A healthy Bharat is a responsibility, and attaining the highest standard of health is a fundamental right of every being. Despite many of Bharat’s remarkable achievements, including the highly successful vaccination drive in fighting the pandemic, and being the pharmacy of the world, many Bhartiyas still grapple with poor health, poor quality health infrastructure, and inadequate health financial risk protection for all.
Despite the continual fall in total fertility rate (TFR) – the average number of children born to a woman – to drop to 1.29 by 2050 (the accepted replacement rate is 2.21), Bharat’s population is still likely to be around 1.6 billion by 2050. While Bharat has the largest cohort of young people, the population above 60 is expected to go up to 21 percent by 2050 as compared to 10.5 percent in 2022. Bharat will want decent health and affordable healthcare for all. The climate change-induced heat effects will further strain every heart, nerve, and sinew. Therefore, the journey towards health equity must entail a serious societal commitment.
Conscionably, Ayushman Bharat (AB) is pivoted on 150,000 Health and wellness centers (HWC), and a cashless secondary and tertiary care scheme called Pradhan Mantri – Jan Arogya Yojana (PM-JAY), through National Health Authority (NHA). With this, the government moved from the role of a provider to a payer (costs have to be rationalized though!), recognizing that providing healthcare services to 1.4 billion people is not a task that either the public or the private sector can achieve alone. AB covers the bottom two quintiles, and commercial insurance covers the top-income quintile, but this still leaves 300 million missing-middle (The government is currently working to empower 300 million e-Shram-registered informal sector workers and help them avail of the benefits of several welfare schemes including insurance). The Pradhan Mantri Bhartiya Jan Aushadhi Pari yojana (PMBJP) offers more than 800 medicines to the poor and marginalized. Patients can access generic medicines at almost half the market price from the government-run Jan Aushadhi Kendras.
The National Digital Health Mission in the form of Ayushman Bharat Digital Mission (ABDM) intends to digitize the entire health ecosystem in India. The National Health Stack shall establish a centralized electronic database containing health records and directories, which is critical in creating an adequate linkage between preventive, primary, secondary, tertiary and follow-up care. The ABDM has the potential to bring about a transformational change as it involves the creation of not just a unique digital health ID for every citizen but the entire backup system around it. Bharat’s fintech industry – which comprises over 10,000 companies – was built on the foundation of Aadhaar and UPI. The health tech industry will be built upon the nationwide adoption of Electronic Medical Records (EMR) standards. Adding AI layers on top of EHR data allows the creation of more powerful healthcare applications.
The healthcare sector has seen a focus on public–private partnerships (PPP) by making it an integral part of the National Health Mission (NHM), and address infrastructure gaps. Yet, Bharat’s hospital density is 1.3 beds/1000 population as against the required 3 beds/1000 mark. Bharat has a doctor-to-population ratio well below the WHO’s ideal ratio of 1:1,000. We need to undertake reskilling of human resources and utilize them fully – for instance, making nurses take doctors’ roles at the primary level. Bharat’s pharmaceutical industry is searching for its next step to move up the value chain in the global pharma sphere, after leading the world in generics and vaccines. And one of the pathways could be biopharmaceutical – specifically biologics and biosimilars. Medicines constitute nearly 50 percent of the health costs incurred by people where patenting plays a significant role. Bharat has to ensure that the recently amended patent rules do not allow frivolous patenting, and increase drug prices.
The Ministry of Health and Family Welfare (MoHFW) is the central legislative body in charge of framing India’s health policies. The National Medical Commission (NMC), constituted under the National Medical Commission Act, 2019 (the NMC Act), is the apex body regulating the quality and delivery of medical services and education. Each state in India also has its own councils to regulate medical professionals. Besides, there are other national regulators too – food safety (The Food Safety and Standards Authority of India – FSSAI), drugs and pharmaceuticals (The Drugs, Medical Devices and Cosmetics Bill 2023), price regulations (The National Pharmaceutical Pricing Authority of India – NPPA), an authority each for various healthcare related professionals: Central Council for Indian Medicine, Indian Nursing Council, Dental Council of India, Pharmacy Council of India and Allied Health Professionals Council for the “wellness” sector. The regulatory space is disparate and challenging. A recent controversy over the presence of carcinogenic pesticide in two popular spice brands provide a nudge that regulations that match best-in-class global standards can only ensure better outcomes.
The Drugs, Medical Devices and Cosmetics Bill 2023
represents a shift in overseeing and regulating the import, production, distribution, and sale of drugs, medical devices and cosmetics. But despite it being a separate entry on the concurrent list, the Drugs and Cosmetic Act has fragmentations. The Centre makes rules for manufacture of drugs but states grant the licenses. States have uneven regulatory oversight, variable drug quality, inconsistent standards enforcement, and insufficient protection from unsafe drugs. This issue is still not addressed. Similarly, the new Bill does not give the national drug regulator an independent corporate character like other regulators such as SEBI or FSSAI. While state governments have viewed drug manufacturing as their target of regulation, it would prudent to shift the focus away from in-state manufacturers to in-state consumers. While Central Drugs Standard Control Organization (CDSCO) and the state regulators have the sway, we need CDSCO to be the central authority for centralized process of issuing manufacturing licenses, and having SOPs for coordinated enforcement. Bharat must ensure single-quality medicine, transparency in drug approval processes, and evidence-based policy making (On drug’s efficacy, most drug regulators across the world make available all drug approval files, albeit with some redactions to protect confidential information).
The Centre enacted the Clinical Establishment (Registration and Regulation) Act in 2010 to provide for the registration and regulation of all clinical establishments in the country to prescribe the minimum standards of facilities and services they provide, and to improve quality and protect patients’ rights but it has largely been ineffective as states and UTs can choose not to adopt it. Healthcare industry’s resistance has led to a handful of states implementing it, resulting in a patchwork of regulations and inconsistent oversight of clinical establishments.
Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care. To achieve UHC by 2030, government has accepted a recommendation of the 15th Finance Commission (XV FC) to increase the public funding on it to 2.5 per cent of GDP by 2025. The XV FC has also recommended ‘health’ to be transferred to the concurrent list of the Constitution allowing for uniform policy formulation and implementation.
This would empower the Centre to establish nationwide standards while preserving state autonomy to tailor policies, and maintain federal balance. A broader approach to healthcare should seek to improve the environment to have an economic impact. Globally, health improvement contributed to one-third of GDP per capita growth of developed economies in the last century.
Arun Agarwal is an author, columnist, teacher and ex-CEO. He is currently a Professor of Practice at Rizvi Institute of Management Studies and Research, Mumbai.