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| Speakers in the inaugural session: (L to R) Ranjit Shahani, Dr K Srinath Reddy, Dr Nata Menabde, Dilsher Singh Kalha, Tapan Ray |
Stakeholders from across the healthcare spectrum, spanning pharmaceutical companies and healthcare institutions, WHO as well as Government of India representatives met on a common platform at a recent Conclave on ‘Improving Access, Innovation and Reach of Healthcare in India’ organised by the Organisation of Pharmaceutical Producers of India.
Speaking about the first aspect, Tapan Ray, Director-General, OPPI reminded the gathering that access to healthcare comprises not just medicines, but more importantly a robust healthcare infrastructure including, doctors, paramedics, diagnostics, health centres and hospitals. In India the demand for these services has outstripped supply but the key focus of the Government has still remained primarily on access to medicines.
Ray commented that there are about 40 health insurance schemes active in the country today, but all of them focus on hospital care; none of them cover domiciliary medical expenses or loss of livelihood due to ill health.
He stressed that there is an urgent need to have a holistic approach in developing adequate healthcare infrastructure, efficient delivery system for medical supplies and creation of a talent pool of healthcare professionals/paramedics to ensure adequate access to healthcare for all the citizens of the country. Ray spoke about a study undertaken by OPPI on ‘Enhancing Healthcare Access in India’, which aims at identifying the key barriers in accessing healthcare today, what needs to be done to eliminate these barriers and develop a roadmap for improving healthcare access in the country.
Moving on to innovation, the second aspect, Ranjit Shahani, President, OPPI and Vice Chairman and MD, Novartis India, commented that access to healthcare has to be considered in context to mortality rates and disease burden. As global population is growing, the disease burden due to non-communicable diseases (NCDs) is growing fast, especially in poor income segments. This is in addition to the burden of communicable diseases, which remains a concern even though it is shrinking. This leads to the vicious circle of poverty and health.
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| Final panel discussion discussing the way forward: (L to R) Bart Janssens, Partner & Director, Boston Consulting Group; Ajit Mahadevan, Partner, Life Sciences, Ernst & Young, Moderator- K G Ananthakrishnan, Dr Rohit Shetty and Anil Varma |
While life expectancy has more than doubled over the last century, the quality of life has not increased. Shahani mentioned how the developing world suffers the most, with nearly 10 million children dying before they reach their fifth birthday and 500,000 women succumbing to preventable illnesses during pregnancy and due to complications during childbirth. The unfortunate irony is that low-cost interventions are available that could prevent at least two-thirds of these deaths. Comparing the top risk factors leading to disease, disability or death, Shahani quoted a report in The Lancet, which pointed out that in the developed countries, tobacco and high cholesterol topped the list, while both these factors were at the bottom of the list for the poorest countries. These countries grappled with another set of issues, centred around deficiency of key nutrition elements like iron, zinc and Vitamin A and sanitation issues. Making the point that the state of poverty is related to the state of health, he showed a clear correlation between a country’s GDP and healthcare spend.
According to him, access to healthcare had three fronts to it: find new and better treatments, making treatments available and finally, improving healthcare infrastructure.
On the first front, he said, “Research-based pharma companies have a long legacy of corporate responsibility in India, with countless contributions to the improvement of health outcomes in the country. We are working every day around the clock to find new treatments and cures for society’s greatest health problems.”
On the second step, he mentioned business practices like differential / innovative pricing, donations, research and development investments for tropical diseases as well as support for broader health and development goals. He projected that by improving access to vaccines, up to 10.5 million lives could be saved every year worldwide; four million in Africa and South-East Asia alone.
Nearing the end of his presentation, he posed a provocative query: Are the poor the wards of the state or of pharma companies and hospitals? While collaborative partnerships are essential to success, Shahani stressed that the primary role of pharma companies is to develop and market high quality medicines for medical needs. While multiple stakeholders need to come together to improve access, one of the key members is the Government. Partners such as UN agencies, NGOs and others also play a meaningful role with expertise and resources.
Committed to improving health indices …
Speaking on behalf of the Government, Dilsher Singh Kalha, Secretary, Department of Pharmaceuticals, Government of India admitted that the healthcare sector in India currently reflected a lack of inclusiveness. Replying to Shahani’s poser, he said the poor were the ‘wards of the state’ and while it could be agreed that the health indices could be better, he sought to correct the impression that the “Government had been sleeping”. Government systems have their inefficiencies, partly due to the multiple departments involved, and he admitted that this reality causes motivation levels to decrease.
He spoke about the challenges presented by the wide geographical spread of the country, stressing that even if there is access, affordability remains an issue. “There have been efforts (like the National Rural Health Mission (NRHM)) and there have been results. No efforts have been spared,” he said.
According to him, NRHM was a good effort as the idea was to go the grassroots but he admitted that “we need to focus on preventive healthcare”.
On the drug pricing policy, Kalha gave an assurance that the Government would balance industry concerns with public health concerns, ensuring that at least the essential medicines would be affordable to the poorer sections. “I am aware that most of the industry makes efforts (to make available affordable medicines)” but he stressed that these efforts need to be enhanced.
Kalha stressed that with health being one of the focus areas of the 12th Five Year Plan, the Government has adopted a more holistic approach, looking at what could be the other barriers beyond drug prices, which could involve other sectors like education, sanitation, nutrition, etc.
… as also financial protection and improving efficiency
Building on the perspective provided by Kalha, Dr (Ms) Nata Menabde, WHO-India Representative, agreed that access goes beyond the health sector, but cautioned that it was premature to wait for improvement in these sectors; the health sector must improve independent of these.
According to her, improving health indices is not enough; financial protection and improving efficiency is as important. Expanding this point, she said, “If the government provides effective financing to deliver services to people in a responsive way, ensures fair regulation and provides the necessary manpower, the performance will dramatically improve regarding easier access to facilities, better quality of services and higher system efficiency. This will ultimately contribute towards improved population health.” Besides financing, she stressed that governance matters and the industry needed to see policy changes from the government’s end.
While pharma companies in India are key suppliers of affordable medicines, ensuring consistent quality is a key aspect. For instance, the UN’s global polio vaccination programme was severely impacted when an India-based supplier had to withdraw its oral polio vaccines from the WHO’s list of pre-qualified vaccines, as the facility where the vaccine was being made needed further corrective actions after a WHO assessment of its quality management system. Menabde cautioned that quality of medicines has to be reliable and consistent.
Alluding to current policy issues like the pharma policy, being debated, she was of the opinion that while reasonable compromises have to be made so that the end concern is met, it cannot be looked at solely from a profit margin issue.
Highlighting the need for Universal Health Coverage in India, Dr K Srinath Reddy, President, Public Health Foundation of India said, “The journey towards a better healthcare system in India has begun with the Prime Minister announcing 12th Five Year Plan as the Plan for Health. The proposed increase in public expenditures on health from the current level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the 12th plan, and to at least three per cent of GDP in the 13th Plan is a step closer towards realising the universal healthcare coverage 2022 vision that seeks to entitle universal health entitlement to every citizen, guarantee access to an essential health package and integrate health care delivery.”
Giving the keynote address, Reddy quoted Gunnar Myrdal, the Swedish economist and Nobel Laureate: Health leaps out of science and draws nourishment from the society around it.
He chose this quote to underline the connection between health, science and society, a connection that unfortunately seems to be lacking in India. He pointed out that while the country’s founding fathers had a vision for Universal Health Care (UHC) way back in 1947, we have been overtaken by many smaller nations; for instance, Sri Lanka achieved UHC in 1950.
 Dr Shailesh AyyangarMD, India & VP, South Asia, Sanofi India |
Citing more statistics, Reddy said that our current public funding of health is 1.2 per cent, lagging Sri Lanka’s 1.8 per cent, Thailand’s 3.3 per cent and China’s 2.3 per cent. Today our nation has the largest number of underweight children (42 per cent under five years). And with a current infant mortality rate (IMR) of 47 per 1000 live births and a maternal mortality ratio (MMR) of 212 per 100000 live births, Reddy predicted that it will be a challenge to meet national goals of 27 per 1000 (IMR) or 100 per 100000 (MMR) by 2017.
The HLEG’s report has since been forwarded to the state governments but sources suspect that not many state health ministers have got around to reading the 300+ pages report, much less actioning or at least deliberating on the recommendations. Or is it that many of the recommendations make them uneasy?
Reddy summarised some of the recommendations in a report prepared by a High Level Expert Group (HLEG) on Universal Healthcare (UHC), of which he is the chair. For example, as part of the road map towards achieving UHC, the HLEG report suggests that all existing schemes need extensive review and may need to be brought under a central umbrella. Indeed, Reddy points out that many countries, most notably the US and UK, are cutting back or rationalising healthcare schemes that have become debt traps.
 Kewal HandaMD, Pfizer |
The Rashtriya Swasthya Bima Yojana (RSYB), Rajiv Arogyasri of Andhra Pradesh and Tamil Nadu Health Insurance Schemes, which were indeed pioneering efforts at the time they were launched, are running out of steam (as well as funds). For example, the RSBY has become non-viable as claims have outstripped premia and the public sector insurer is reportedly threatening to walk out of the scheme if premia are not increased.
Reddy also quoted from reports that schemes like the Rashtriya Swasthya Bima Yojana, Rajiv Arogyasri of Andhra Pradesh and Tamil Nadu Health Insurance Schemes do not do what they were supposed to do; i.e. reduce health spend. Studies have proved that health expenditure of poorer sections of households under these government-promoted schemes has actually risen, because such schemes do not cover outpatient care, medicines or lab tests, all of which form a larger slice of the out-of-pocket spend on healthcare.
The inaugural session was followed by sessions taking forward this theme. Dr Shailesh Ayyangar, Managing Director, India and Vice President, South Asia, Sanofi India chaired a session on Improving Access to Healthcare, while Kewal Handa, Managing Director, Pfizer anchored the session on Moving Ahead in the ‘Decade of Innovation’.
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