Healthcare in india
2014CHL291
[Healthcare in india]The major diseases and which India is
facing along with the changes which have happened in the last year
are discussed in this report. Along with this we also look into the
scenario in 2025 and provide the possible solutions which India
should follow for a positive change.
Ankit AwasthiTop diseases leading to loss of life in India and
its comparison with developed countriesDiseases claiming maximum
life in India
Coronary Heart Disease
Ref :
http://www.worldlifeexpectancy.com/cause-of-death/coronary-heart-disease/by-countryCountryMortality
rate(per 100000)India165.8United States80.5United
Kingdom68.8Australia60.3
CAUSESSmokingHigh levels of certain fats and cholesterol in the
bloodHigh blood pressureHigh levels of sugar in the blood due to
insulin resistance or diabetesBlood vessel inflammationDiabetes
Mellitus
CountryMortality rate(per 100000)India23.8United
States15.2United Kingdom5.0Australia9.9
CausesGenetic Susceptibility TCF7L2Obesity and Physical
InactivityAbnormal Glucose Production by the Liver Metabolic
Syndromehigher than normal blood glucose levelshigh blood pressure
abnormal levels of cholesterol and triglycerides in the
bloodincreased waist size due to excess abdominal fatInfluenza and
pneumonia
CountryMortality rate(per 100000)India68.0United States9.7United
Kingdom23.7Australia7.0
Stroke
Diarrhoeal Disease
Cancer
CountryMortality rate(per 100000)India75United States123.8United
Kingdom137Australia118.8
Akshat RajDual Burden of Infectious and Chronic DiseasesAs
discussed above, we can see that thebiggest challengefor India is
thedual fightof containing a developing countrys health concerns
while a range of developed world disorders are at its doorstep. On
one hand India is combating basic health concerns such as
malnutrition, low immunization rates, hygiene, sanitation, and
infectious diseases. On the other hand, environmental pollution and
lifestyle choices such as alcohol consumption, smoking, and high
fat diet are set to increase the incidence rates of
hypertension/high blood pressure, cardiovascular disease, diabetes
and cancer to almost epidemic levels.What is Healthcare
System?Before we look into the changes in Indias healthcare system,
it is necessary to understand what we mean by the term healthcare
system.World Health Organisation (WHO) defines a health system as
one which consists of all organizations, people and actions whose
primary intent is to promote, restore or maintain health. This
includes efforts to influence determinants of health as well as
more direct health-improving activities. A health system is
therefore more than the pyramid of publicly owned facilities that
deliver personal health services. It includes, for example, a
mother caring for a sick child at home; private providers;
behaviour change programmes; vector-control campaigns; health
insurance organizations; occupational health and safety
legislation. It includes inter-sectoral action by health staff, for
example, encouraging the ministry of education to promote female
education, a well-known determinant of better health.Changes in our
Healthcare System in the Last decadeIn the last decade, Indias
health system developed well in a few areas. Public sector efforts
gained momentum with the adoption of the Millennium Development
Goals (MDGs), as the government set targets to reduce the MMR by
three quarters between 1990 and 2015; to halt the spread of
HIV/AIDS, malaria and other major diseases; and to reverse their
spread by 2015.The Eleventh Five-Year Plan brought about
long-awaited healthcare reforms. These led to greater intensity and
some changes in the direction of public sector initiatives. Within
the private sector, healthcare facilities grew rapidly and
insurance coverage increased. The past decade also witnessed
several pilots of public-private partnerships, particularly in
hospitals and diagnostic services.Rise of the Private Health Care
SectorOver the past decade or so the increase in the expenditure by
private companies in the health care sector has been huge, as can
be witnessed from the Figure A. Also, in the last decade the
private sector added about 70% of the total hospital beds (Figure
B).Figure A Percentage of Private and Public spending as a part of
total health care spendingFigure B Beds added by Private and public
sector, 2002-2010 (Source McKinsey)
Indias Public health care expenditure is alarmingly low, and
amounts to around only 1% of its total GDP while in comparison to
Russia (~3%), USA (~15%) and UK (8.5%).Another thing of concern has
been the increasing OOP outlays (70%), i.e. Out-of-pocket spending
on health facilities by people, of this 50% is on drugs.The reasons
for Private sector to pick so much have been both the positive
stimulus for private companies and hospitals and the negative
stimulus to public sector. Poor public healthcare facilities i.e.
unavailability of attendants, poor infrastructure, etc. increased
the market for private health care and also many external drivers
of private sector growth like Medical Tourism have also come up.But
High Involvement of Private Sector is undesirable because of
various externalities and also because of the problem of
informational asymmetry (Doctors have more information about the
disease than the patient, and may potentially exploit
patients).
Figure C Healthcare system spending (Source McKinsey)
Pharmaceutical SectorIndia has emerged as a major supplier of
several bulk drugs, producing these at lower prices compared to
formulation producers worldwide. (Exports US $13 Billion/Year)
which is 3rd Largest in World, in terms of Volume. And it is
growing at the rate of 15-20%, annually. Indian Pharmaceutical
Industry has helped the world in a very positive way by bringing to
people many generic drugs at much cheaper rates.The last decade saw
the advent of Product Patent Regime (January 2005), which brought a
considerable change in the policies of the Indian Pharma companies.
Now many bigger of the Indian firms, have increased their
investments in R&D to sustain themselves. Also, now many
Multinational firms are now targeting high end patients while some
Indian firms have chosen to target semi-urban and rural
populations.It is important for Indian Pharmaceutical companies to
reinvent themselves to sustain themselves.Changes in Government
PoliciesIn light of the MDGs (Millennium Development Goals) that
were established following the Millennium Summit of the United
Nations in 2000, the Indian government has taken long strides in
the right direction. As part of the Eleventh Five Year plan the
government has been increasing the Share of public spending in
healthcare since 2005 steadily.Also, Various
Public-Private-Partnerships (PPPs) have been setup to
undertake/solve many issues as soon as possible.Apart from the
above the major government schemes/programs which saw the light of
the day in the last decade are National Rural Health Mission (NRHM)
(2005) Rashtriya Swasthya Bima Yojana (RSBY) (2008) Jan Aushadhi
Initiative (2008)Others Medical Tourism is now one of the major
external drivers of growth of the Indian healthcare sector, seeing
an exponential growth in the last decade.No. of Medical Tourists:
2005 -150, 000; 2011 850,000. (Source: Confederation of Indian
Industry & ASSOCHAM)It is so because the treatment and
medicines in India are much cheaper as compared to many developed
countries while the quality of services is at par. India was
declared Polio Free on March 27, 2014. Similar success is also
needed for diseases like TB, etc. Clinical Trials India has become
a more attractive market for clinical trials, because of various
policy changes it took, which has made its policies similar to
those around the world. Telemedicine Providing access to
diagnostics and Treatments through Video Conferencing.
Challenges in Indian Health Care SystemVinita KumariIndias
health care system is overburdened by increasing population. India
faces the twin epidemic of continuing/emerging infectious diseases
related to poor implementation of the public health programs as
well as chronic degenerative diseases which is the result of
demographic transition with increase in life expectancy. About 40
per cent of all deaths in India are due to infections. The majority
of the remainder are mainly due to non-communicable conditions such
as cardiovascular diseases (heart attacks and associated
conditions, including strokes, are alone responsible for a quarter
of all mortality), chronic respiratory disorders and cancers.
Indias government spending on health care is less than 2% of GDP,
among the lowest worldwide. Even though Indias private health
insurance industry grew its business volumes by 35% annually in
recent years, 85% of the population remains uninsured. About 65% of
Indians that incur expenditures on major health problems become
indebted for life. Economic deprivation in a large segment of
population results in poor access to health care. Poor educational
status leads to non-utilization of scanty health services and
increase in risk factors. While India has emerged as a destination
for drug development, a key obstacle moving forward is matching the
priorities of the drug developer with those of the physician and
the patient in clinical trials. The major challenges that India
face in the health care industry are: Low investment by government
in health care sector: Health cares spend is not growing as same
pace as countrys GDP. Indias healthcare spending as a percentage of
GDP has reduced from 4.4 percent in 2000 to 4 percent in 2010. Lack
of infrastructure: Infrastructure gaps are substantial and
underutilization of existing resources further adds to the problem
of meager infrastructure. Public sector hospitals are not well
maintained and their utilization remains low. In rural areas there
are very few hospitals and health care centres and villagers have
to cover miles to access health care services. Lack of health
workforce: The total number of doctors and nurses in the country
lags the WHO benchmark of 2.5 doctors per 1000 people at 2.2 per
1000 people. Despite the scarcity of medical personnel the problem
of underutilization exists. Many registered medical practitioners,
nurses are not actively involved in the formal sector, density of
practicing workforce falls to 1.9 per 1000. High cost of health
care services: Indias healthcare costs may be among the lowest in
the world but they are still out of the reach of a vast majority of
its citizens. Most people cant even afford conventional treatments
at subsidised prices in public hospitals. Access to affordable and
quality health care is still a dream for most rural Indians.
Government hospitals can hardly fill the gap and therefore, most
rural Indians are left with no choice but to rely on costly private
hospitals. On a day-to-day basis many people experience outlays on
drugs (which to varying degrees also encompass professional and
institutional fees, as well as taxes) as the dominant element in
the out-of-pocket expenditures they believe are needed to protect
their health. Many sources suggest that a half of total health care
outlays are spent on purchasing drugs. Each year, 39 million people
are pushed into poverty by out-of-pocket payments for healthcare,
with households on average devoting 5.8% of their expenditures to
medical care.
Major diseases in India and their economic burdens on
Indians:
CancerCancer is one of the leading causes of death in India,
with about 2.5 million cancer patients, 1 million new cases added
every year and with a chance of the disease rising five-fold by
2025.This is owing to the poor availability of prevention,
diagnosis and treatment of the disease. All types of cancers have
been reported in Indian population including the cancers of skin,
lungs, breast, rectum, stomach, liver, cervix, esophagus, bladder,
blood, mouth etc. Cancers of lung and mouth in men and cervix and
breast in women are the biggest killers. Ignorance among public,
delayed diagnosis and lack of adequate medical facilities has given
cancer the dubious distinction of being a killer disease.As per a
Boston Consulting Group study, 70-80% of cancer patients are
diagnosed late when treatment is less efficient and 60% of them do
not have access to quality cancer treatment. Out of 300+ cancer
centres in India, 40% are not adequately equipped with advanced
cancer care equipment.High treatment costs are one of the main
reasons why cancer care is out of reach for millions of Indians. If
detected early, treatment is effective and cheaper. However, if
detected late, it is more expensive (can even lead to bankruptcy)
and also reduces chances of survival. An average cancer patient
bears an economic burden of Rs 36,812 for the entire cancer therapy
at an institution like the All India Institute of Medical Sciences
(AIIMS) where services are free or highly subsidized. Chemotherapy
and hormonal drug therapy can cost from Rs10,000 to Rs 4 lakhs
depending on the drugs used and duration of treatment. Some breast
cancer patients, for example, need targeted treatment drugs, such
as Herceptin or Herclon, made by global major Roche, which cost
around Rs 75,000 for a course; a patient could need up to 17
courses. Similarly, a drug called Avastin - used to treat colon,
kidney, lung and gall bladder cancer - can add around Rs 8 lakh to
a patient's bill at around Rs 1 lakh a cycle. India has a
population of approximately 1,200 million with a requirement of
more than 1,200 Radiation Therapy (RT) machines. At present, there
are just 400 RT machines that are available for cancer treatment.
Access to cancer detection technologies -- quality pathology labs,
imaging equipment, especially PET/CT or molecular imaging that can
detect cancer at least 5 years earlier than any other technology --
needs to be improved.
DiabetesAt present, India is considered as the diabetic capital
of the world. In India, 63 million people have diabetes as of 2012,
and the number is estimated to increase to 101 million by 2030.
Diabetes is a metabolic disease in which a person has high blood
glucose, either because the body does not produce enough insulin,
or their cells do not respond to the insulin produced. People with
diabetes develop further health complications as a result of
inadequate blood sugar control, a condition that can lead to heart
disease and stroke, as well as damage to kidneys, nerves and
retina.Because of its chronic nature, the severity of its
complications and the means required to control them, diabetes is a
costly disease. Diabetes consumes between 5% and 25% of the income
of an average Indian family, which translates to USD 2.2 billion a
year on diabetes care and treatment. Many patients are unaware of
treatment expenses and are not able to plan the budget. Direct
costs to individuals and their families include medical care,
drugs, insulin and other supplies. Since it is a chronic disease it
requires prolonged treatment like regular doses of insulin
injection, regular intake of tablets to maintain metabolism of
body.In India, more than half of patients have poor glycaemic
control and have vascular complications. Therefore, there is an
urgent need to develop novel therapeutic agents of diabetes without
the development and progression of complications or compromising on
safety.
Tuberculosis (TB)Tuberculosis (TB) is one of the major public
health problems in India with a significant impact on the health
and economy of the country. India is the highest tuberculosis (TB)
burden country in the world, accounting for nearly one-fifth of the
global incidence. Annually more than 250,000 people die of TB. This
is most unfortunate as TB is a curable disease if treated
appropriately and adequately. Almost 70% of TB patients are aged
between 15 and 54 years. The disease is more common amongst the
poorest and the marginalized sections of the community. Whilst
two-thirds of cases are male, TB takes a disproportionately larger
toll among young females, with more than 50% of cases occurring
amongst females less than 34 years of age. The most reliable test
for diagnosis of TB is smear microscopy which is widely used under
the RNTCP(revised national tuberculosis control programme).
However, the private sector does not prefer this simple and
reliable test; instead a number of antibody based blood tests
(serological tests) which are nonspecific are being widely used for
diagnosing TB. Patients are therefore often falsely diagnosed based
on these unreliable tests and unnecessarily treated for a disease
they are not suffering from while incurring unwarranted out of
pocket expenditure. It is estimated that over 1.5 million of such
unreliable serological tests are performed in India annually
primarily by private laboratories. A cause for concern is the
potential threat of extensively drug-resistant tuberculosis in
India, with unregulated availability and injudicious use of the
second-line drugs and no system to ensure adherence to standardized
regimens and treatment for multidrug-resistant tuberculosis.
Multidrug-Resistant TB (MDR-TB) is the resistance to the two most
effective first line drugs isoniazid and rifampicin. When these
first-line drugs fail, second-line drugs are used for treatment.
The cost of these drugs is staggering, as much as 1400 times that
of regular treatment, with severe side effects and prolonged
duration of treatment over 2 years.India needs an enhanced model
for the control of tuberculosis. District public health ocers are
needed to receive reports about all cases that are diagnosed in all
health-care clinics in the district.
ConclusionIndias health care industry needs managers with
knowledge about the reality at the ground level to help grapple
with the above challenges.Most people in India buy healthcare from
the private sector, a compulsion that accounts for a high
proportion of healthcare-related expenditure. To reduce the burden
of healthcare costs, the government must improve availability and
affordability of generic and essential medicines in the market.
Government needs to understand the scope of Indias health care
gaps, work to build infrastructure to reach rural pockets, and to
create innovative financing to deliver health care to the
underprivileged. Creating incentives for local companies, roping in
support from global players and putting in place public-private
partnerships are the main areas for the improvement of Indian
health care services industry. Rishi YadavMajor Programmes by
Ministry of Health and Family welfare Communicable Diseases
Non-Communicable Diseases, Injury & Trauma Pradhan Mantri
Swasthya Suraksha Yojana - PMSSY Poor Patients-Financial Support
Other National Health Programmes National Health
MissionCommunicable Diseases Human Immunodeficiency Virus
Infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) -
Department of AIDS Control State AIDS Prevention and Control
Societies Revised National TB Control Programme (RNTCP)Second
largest DOTS (Directly Observed Treatment, Short course) programme
in the world. However, India's DOTS programme is the fastest
expanding programme, and the largest in the world in terms of
patients initiated on treatment, placing more than 100,000 patients
on treatment every month. National Vector Borne Disease Control
Programme (NVBDCP)Central nodal agency for the prevention and
control of vector borne diseases i.e. Malaria, Dengue, Lymphatic
Filariasis, Kala-azar, Japanese Encephalitis and Chikungunya in
India. Integrated Disease Surveillance Project (IDSP)Integrated
Disease Surveillance Project (IDSP) was launched with World Bank
assistance in November 2004 to detect and respond to disease
outbreaks quickly. National Leprosy Eradication Programme(NLEP)The
National Leprosy Eradication Programme is a centrally sponsored
Health Scheme of the Ministry of Health and Family Welfare, Govt.
of India.Non-Communicable Diseases, Injury & Trauma National
Mental Health Programme (NMHP) National Programme for Prevention
and Control of Deafness (NPPCD) National Programme for Control of
Blindness(NPCB) Pulse Polio Programme Universal Immunization
Programme (UIP)Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) Aims
at correcting the imbalances in the availability of affordable
healthcare facilities in the different parts of the country in
general, and augmenting facilities for quality medical education in
the under-served States in particular. The scheme was approved in
March 2006. The first phase in the PMSSY has two components
-setting up of six institutions in the line of AIIMS; and
upgradation of 13 existing Government medical college institutions.
In the second phase of PMSSY, the Government has approved
thesetting up of two more AIIMS-like institutions, one each in the
States of West Bengal and Uttar Pradesh andupgradation of six
medical college institutionsnamely Government Medical College. The
estimated cost for each AIIMS-like institution is Rs. 823 crore.
For upgradation of medical college institutions, Central Government
will contribute Rs. 125 crore each. In thethird phase of PMSSY, it
is proposed to upgrade the following existing medical college
institutions namely Government Medical College, Jhansi, Uttar
Pradesh; Government Medical College, Rewa, Madhya Pradesh;
Government Medical College, Gorakhpur, Uttar Pradesh; Government
Medical College, Dharbanga, Bihar; Government Medical College,
Kozhikode, Kerala; Vijaynagar Institute of Medical Sciences,
Bellary, Karnataka and Government Medical College, Muzaffarpur,
Bihar. The project cost for upgradation of each medical college
institution is Rs. 150 crores per institution. Central Government
will contribute Rs. 125 crores.State Government will contribute Rs.
25 crores.Poor Patients-Financial Support Rashtriya Arogya Nidhi
(RAN)The Scheme provides for financial assistance to patients,
living below poverty line who is suffering from major life
threatening diseases, to receive medical treatment at any of the
super specialty Govt. hospitals / institutes or other Govt.
hospitals .The financial assistance to such patients is released in
the form of one time grants to the Medical Superintendent of the
hospital in which the treatment is being received. RAN (Health
Ministers Cancer Patient Fund)Financial assistance to BPL Patients
suffering from Cancer, to receive medical treatment at any of the
super specialty Govt. hospitals / institutes or other Govt.
hospitals .The financial assistance to such patients is released in
the form of one time grants to the Medical Superintendent of the
hospital in which the treatment is being received. Health Ministers
Discretionary Grant (HMDG)Financial Assistance up to a maximum of
Rs. 1,00,000/- is available from 01.01.13 to the poor indigent
patients from the Health Ministers Discretionary Grant to defray a
part of the expenditure on Hospitalization/treatment in Government
Hospitals in cases where free medical facilities are not
available.
Other National Health Programmes Medical & Para-Medical
Institution in North EastNorth Eastern Indira Gandhi Regional
Institute of Health and Medical Sciences, ShillongRegional
Institute of Medical Sciences, Imphal Regional Institute of
Paramedical and Nursing Sciences National Programme for Health Care
of the Elderly(NPHCE)An articulation of the International and
national commitments of the Government as envisaged under the UN
Convention on the Rights of Persons with Disabilities (UNCRPD),
National Policy on Older Persons (NPOP) adopted by the Government
of India in 1999 and Section 20 of The Maintenance and Welfare of
Parents and Senior Citizens Act, 2007 dealing with provisions for
medical care of Senior Citizen. Department of AyushDepartment of
Indian Systems of Medicine and Homoeopathy (ISM&H) was created
in March,1995 and re-named as Department of Ayurveda, Yoga &
Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November,
2003 with a view to providing focused attention to development of
Education & Research in Ayurveda, Yoga & Naturopathy,
Unani, Siddha and Homoeopathy systems. Central Government Health
Scheme (CGHS)The Central Government Health Scheme (CGHS) provides
comprehensive health care facilities for the Central Govt.
employeesand pensionersand their dependents residing in CGHS
covered cities.National Health Mission National Rural Health
MissionNRHM The National Rural Health Mission (NRHM) was launched
by the Honble Prime Minister on 12th April 2005 National Urban
Health MissionNUHM The National Urban Health Mission (NUHM) as a
sub-mission of National Health Mission (NHM) has been approved by
the Cabinet on 1st May 2013. Mother and Child Tracking System
(MCTS)Ministry of Health and Family Welfarelaunched the Mother and
Child Tracking System (MCTS)in December 2009. The focus in MCTS is
on the Beneficiary Based Monitoring of the delivery of services to
ensure that all pregnant women and all new born receivefullmaternal
and child health services. Accredited Social Health Activists
(ASHAs)Community Health volunteers called Accredited Social Health
Activists (ASHAs) Janani-Shishu Suraksha KaryakramJSSK launched on
1st of June, 2011 is and initiative to assure free services to all
pregnant women and sick neonates accessing public
healthinstitutions. In order to reduce the maternal and infant
mortality, National Mobile Medical Units (NMMUs) District Hospital
and Knowledge Center (DHKC) National Iron+ Initiative Anmol
SarrafWhat are the major successes that we have achieved in the
last decade?Polio free statusIndia as well as WHO's Southeast Asia
region was certified polio-free in March this year by an
independent commission under the WHO (World Health Organization)
certification process.
Polio eradication is one of the biggest public health successes
of India. From being one of the top three countries reporting
polio, there hasn't been a single polio case in the country for the
last three years.Several conditions must be satisfied before a
region can be certified polio-free at least three years of zero
confirmed cases due to indigenous wild poliovirus; excellent
laboratory-based surveillance for poliovirus; demonstrated capacity
to detect, report, and respond to imported cases of poliomyelitis;
and assurance of safe containment of polioviruses in laboratories
(introduced since 2000).In 1998, India had a high of nearly 2,000
cases of paralytic polio from the wild poliovirus, and as recently
as 2009, it still was home to most of the worlds polio cases. By
2011, it had wiped out wild polio cases, and now it has maintained
that status for three years.Reduction in prevalence of HIV/AIDS,
MalariaSince the focus shifted from eradication to control, the
programme was renamed as National Anti-Malaria Programme (NAMP)
during year 1999. It is important to note that the Directorate
responsible for prevention and control of malaria at central level
was also made responsible for prevention and control of filariasis,
Kala-azar, Japanese Encephalitis, Dengue and Chikungunya. With the
convergence of prevention and control of other vector borne
diseases, the Directorate of NAMP was renamed as Directorate of
National Vector Borne Disease Control Programme (NVBDCP) in 2003.
The NVBDCP is presently one of the most comprehensive and
multi-faceted public health programmes in the country. The NVBDCP
became an integral part of the NRHM launched in 2005. The special
focus of the NVBDCP is on resource challenged settings and
vulnerable groups. The incidence of malaria in the country started
halting and sustaining reversal of cases for last one decade. The
malaria cases were brought down from 2,031,790 cases in 2000 to
1,816,569 cases in 2005 and further brought down to 1,067,824 cases
in 2012. The Country is heading towards achieving target of 50%
reduction in incidence of malaria cases against the baseline. The
annual incidence rate (cases of malaria/1000 population) of Malaria
has come down from 2.57 per thousand in 1990 to 1.10 per thousand
in 2011, and to 0.88 cases (provisional) per 1000 population in
2012. The malaria death rate in the country was 0.09 deaths per
lakh population in 2000 which has come down to 0.04 deaths per lakh
population in 2012. The total positive cases of Malaria and deaths
due to Malaria have shown declining trend from 2011 and 2010
respectively. The indicators Annual Parasite Incidence (API) per
1000 population and Deaths due to Malaria are showing declining
trend in the recent past and the challenge is to sustain that
trend.
(http://mospi.nic.in/Mospi_New/upload/mdg_2014_28jan14.pdf)HIV
infections have declined by 56 per cent during the last decade from
2.7 lakh in 2000 to 1.2 lakh in 2009 in our country, Indian Health
and Family Welfare Minister Ghulam Nabi Azad said in the national
capital. This has been possible due to political support at the
highest levels to the various interventions under National AIDS
Control ProgrammeMore than one third of all measles deaths
worldwide (around 56 000 in 2011) are among children in India. With
support from WHO, in November 2010, India launched a massive
polio-style measles vaccination project in 14 high-burden states,
in a three-phase campaign.With two phases of the measles
vaccination campaign completed, and the third phase ongoing, more
than 102 million children in 344 districts have been vaccinated,
achieving between 87% and 90% coverage. (Improving measles control
in India, April 2013, WHO)Mortality of children below five years of
age is declining...Indicator: Under Five Mortality RateThe
Under-Five Mortality Rate (U5MR) is the probability (expressed as a
rate per 1000 live births) of a child born in a specified year
dying before reaching the age of five if subjected to current age
specific mortality rates. In India, U5MR has declined from an
estimated level of 125 in 1990 to 52 in 2012.
Indicator: Infant Mortality RateInfant Mortality Rate (IMR) is
defined as the number of deaths of infants of age less than one
year per thousand live births. In India, the Infant Mortality has
reduced by nearly 50% during 1990- 2012 and the present status is
at 42 per 1000 live births.
As per the historical trend, the IMR is likely to reach 40
deaths per 1000 live births, missing the MDG target of 27 with a
considerable margin. However, as IMR is declining at a sharper rate
in the recent years, the gap between the likely achievement and MDG
target 2015 is set to reduce.Indicator: Proportion of one year old
children immunised against measles. The national level coverage of
the proportion of one-year old (12-23 months) children immunised
against measles has registered an increase from 42.2% in 1992-93 to
74.1% in 2009 (UNICEF &GOI-Coverage Evaluation Survey 2009). At
the historical rate of increase, India is expected cover about 89%
children in the age group 12-23 months for immunisation against
measles by 2015. Thus India is likely to fall short of universal
immunisation of one-year olds against measles by about 11
percentage points in 2015.Maternal Mortality Ratio is declining
faster....Indicator: Maternal Mortality RatioThe Maternal Mortality
Ratio (MMR) is the number of women who die from any cause related
to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or
within 42 days of termination of pregnancy, irrespective of the
duration and site of the pregnancy, per 100,000 live births.
The problem in estimating MMR is due to the comparative rarity
of the event, necessitating a large sample size. However, even with
this constraint, Sample Registration System (SRS) data indicates
India has recorded a deep decline of 45.6%in MMR from 327 in
1999-2001 to 178 in 2010-12 and a fall of about 30% happened during
2006-12.
In addition to Maternal Mortality Ratio (MMR), the Maternal
Mortality Rate (MMRate - Number of maternal deaths in a given
period per 100000 women of reproductive age during the same time
period) and Adult lifetime risk of maternal death (The probability
that a 15-year-old women will die eventually from a maternal cause)
are important statistical measures of maternal mortality.The
maternal mortality rate at all India level has come down from 20.7
in 2004-05 to 12.4 in 2010 -12. At all India level, lifetime risk
declined from 0.7% in 2004-06 to 0.4% 2010-12 and all the major
States have shown decline during this period.Indicator: Proportion
of births attended by skilled health personnelThe institutional
deliveries in India increased from 40.9% in 2002-04(District level
Household Survey) to 72.9% in 2009 (Coverage Evaluation Survey). As
per Coverage Evaluation Survey (CES), 2009, delivery attended by
skilled personnel is 76.2% which was 47.6% as per District level
Household Survey (DLHS-2002-04).Sustaining the declining trend in
prevalence of HIV/ AIDs...The HIV epidemic in India continues to
decline at the national level with an overall reduction in adult
HIV prevalence, HIV incidence (new infections) and AIDS-related
mortality in the country. The latest HIV estimates provide sound
evidence on the current trend of the epidemic. The adult (1549
years) HIV prevalence has decreased from 0.45% in 2002 to 0.27% in
2011. India has demonstrated an overall reduction of 57% in
estimated annual new HIV infections among adult population from
2.74 lakhs in 2000 to 1.16 lakhs in 2011. The trend of annual AIDS
deaths is also showing a steady decline since the roll out of free
Anti-Retroviral Treatment (ART) programme in India in 2004.
India has demonstrated an overall reduction in the estimated
annual new HIV infections (in all age-groups) from 2.96 lakhs in
2000 to 1.30 lakhs in 2011. The estimated annual new HIV infections
among adult (15+ years) population has declined steadily over the
past decade by about 57% from 2.74 lakhs in 2000 to 1.16 lakhs in
2011. Males account for approximately 61% of total new annual HV
infections in 2011 whilst women account for an estimated 39% of
total new HIV infections.Total number of annual AIDS related deaths
in India is declining over the past years. It is estimated that
about 1.48 lakh (1.14 lakhs-1.78 lakhs) people died of AIDS related
causes in 2011 in India. In comparison with the 2.06 lakhs (1.67
lakhs-2.45 lakhs) AIDS related deaths estimated in 2007, this marks
a near 29% reduction in estimated number of AIDS related deaths
during 200711. Deaths among HIV infected children account for 7% of
all AIDS-related deaths.It is estimated that the scale up of free
ART since 2004 has saved cumulatively over 1.5 lakh lives in the
country till 2011by averting deaths due to AIDS-related causes.
With the current scale up of ART services, it is estimated to avert
around 50,00060,000 deaths annually in the next five years.Wider
access to Antiretroviral Therapy (ART) has led to 29% reduction in
estimated annual AIDS-related deaths during NACP-III period
(2007-2011).
(http://mospi.nic.in/Mospi_New/upload/mdg_2014_28jan14.pdf)Improved
Life-ExpectancyStatistics released by the Union ministry of health
and family welfare show that life expectancy in India has gone up
by five years, from 62.3 years for males and 63.9 years for females
in 2001-2005 to 67.3 years and 69.6 years respectively in
2011-2015. Experts attribute this jump higher than that in the
previous decade to better immunization and nutrition, coupled with
prevention and treatment of infectious diseases. The World Health
Organization defines life expectancy as "the average number of
years a person is expected to live on the basis of the current
mortality rates and prevalence distribution of health states in a
population". In India, average life expectancy which used to be
around 42 in 1960, steadily climbed to around 48 in 1980, 58.5 in
1990 and around 62s in 2000.Accredited Social Health
ActivistAccredited social health activists (ASHAs) are community
health workers instituted by the government of India's Ministry of
Health and Family Welfare (MoHFW) as part of the National Rural
Health Mission (NRHM). The mission began in 2005; full
implementation was targeted for 2012. Once fully implemented, there
is to be "an ASHA in every village" in India, a target that
translates into 250,000 ASHAs in 10 states. The grand total number
of Ashas in India was reported in January 2013 to be 863,506.ASHAs
are local women trained to act as health educators and promoters in
their communities. The Indian MoHFW describes them as: ...health
activist(s) in the community who will create awareness on health
and its social determinants and mobilize the community towards
local health planning and increased utilization and accountability
of the existing health services.Their tasks include motivating
women to give birth in hospitals, bringing children to immunization
clinics, encouraging family planning (e.g., surgical
sterilization), treating basic illness and injury with first aid,
keeping demographic records, and improving village sanitation.[5]
ASHAs are also meant to serve as a key communication mechanism
between the healthcare system and rural populations.One of the
success stories being attributed to NRHM is a huge increase in
institutional deliveries. ASHAs (around 7.5 lakh in number) at
grass root level have done a phenomenal job in mobilizing women
from valuable community to come to institutions (the number of
beneficiaries under JSY had increased from 7 lakhs in 2005-2006 to
over 86 lakhs in 2008-2009). It is critical to ensure that there is
corresponding increase in inputs available at the facilities, so
that health outcomes for mother and baby are ensured. There
definitely have been gains as shown by statistics - infant
mortality rate has come down to 53/1000 live births, maternal
mortality rate has come down to 254/1000 live births and total
fertility rate is now 2.7.Mohit SoniHEALTHCARE IN INDIA - 2025At
the turn of this century, health outcomes in India and the quality
of health system in India significantly lagged those of peer
nations and WHO standards. The progress made in the last decade has
been mixed. While substantial ground has been covered, a lot is
still left to be achieved. The government, recognizing the need for
reforms, introduced the 11th and 12th Five - Year - Plan. The
private sector has also played an important role in improving
quality and access to healthcare facilities in India in the last
decade.The situation today is complicated by rising inequality in
healthcare access across states and demographic sections within the
population. It is evident, that a Status Quo approach will be
inadequate to tackle this challenging situation. Indias healthcare
reform will need to operate at a scale never seen before. Almost
all health indicators in India, today, will not meet the objectives
of WHO Millennium Development Goals (MDG) - 2015.Spend of
healthcare by the government will have to increase, infrastructure
gaps will need to be closed, workforce scarcity and utilisation
will have to be addressed. Policies will have to be defined to
begin on this path of inclusive healthcare and Universal Health
Coverage. This will demand active collaboration between the private
and the public sector, with the government taking the initiative.
The journey, started in the last decade, now needs to pick up
momentum to meet the huge demand for affordable yet quality
healthcare. 12th Five Year PlanThis plan, drafted by the Planning
Commission, defines the governments long term strategy for
Healthcare based on the vision of UNIVERSAL HEALTH COVERAGE.It
envisions assured access to a defined essential treatment and
medicines to a large percentage of the population. While Universal
Health Coverage mist be the primary focus, secondary focus has to
be on the efficiency and quality of healthcare.PROBLEMS FACED BY
INDIAN HEALTHCARE SECTOR Shifting Disease Patterns High Costs
Infrastructure Gaps Inadequate Workforce and underutilization of
existing workforce. Inequitable Insurance Cover Rural and Urban
Inequity in terms of facilities available. Lack of holistic
regulatory environment. Childcare and Low Rates of
ImmunizationSTATUS QUO - CANNOT BE MAINTAINEDA status quo approach
will be rendered ineffective due to epidemiological pressures,
burgeoning healthcare demand, existing and growing inequities in
access and delivery and unregulated growth of the sector.1. Gap in
Healthcare Spending: If the current trajectory of spending growth
were to continue, the total healthcare expenditure ll intact drop
from the current 4% GDP to 3.65%GDP by 2022.1. Gap in Healthcare
Infrastructure: At current growth rates, infrastructure will be
unable to keep pace with the demand. India may end up with a bed
density of 1.7 - 1.9 per 1000 people.1. Gap in Healthcare
workforce: As per the Twelfth Five - Year plan, the physician and
nurse density is expected to reach around 0.7 and 1.7 per 1000
people respectively by 2022. Of these, if current utilization
numbers were to be maintained, the active workforce would only be
0.5 and 0.8 per 1000 people respectively.
PROJECTIONS FOR 2025
1. BRIDGING RURAL - URBAN DIVIDE:
Fig 1: Rural India accounts for 50 - 70% of NCDs.In order to
understand the inequity, its magnitude and manifestation across
rural - urban divide and income segments and its alarming
trajectory, we analyse six segments of the population - Urban Rich,
Urban Middle Class, Urban Poor, Rural Rich, Rural Middle Class and
Rural Poor.Rural India also accounts for 70 % of the communicable
diseases.The number of hospital beds in Urban India is twice as
much as those in Rural India.Healthcare in India also has a vast
regional inequity. (Eg: There were 533 people per government bed in
Arunachal Pradesh in 2008. The same figure for Jharkhand was 5494
people per government bed.)In order to bridge this growing inequity
and meet WHO Bed Density standards, India must target a bed density
of 1-1.2 per 1000 people by 2022. Rural Medical Practitioners and
AYUSH [1] workers should be drafted into mainstream healthcare
sector. Programs like NRHM / ASHA / Janani Suraksha Yojana [2] must
be scaled up and promoted. 2. MUCH IMPROVED FINANCIAL ACCESSS:At
least 75 % of the population should be insured.(Assuming 100 %
coverage for poor population and 60 % coverage for the middle
class). The remaining should receive free healthcare through
government schemes and public provisioning like RSBY [3].
3.OVERCOMING WORKFORCE SHORTAGE:By 2022, India should aim for
for a doctor and nurse density of 0.7 and 1.7 per 1000 people. For
this to happen unto 90% of the registered practitioners will need
to practise.4. INFRASTRUCTURE GAPS TO BE FILLED:Infrastructure
would need to scale up with increased utilisation reaching an
overall bed density around 2.1 per 1000 people including 1 -1.2
beds per 1000 people in rural areas and 3.8 - 4.2 beds per 1000
people in urban areas.Fig 2: Infrastructure requirement by 2022 -
Bed Density
5.REDUCING OUT OF POCKET(OOP) EXPENDITURE AND INCREASING
EXPENDITURE ON HEALTHCARE:In order to achieve the desired financial
access and build the desired level of infrastructure, total
spending will need to be at 5.5% of the GDP, up from the current
4%. OOP spend will also need to come down from the current 61% to
23%. This would require 17,00,000 to 21,00,000 crores investment by
2022.
Fig 3: Total Healthcare Expenditure (THE) and OOP share by
2022.6. CATERING TO A HIGHER DEMAND:Hospitalizations are expected
to rise from the current 4.8 per 100 people to 6.5 per 100 people.
The healthcare facilities need to be scaled up with this in mind.7.
BETTER HEALTH INDICATORS:The Infant Mortality Rate (IMR)[4] and
Maternal Mortality Rate (MMR)[5] have to be reduced to 25 and 100
respectively, in order to meet the MDG. Along with this, India has
to aim for universal immunization.Apart from the above-mentioned
points, quality of healthcare needs to be in focus, enabled by an
effective regulatory system. This framework will need to include
legislation for standardisation of treatment practices, clinical
establishments and malpractice mitigation. Diagnostics, trauma care
and emergency care also need to be scaled up to meet the increasing
demand. Diagnosis of chronic and Non Communicable Diseases (NCD)
will have to be more in line with that of developed countries. An
effective awareness and health education program can also reduce
the NCD burden. SOME CHANGES TAKING PLACE Electronic Health Records
(EHR) : Hospitals and patients are maintaining EHR, which can be
stored and analysed for trends. This is helping improve integration
of primary and tertiary healthcare services (eg : referrals from
one hospital to another)
Tele Medicine and Next Gen Diagnostics:To combat the low density
of primary healthcare centers and doctors in rural and remote
areas, small community centers are being set up. Patients and
doctors can interact via Video Conference.There is an increased
demand for home based diagnostic and monitoring devices. These
devices can measure Blood Glucose Levels, ECG, etc and transmit the
results to the physician. This is reducing the cost of diagnostics
and making facilities available in remote areas.The government will
need to play the lead role to drive Indias healthcare
transformation journey. It will need to make an important choice
with regards to its primary role - as a provider or payor. India
can learn immensely from the healthcare reforms of peer countries
like Thailand, Brazil and South Korea over the last 4 decades.A few
areas, highlighted earlier, will merit joint action by the
government and the private sector. The reform journey, initiated in
the last 10 years, now needs to gain momentum. What peer nations
achieved across 3-4 decades needs to be achieved in much lesser
time. Therein lies the importance of the next decade.
Chinmay JoshiRecommendationsFor any country, healthcare
facilities play an extremely important role in the development of
the country. In modern Human Development Index, health is
considered to be an extremely important factor. In case of
developing countries, the role of government in the provision of
the medical and healthcare facilities is all the more important as
the large concentration of poor may be exploited by the private
sector.A look at Indian healthcare related data tells you about the
dismal state that public health services are in India. We start by
looking at the vulnerabilities in the Indian public health system
which need to be targeted for significant improvement.Important
Targets Lack of Government Expenditure Historically, Indian
governments expenditure in health sector has been abysmally low.
This results in high OOP (Out of Pocket) expenditure by the people
which forces millions of people below poverty line. A stable public
health structure is a necessity of a developing nation and poor
medical services can cripple the nation economically. The
government expenditure will have to increase significantly in the
right direction to improve the current affairs of the system. Lack
of Primary Care There are huge number of cases, especially in rural
India where there are large number of deaths due to female
foeticide and infanticide as well as inadequate nutrition for
mother and newborn child. The situation is not improving much and
infant & maternal mortality has been huge in India. This has a
lot of causes which are lack of education, resources in the rural
areas, improper government expenditure but more importantly,
healthcare facilities for women & children have to improve.
Lack of Sanitation facilities The lack of sanitation facilities is
a widely recognized problem in our country which has several times
led to epidemics in some parts. There is severe scarcity of clear
drinking water and many diseases like diarrhea, typhoid, cholera
etc. These are basic amenities which have to be provided and any
kind of action that is supposed to be taken in public health has to
focus on this aspect. Lack of Human Resources Again, this is a
widely recognized problem in our country that in rural areas, there
is a severe lack of human resources in the medical sector. Despite
being one of the countries with premier medical institutes, India
has been unable to cater to the demand of its humongous population.
A large number of doctors, nurses and medical professionals are
added to the workforce but the numbers are highly unevenly
distributed and there is a domino effect of medical professionals
moving to urban India.The above mentioned vulnerabilities can be
viewed as problems but importantly, we must realize that these
problems are not the causes of the terrible state of Indias public
health but the results or rather more of indicators and the
solutions should be aimed at improving these indicators.
Suggested Solutions While we try to look for solutions and
actions to improve the present condition of Indias healthcare
facilities, we must realize that any true solution that provides
significant improvement will take a large amount of time and
expenditure. We, therefore, try to look out for both long-term as
well as short-term solutions.Long Term Action - Concerted &
Integrated Public Healthcare and Medical Service Program If we
compare Indian public healthcare system to other developing
countries, we realize that India is doing considerably bad. A
closer look at the Indian system reveals that major cause of such a
poor state is the original ideology of the Indian government with
which it has tried to implement health programs. The central
government has, generally, mixed up public health care and medical
services and focused heavily on single-issue health programs.
Although, this intermingling of medical and health services was
intended to improve coordination between various different
services, it ended up marginalizing public health services. The
program that had intended to eradicate polio was extremely
successful and the government of India boasts of complete
eradication of polio as a disease. Unfortunately, the examples of
such successful programs arent many and this focus on single-issue
programs has led to concentration of resources on some important
diseases and disallowed the development of an integrated public
health care system that proactively delivers wide range of services
including medical services as well as implementation of sanitary
regulations. Instead, with the single-issue programs doctors
several times end up treating patients who should not have been ill
at the first place.Many countries like Bangladesh and Thailand have
such robust and strong health care programs which continue to
deliver medical goods to their public. In India, Tamil Nadu has a
strong public health and medical structure and we analyze that.In
the state health department, there are three separate directorates
under the health secretary namely, the Directorate of Public
Health, of Medical services, and of Medical Education. This is the
cornerstone of the structure as the separate directorates enjoy the
freedom of planning and policy making in their respective
departments. The directorates have separate and significant budgets
which enable them to all the activities related to the
implementation of their policies. Also, the separate budget helps
them in maintaining a trained, experienced and dedicated taskforce
which includes not only managerial and grassroots level workers but
also, a range of technical staff. This healthcare structure is
legalized by the legislative assembly in the state. This gives
considerable power to the health officers in the state so that they
can act to any kind of complaint regarding to any activity that
threatens to jeopardize the environment. In our country, we badly
need such a structure of health system that proactively caters to
the demand of the public. Such a system will not only provide
stable medical services, but also provide healthcare services such
as vaccinations, regular check-up camps, health awareness campaigns
etc. This kind of a system will require dedicated funding and
sincere efforts, and no doubt this will take time to build but only
such a system can truly provide to improve the level of health of a
nation.Short Term Solutions It will some amount of dedicated
efforts to build the above mentioned system and more importantly,
it will require significant amount of time. Therefore, to tackle
immediate problems there would be a pressing need for efficient and
available short term solutions.Health Insurance Schemes Health
Insurance schemes are ingenious in providing security cover to the
people. The objective, in this case, would be reduce the OOP
expenditure and provide security in terms of healthcare. People,
especially in Urban Areas, are opting for private insurance schemes
which provide them security cover from various diseases. Indian
government has launched its own health insurance scheme, namely,
RSBY (Rashtriya Swasthya Bima Yojna) which has successfully
provided cover to around 11 crore BPL people. This program has won
accolades from WB as well as WHO and can be extended to provide
some kind of subsidized health insurance to the
people.Public-Private Partnership Public-Private Partnerships (PPP)
are contract-based joint ventures where the private party provides
for the services and the cost is borne out by the government. In
health sector, PPPs can be used extremely efficiently as short term
measures. While the private sector should be able to provide
excellent quality and best modern practices for patients, the
government can also use it as an opportunity to monitor and
regulate the practices in the medical services provided by the
private sector. This would not only provide efficient service to
the patient but also, widen the reach of such facilities. It should
be noted that the key objective again is to reduce the out of
pocket expense and provide good quality medical facilities.The
above mentioned short term solutions have been in place for some
time now and are developing on the way. They have their own
importance because of the time frame. But we need to realize that
the long-term solution is of primary importance and if we keep
taking the shorter route, there will not be significant improvement
in the health status of the nation.
References Public Private Partnerships for Healthcare in India,
B. Birla, U. Taneja, The Internet Journal of World Health and
Societal Politics, 2008 Volume 7 Public-Private Partnership in
Health Care: Contexts, Models and Lessons, A. Venkat Raman, Faculty
of Management Studies, University of Delhi,
http://www.who.int/global_health_histories/seminars/Raman_presentation.pdf
The Early Success of Indias Health Insurance for the poor, RSBY,
Victoria Fan, 6/10/13, Center for Global Development The state of
healthcare in India is dismal: Amartya Sen, Nirmalya Dutta, The
Health Site,
http://health.india.com/healthcare/the-state-of-healthcare-in-india-is-dismal-amartya-sen/
Five Ways to Improve Indian Healthcare, Tripti Lahiri, 19/12/2011,
The Wall Street Journal How to Improve Public Health Systems
Lessons from Tamil Nadu, Monica Das Gupta, B. R. Desikachari, T.V.
Somnathan, P. Padmanaban, The World Bank, Development Research
Group HealthCare Financing Reforms in India, M. Govinda Rao, Mita
Choudhury, March 2012, National Institute of Public Finance and
Policy[1]:http://en.wikipedia.org/wiki/Department_of_Ayurveda,_Yoga_and_Naturopathy,_Unani,_Siddha_and_Homoeopathy[2]
:
http://en.wikipedia.org/wiki/Janani_Suraksha_Yojana_(India)http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/janani-suraksha-yojana/background.html[3
: http://en.wikipedia.org/wiki/Rashtriya_Swasthya_Bima_Yojana[4]:
http://en.wikipedia.org/wiki/Infant_mortality[5]:
http://en.wikipedia.org/wiki/Maternal_death McKinsey and Company,
India - India Healthcare Inspiring Possibilities and Challenging
Journey India - An uncertain Glory - Jean Drze and Amartya Sen WHO
World Health Statistics, 2012
http://timesofindia.indiatimes.com/india/India-WHOs-SE-Asia-now-polio-free/articleshow/32790183.cmshttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/From_India_Achievement_Lessons_Learned_and_Hope(Sharp
drop in HIV cases in India, Xinhua, 16th August, 2012, The
Hndu)http://www.dailymail.co.uk/indiahome/indianews/article-2425853/Indian-scientists-make-dengue-vaccine-breakthrough-early-trials-creates-robust-immunity.htmlhttp://indiatoday.intoday.in/story/scientists-at-icgeb-develop-dengue-vaccine-from-pichia-pastoris-yeast/1/310642.htmlhttp://www.thehindu.com/sci-tech/health/medicine-and-research/india-unveils-first-indigenous-rotavirus-vaccine/article4714757.ecehttp://timesofindia.indiatimes.com/india/Now-a-desi-rotavirus-vaccine/articleshow/20058187.cmswww.dnaindia.com/world/report-indian-scientists-develop-japanese-encephalitis-vaccine-1898431http://www.thehindu.com/news/national/india-launches-vaccine-to-prevent-japanese-encephalitis/article5201813.ecehttp://world.time.com/2013/01/13/how-india-fought-polio-and-won/http://pib.nic.in/newsite/erelease.aspx?relid=99873http://www.un.org/millenniumgoals/http://www.healthissuesindia.com/infectious-diseases/https://www.icicilombard.com/health_insurance_info/Knowing-top-10-killer-death-diseases-in-India.htmlhttp://indiatoday.intoday.in/story/India%27s+no.1+killer:+Heart+disease/1/92422.htmlhttp://www.worldlifeexpectancy.com/news/india-vs-china-top-10-causes-of-deathhttp://timesofindia.indiatimes.com/india/Life-expectancy-in-India-goes-up-by-5-years-in-a-decade/articleshow/29513964.cmshttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/keyword/poliohttp://www.jhsph.edu/research/centers-and-institutes/ivac/IVACBlog/The_Road_to_Conquering_Polio_A_Major_Milestonehttp://www.indexmundi.com/facts/india/mortality-rate
Jennifer G. ,Taylo D., Health and Health Care in India, UCL school
of Pharmacy Jacob J. T., Dandona L.,Sharma P. V., Kakkar M.,India:
Towards Universal Health Coverage: Continuing challenge of
infectious diseases in India, Lancet 2011, Gudwani A.,Mitra P.,Puri
A. Vaidya M., India Healthcare: Inspiring Possibilities,
Challenging Journey ,McKinsey & Company ,December 2012
Tuberculosis Challenges for India, Policy brief series: No.12: 2011
February-March, http://www.clraindia.org/include/TBbriefnew.pdf
Innovating Around Indias Health Care Challenges, Health Economics,
29 July 2010,
http://knowledge.wharton.upenn.edu/article/innovating-around-indias-health-care-challenges/
Kapur A., Economic analysis of diabetes care, March 2007,
http://icmr.nic.in/ijmr/2007/march/0319.pdf India and the fight
against cancer,
http://www.moneycontrol.com/gestepahead/article.php?id=965373 Price
Water House Coopers (PWC), Health care in India Emerging Market
Report, 2007. Jennifer G. ,Taylor D., Health and Health Care in
India, UCL school of Pharmacy. Balarajan Y,Selvaraj S &
Subramanian SV (2011) Healthcare and equity in India. The Lancet
377, 505-15. McKinsey & Company, India Healthcare: Inspiring
Possibilities, Challenging Journey, Healthcare Systems and
Services, December 2012. Kannan, R. (2013, July 30). More People
opting for Private Healthcare. The Hindu. KPMG, The Indian
Pharmaceutical Industry Collaboration for Growth, 2006.
.