Act now: Open letter to the health minister of India

This piece has been co-written by Dr Edmond Fernandes and Dr Rajan Dubey.

 |  Breaking views  |   Long-form |   12-01-2016
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Dear JP Nadda,

Hope this finds you in a good health. Wishing a Happy 2016 to you and your ministry. 

Sir, we are all but compelled to write and bring a bitter truth to your attention.

We are living in times where the rest of the world has embraced public health fully, systematically and as one of their ultimate state goals.

As a nation, the dream - that we would to rise to the occasion and change the fortunes of men and women nursing great hope and enterprise - hasn't yet materialised. Rather, it has been summarily sidelined, if the dismal condition of healthcare in our country is anything to go by.

Sir, you would agree that India's spending (in terms of the fraction of its GDP) on healthcare is abysmally low and is crying out loud for help. While the rich can look forward to the private sector to address their health needs, it is the poor, the neglected, the downtrodden and the marginalised amongst us who suffer and bear the brunt of an inadequate healthcare system. Why should they be left to live on the mercy of the Almighty? This neglect especially holds true for the allocation of budgetary weightage for a sizeable number of our staggering population.

Another problem this country is facing is this: a United Nations report has projected India's population to reach 1.45 billion by 2028, making it the world's most populous nation, surpassing China. Further, India will also be faced with the challenge of having 168 million people in the "geriatric age group" by 2026, needing extra effort and funds to care for our old.

If India is to leverage its demographic dividend, then it is imperative that it nurtures a healthier population.

Life doesn't count for much unless we are willing to make the world a little better and healthier than what we inherited as children. But the irony is that our government hospitals continue to be poorly funded and utterly mismanaged, often being cockroach-infested, often making do with rotting infrastructure.

The tragic incidents at Bilaspur, Chhattisgarh, Badwani, Madhya Pradesh as well as the rising number of infant deaths in derelict hospitals of West Bengal and Odisha present a shoddy picture of what exists on the ground. Even the medical facilities in the national capital are no exception in many ways.

Health minister, have you formed any group to delve into the future of healthcare, to make it both affordable and effective? Has the government engaged the stakeholders - such as doctors, medical students, post-graduates, nurses, public health experts, physiotherapists, lab technicians, dentists and others - to bring about innovation in the sector?

It is highly unlikely that you have.

We are equally passionate about this country and about protecting its people as you might be.

But because you occupy the highest office for healthcare in India, great responsibility rests on your shoulders.

Nevertheless, it is always kind to remember to reach out to people beyond New Delhi's posh avenues.

Our public health sector is begging for reforms and is in dire need of healing. But there is absolutely no initiative in this direction.

Beyond sloganeering, can we grow intellectually and take our brothers and sisters along the way to keep them healthy?

We are proud Indians not because of the times we live in, but because what our country has grown from what it was to what it is, and we have the hope to what we can make it into. But it is time to act because rhetoric will not further the cause of public health.

What is of bigger concern is that India is estimated to lose USD 4.8 trillion between 2012 and 2030 due to non-communicable diseases. It is, therefore, critical for India to transform its healthcare sector.

Currently, we see communicable diseases still taking a massive toll on our population. On the other hand, healthcare is traditionally seen as a social sector in India, with less government focus and low budgetary allocation.

India currently spends cumulatively 4.2 per cent of its GDP on healthcare, with just 1 per cent being contributed by the public sector, amongst the lowest globally.

We need to ask ourselves what kind of India we seek to give to coming generations and citizens of the future.

Health minister, we are pained to write that your government, instead of expanding the scope of public investment in the decrepit sector, has, in fact, ordered a 20 per cent cut in healthcare budget citing "fiscal strain". Do you realise at what immense risk you have put major disease control initiatives in a country where public health spending is mainly intended to cater to the poor?

What kind of justification can you offer for such a step to millions of our below poverty line citizens who continue to die from common and utterly treatable diseases?

India has been branded the "most depressed country in the world" by World Health Organisation (as per authentic data). Our social value systems are rapidly depleting, aggravating mental health problems.

The elderly are left to fend for themselves. Maternal health is still neglected. Out-of-pocket spending to get quality healthcare is pushing many families to the brink of devastation. In addition, millions are silently dying on the roads, while another set of millions are facing disaster after natural disaster, with only NDRF as an isolated force fighting a losing battle every time.

Two main reasons healthcare sees market failure and therefore necessitates state intervention are one, presence of externalities and two, information asymmetries.

India spends approximately one per cent of its GDP on public health as compared to 3 per cent of China and 8.3 of USA. It was hoped that the current prime minister would upgrade the basic health infrastructure with the kind of promise and slogans he made before the Lok Sabha elections, but sadly the issue is deeply sidelined as a non-priority item in his nation-building agenda.

We further wish to tell you that the Union health ministry is completely on ventilator support and needs radical surgery. We have high hopes from your august office that you would seriously ponder on this important and urgent matter.

It is the right of every Indian to get quality healthcare at their very doorsteps.

In the light of the above submission, we recommend the following with immediate priority to bail India out of the ailing and ageing public health crisis:

1.    Revival of ESIC and conversion of it in National ESIC, manned and managed by National medical services

2.    Mandatory ESIC for all public and private sectors below Rs. 45,000.

3.    Indian government should allocate a mandatory minimum of 3 per cent of GDP on health.

4.    Finance ministry cannot dictate terms on health services. Make it separate from regular budgetary process. We demand separate health budget just like railways.

5.     Kindly ensure that India's out-of-pocket expenditure on health is not more than 35 per cent in next three years, and we will tell you how to do it, if you need help.

6.    We demand a mix of tax-based system financing for primary and secondary comprehensive services packages.

7.    We demand tertiary care by an insurance-based system.

8.    We demand all allopathic doctors in national and state systems to be paid at-par with UPSC Grade 1 services, non-reservation-based entry and promotion for all doctors in national health system to   "Indian Medical Services". UPSC will not conduct these services. We need a separate board to select and conduct recruitment of doctors like DNB.

9.    We want revival of MCI with engagement of younger doctors who bring reforms to the table and direct control of MCI over SMC's across states. MCI will grow only when we have a cocktail mix of the older and the younger medical practitioners talking to each other and not otherwise.

10.    We need special efforts and finance scheme to fund doctors to bring state of the art facilities and to give emphasis on bringing back doctors from USA and Europe to India.

11.    We want PHCs to be manned and managed by BSC and MSC nursing staff and 2-3 medical doctors. Females need to be provided with round-the-clock security and surveillance under information to the superintendent of police.

12.    We demand change in staffing and recruiting policies in states.

13.    We demand government of India recruits "family welfare staff" and use them to shape India's crumbling family bonds and ties.

14.    We demand nursing cadre to be linked for promotions and MSC nursing to get better opportunities in public health system.

15.    We demand fully integrated IT systems in all medical colleges of India.

16.    We demand a stipend of minimum Rs 50,000 to all medical postgraduates across all medical colleges in India, both in private and government irrespective of the year of study, state of study and caste or religion.

17.    We want government to acknowledge services of doctors to community and give plan to improve their security in working places besides upgrading crumbling infrastructure.

18.    Paramedical staff should be given better trainings and their institutes in government sector to improve in infrastructure and quality.

19.    Triple the funds to all government medical colleges of India from the current level.

20.    Divert all CSR allocations for the next 15 years mandatorily on health systems and social determinants of health.

21.    Ensure easy loan services for health and paramedical services students across India by special schemes.

22.    Increase number of PG seats by at least four times the current intake. Government medical colleges should have six-monthly intake of PG seats.

It is with great hope that you will respond to this public letter, especially for those millions to whom this letter may not reach in spite of the government's tireless promotion of Digital India.

Can we make in India a world class healthcare system? For those Indians who fall through the cracks in our crumbling infrastructure, but who look forward to that mountain-moving faith in democracy?

We hope an enlightened government and an enlightened opposition will feel the need to act now. We will be more than willing to help shape this dream.

Medically yours,

Dr Edmond Fernandes and Dr Rajan Dubey,

Proud Citizens of the Republic of India.

[We can be reached at dredmond@edmond.in and dubeyrajan@gmail.com ]

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