the June to August period cause heat-stroke in children, some doctors surmised.
However, in both theories, undernutrition and poverty play important roles: When a child sleeps hungry, her blood sugar levels dip and the body does not have enough reserves in the liver, leading to hypoglycemia. Lack of health infrastructure and ground-level staff, and a delay in bringing the children to the hospital also increased the death toll.
Malnutrition Rampant in Children, Adolescents
One in three (35%) children younger than five years were stunted (low height for age) and underweight, one in six (17%) were wasted (low weight for height), and two in five (41%) were anaemic, found the Comprehensive National Nutrition Survey (CNNS), the first of its kind that gave nutritional status of children aged 5-14 years.
The prevalence of stunting, wasting and underweight in children has declined compared to the figures of National Family Health Survey, 2015-16: There has been a 3.8-percentage-point decline in stunting, 4-percentage-point decline in wasting, and 2.5-percentage-point decrease in underweight children from 2015 to 2018, the CNNS found.
However, there is another challenge—of overnutrition and non-communicable diseases: 5% of children and adolescents (5-19 years) were overweight, one in 10 children (5-9 years) were pre-diabetic, and 1% of children in that age group were already diabetic, the CNNS found, as IndiaSpend reported in October 2019.
India launched POSHAN Abhiyaan, the national nutrition mission, in March 2018 to improve nutrition among children, pregnant women and lactating mothers. It aimed at achieving convergence between different departments such as women and child development with health and public distribution system.
POSHAN Abhiyaan’s focus on behaviour change, on recognising social determinants such as age at marriage, child bearing and sanitation, and on improving key drivers such as complementary feeding are welcome, said Purnima Menon, senior research fellow, International Food Policy Research Institute.
However, the states with high burden of malnutrition where things need to move fast continue to have health systems ridden with governance challenges such as low fund utilisation and human resource gaps. This can limit the ability to really scale up interventions, she said. Also, the key driver of all forms of nutrition, which is poverty, needs more focus in the mission, she said.
Does Air Pollution Kill or Not?
There is no Indian study that shows the impact of air pollution on people’s lives and health, union environment minister Prakash Javdekar said in the Lok Sabha on December 6, 2019, reiterating the government’s stand. His statement drew sharp reactions from public health and environment experts.
One in eight deaths in India was due to air pollution, a December 2018 study co-authored by researchers at the Indian Council of Medical Research showed. In 2017, 1.24 million had died due to air pollution, and Indians could live 1.7 years longer if they breathed clean air, as IndiaSpend reported in December 2018.
“We have brought together and analysed tens of thousands of studies showing effect of air pollution on health from every population of the world,” the World Health Organization’s (WHO) climate lead Diarmid Campbell-Lendrum told The Times of India on December 9, 2019. “We are yet to find a study which shows any population, including India, which is immune from the health impacts of air pollution,” he said.
All year round, the level of air pollution in Delhi remains three times higher than the national standard. Unless we bring down the annual concentration significantly, the health burden will not reduce, Sagnik Dey, associate professor at the Centre for Atmospheric Sciences at the Indian Institute of Technology, Delhi, told IndiaSpend in November 2019. To fight air pollution, governments need not only emergency measures when pollution spikes, but year-round air pollution reduction drives across sectors, he said.
India Gets a National Medical Commission Bill
Besides regulating medical institutions and assessing human resource requirements, the law determines the fees for up to 50% of the seats in private medical institutions. It also allows community health providers to provide primary and preventive care at mid-level under the guidance of a medical practitioner.
This is crucial because India’s current density of healthcare workforce—including doctors, nurses, midwives—per 10,000 population is 20.6 in 2016, compared to 22.8 recommended by the WHO. India would need 250,000 health workers to meet this requirement, IndiaSpend reported in July 2019.
Success in Malaria Continues
India is among the 11 most malaria-affected countries in the world, accounting for 70% of cases globally. In 2018, India registered 2.6 million fewer malaria cases than in 2017. This was 51% fewer than in 2017 and 60% fewer than in 2016, according to the World Malaria Report, 2019.
India’s strategy included indoor insecticide spraying, reduction of mosquito-breeding spots, and free distribution of long-lasting insecticidal nets. Treating asymptomatic or afebrile malaria played an important role in reducing malarial infections, we reported in November 2018.
Currently accounting for 3% of global malaria cases, India aims to eliminate the disease by 2030.
Meanwhile, despite announcing that leprosy had been eliminated in India in 2005, the Central Leprosy Division of the health ministry reported that 135,485 new leprosy cases were detected in India in 2017, of which nearly half (67,160) had been diagnosed at an advanced stage, IndiaSpend reported in January 2019. That meant, on average, somebody was diagnosed with leprosy in India every four minutes.
Tackling tuberculosis (TB) remained similarly challenging—although fewer cases were detected in 2018 than in 2017, the rate of decline (1.8% per annum) is not enough to meet India’s target of eliminating TB—a disease that killed one in six of those infected in 2018--by 2025, according to the WHO’s 2019 Global TB report.
(Yadavar is a special correspondent with IndiaSpend/HealthCheck.)
(This article was originally published on IndiaSpend and has been republished with permission.)
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