India is the second most populous country on Earth, the largest democracy in the world, and it has one of the most rapidly growing economies on the planet. The largest impediment to India continuing along this economic trajectory and becoming a dominant world power is the poor health outcomes of much of its population.
India ranks 119 out of 169 countries on the human development index, a measure of the health of populations.
There are 400 million Indians living in extreme poverty. The infant mortality rate is abysmal: 1.7 million children die annually before the age of 1, many of preventable and treatable diarrheal diseases. Fewer than half of the children are fully immunized. Only two other countries in the world have more cases of HIV-AIDS than India.
But the situation is changing, and quite rapidly.
India has effectively wiped out polio, a once unthinkable achievement. It’s a sign that the ravages of infectious disease are being taken seriously. It should result in massive health gains.
In recent years, national and state governments have made tackling health inequities a priority, and it hasn’t been just empty rhetoric.
For example, the massive investments made in primary care to deal with polio will pay enormous dividends. Just last week, India announced a plan to provide essential medications free to the population.
Much of the media attention focused on one aspect: that only generic drugs (not brand-name ones) will be included in the plan. But much more noteworthy is that the drug plan is rolling out immediately and more than half the population should have pharmacare within five years.
The drug plan is just the first step toward universal health care, something India hopes to have in place by 2020.
Last year, the medical journal The Lancet published a series of 16 papers examining the benefits and impediments to universality and culminating with a call to action that included a detailed timetable for action. That was followed by a high-profile conference, which drafted the Kolkata Declaration, demanding a publicly funded universal health-care system.
Politicians are paying attention. In his Independence Day address, the Prime Minister promised to double public spending on health care, to 2.5 per cent of gross domestic product from the current 1.2 per cent.
About 50 countries in the world have universal health-care programs. India is looking to join their ranks, but we should not underestimate how difficult that will be.
Currently, it has one of the most fragmented and commercialized health-care systems in the world. The chasm between rich and poor is enormous: There is world-class health care available to those with money (and increasingly popular with health tourists from Western countries) but unregulated health services of shameful quality for the poor.
Because there is not much of a health-insurance system, out-of-pocket spending is the norm. About 80 per cent of all health costs in India are paid out-of-pocket, and less than 20 per cent provided publicly. (In Canada, the split is 70 per cent public funding and 30 per cent private, most of that paid with insurance.)
Universal health care is not a new goal for India. Even before independence in 1947, the Bhore Committee report recommended a national system for preventive and curative health care, and similar recommendations were made by the Mudaliar Commission in 1966.
The difference today is that, with its booming economy, India can no longer plead poverty. And the increasingly educated and economically empowered population is more demanding.
A study, published in the journal Public Library of Science One, estimated that universal health care would cost only $48 (U.S.) per capita, and governments would have to increase public spending to only 3.8 per cent of GDP. (Public health spending accounts for about 8 per cent of GDP in Canada.)
A task force commissioned by the federal government to develop a framework for universal health care recommended that a basic package of services be made available to all and citizens have the ability to purchase this insurance from either public or private providers.
This is essentially the model used in many European countries. However, the expert group also recommended that taxation be used as the principal method of financing and that there be no user fees, which is more in line with the Canadian model.
These details will be worked out with time.
The essential point is that a country with a population of 1.2 billion implementing universal health care would be – and will be – a dramatic development for global health.
It is a move that Canada should greet with a mixture of enthusiasm and shame.
Enthusiasm because this country’s medicare system has served as an inspiration and a model. But we should be ashamed that, while countries like India are boldly forging ahead, we have rested on our laurels and allowed our system to stagnate.
For example, Canada has been talking about national pharmacare for decades. There has been little action and an endless litany of excuses, foremost that the constitutional division of powers is an impediment.
It’s hard to imagine that our constitutional quirks are harder to overcome than the complex regional, religious and political divisions in India.
Yet India is forging ahead with fundamental health reform to ensure a healthy population and a healthier economy, while Canada continues to futz around.