Make no mistake – the government’s ambitious health care programme Ayushman Bharat for 1.3 billion Indians is a potential game changer. The operative word is potential. Will it succeed? Depends on us. Will it fail? Depends on us. Resource mobilization, scaling and implementation are India’s biggest problems. They need long gestation periods, sweat, passion and tears. There are no instant results here. The biggest stumbling block I see is corruption – of two types. The first one is obvious and is built into every phase from the drawing board to far away dispensaries. It involves money. About the second one, I’ll write in the concluding lines of this piece.
The focus of this post will be on non-communicable diseases (NCDs) that contribute to some 5.90 million deaths (60 per cent) of all deaths from medical causes in India. These diseases include cardiovascular diseases (CVDs), cancers, diabetes, obesity, chronic respiratory diseases (Hello Delhi), musculoskeletal diseases and mental disorders. Statistics in India are not trustworthy for the simple reason that there is shabby maintenance of data barring a few pockets. Irresponsible extrapolation is common practice. This must be corrected poste haste.
The NCD story is interesting. It is the result of a major public health success – that of people living longer. By 2025, it is estimated that life expectancy will be 73 years, an increase of eight years since 1995. While infectious diseases make – Malaria, HIV/AIDS – make headlines, NCDs like diabetes and cancer have emerged as a significant public health threat accounting for 40 million death a year and 72 per cent of all deaths globally. The research pipeline for communicable diseases is almost empty as there’s no financial interest in curing people. Bottom lines are attracted to chronic diseases, as people with an NCD need regular check-ups.
The reason I have decided to write about this aspect of public health is because I live with cancer and I would like to hope that I am an informed patient. Sometimes a careless one but, certainly pretty close to what’s happening in my world of Multiple Myeloma (MM). Gene editing machines are all set to transform the cancer landscape but the treatment, wherever available is exorbitant. There is a robust conversation in India and outside about who pays, patients’ rights as well as the responsibilities of pharmaceutical companies. The debate about Insulin (for treating diabetes) in the United States (US) is the one to watch as it has touched a raw nerve. Patients are posting their jaw-dropping bills on Twitter.
Debates occur when people from all angles raise questions and share stories – the last is critical as it humanises the numbers and drives home the point that it is okay to be faced with a difficult diagnosis and grief shared is grief halved. We learnt in school. Patient’ stories in India must be told and retold.
A growing list of actors in India’s film industry has come out and spoken about their diagnoses whether it be cancer or mental health conditions. A countrywide dialogue is just beginning but it is not quick or deep enough to bring about a public health revolution or even a movement that the country desperately needs. Unless undertaken on a war footing health will drag down all of India’s successes and its development agenda will remain unfinished and diseased.
Like clockwork, NCDs typically hit people in their mid-forties and fifties when they are at their productive best. Major risk factors are unhealthy diets, tobacco use, air pollution, alcohol and lack of physical activity. When I was working at the World Health
Organisation (WHO) in the late nineties, I used to write speeches for the head of the organisation, former Norwegian Prime Minister Dr. Gro Harlem Brundtland and Dr. Derek Yach who was the lead person in the organisation on NCDs and mental health. Sometimes focussed on tobacco control, other times on cancer or CVDs, the speeches and talking points were always framed in the context of the galloping burden of NCDs that would ravage developing countries. India was always on the radar. What were once statistics are now people – friends, family and yours truly.
A major part of the global burden of disease would be addressed if India took a firm grip on its public health issues that ranged from malaria and tuberculosis to NCDs, the experts would discuss. In a short span of ten years India has become the diabetes capital of the world and national and international pharmaceutical companies are fighting it out to corner markets for themselves. Tuberculosis – the most deadly kind – has returned with a vengeance. Non-compliance is part of the problem. The disease burden that shows no signs of slowing casts long shadows on conferences and meetings as if mocking them in a deathly dance.
I dream of the day when the Indian Parliament will come to a halt and not budge until the national health spending is upped to five per cent of the GDP. It is for us, we the people of India, to make that happen. Left to our lawmakers, they would strike work if canteen food prices are raised by ten rupees and argues that most Indians can afford to buy bottled water for Rs. 30. That is the level of debate across most sectors and health if ever, finds a cost-driven and nor rights-driven platform.
Health is a right and it is an investment, not expenditure, as many lawmakers seem to think. Health is also a state subject but judging by events in my state Karnataka, politicians prefer to cool their heels in fancy resorts waiting to be bought like cattle in a bazaar instead of getting along with the work of state and nation building. This, more than anything else, brings shame to India.
There is no need to be needlessly happy that public health guru Bill Gates has welcomed Ayushman Bharat. Nor is there reason to worry, as some critics have done this week saying that the Oxfam report that tells us about the competition between the rich and the super-rich says only 32 per cent of Indians are covered by the new health scheme. Thirty-two per cent is a good start. Of course a 100 per cent would be excellent, but one of the first things you learn when you work in the social sector is that there will never be enough money and resources to meet all needs. Besides, seeking external praise is a sign of deep insecurities.
And now to the other type of corruption that is ethical and intellectual and feeds on money corruption. To those (mainly former bureaucrats, policymakers, academics and some journalists) who find fault with just about everything this government does, how about being constructive in your criticism so we can all participate in nation building? The penny about cleanliness has dropped, so has the need for women to have toilets. People who have always had these facilities and access to more will never understand what it takes to turn a thought process around. Ironically, the naysayers wedded to their privileges are best examples of the very processes they criticize i.e. the failure of others to see their points of view! Some of them have overseen India’s biggest public health scandals and daylight robbery without batting an eyelid because they benefitted. Indeed public-private partnerships have a chequered past, so let us make it better. Health is not about you or me – it is about us. Public health is about going from person to people – let that sink in.
Criticize, question and re-frame Ayushman Bharat so the second draft becomes better than the first – policy work is always work in progress. But calling it predatory or trivialisation of health is to display ignorance, to say the least. To frame it as Modicare – as some disgruntled retired healthocrats are doing - is plain and simple mischievous. The India on the move has little time and even lesser energy for losers.