K M Venkat Narayan: Letter to Prime Minister Narendra Modi—please make the nation’s health an urgent priority

Dear Prime Minister Modi: Congratulations on your impressive victory in the world’s largest election, and best wishes as you take office. Talking to people in my native city of Bangalore, I can sense the palpable excitement and optimism that your win has brought to the youth in India. People are longing for a decisive government that can usher in important policy changes and set the country forward: your emphasis on economic development, affording opportunities to the common man, and eliminating or reducing poverty all resonate very much with the people.

There is one other priority that needs urgent attention: people’s health. This is a critical need, not only because good health is important in its own right, but also because it will help realize the country’s economic and creative potential. A huge advantage that India has today is the “demographic dividend,” with 50% of her population under the age of 25 years. Health should be an important priority to realize the full potential of these young people, and to ensure that they’re not lost from the workforce during the peak of their productivity. Furthermore, with a substantial number of people living longer into ripe old ages, it will be important to keep them healthy, productive, and fulfilled.

Clearly, there will be many demands for health in India, but I want to urge you to attend to four urgent priorities.

1) Invest in, strengthen, and modernize the public health infrastructure. A lot of the determinants of good health reside outside of the healthcare sector, and, indeed, a majority of the impressive gains that the world has achieved in health have come from public health approaches for: better nutrition, hygiene, and sanitation; safe water; a healthy environment; immunization drives; and poverty elimination. India has the mechanisms and the capability to deliver public health, as was very evident by the country’s important contribution to the global eradication of dreaded diseases like smallpox and polio. However, strengthening public health and making it relevant to today’s needs should be an important priority:

Firstly, India needs modern health information systems to measure and monitor the country’s health status in a dynamic manner, and also to guide decisions and investments.

Secondly, a well resourced, strong, and independent central agency is needed for India to strengthen public health, to build the science base, and to connect federal and state level policies and resources for effective action. A model to consider might be the US Centers for Disease Control and Prevention (CDC), which has inspired similar agencies in Europe, China, etc.

Thirdly, greater emphasis and mechanisms are needed to promote inter-sectoral collaboration, so that other major players—such as agriculture, urban planning, sports and entertainment, schools and education, economics, industry, technology, and citizen involvement—can all be brought to pay attention to health.

Lastly, India needs to modernize and expand the training of public health professionals at every level, from grassroots community health workers to highly trained public health science experts. Indeed, some impressive work is already happening through the Public Health Foundation of India (PHFI) and at several medical colleges. These need to be built upon, and public health education needs to be integrated across all education systems in the country. The creation of an independent university of public health, with a network of institutes across the country, may catalyze the development of public health.

2) Prevent and control non-communicable diseases (NCDs). Even as India deals with a massive unfinished agenda of undernutrition, infectious diseases, and maternal and child health, the country is rapidly facing the gigantic challenges of chronic NCDs—such as diabetes, heart disease, stroke, cancers, lung disease, road traffic accidents and injuries, and poor mental health. India already has the world’s largest numbers of people with heart disease, leads the world in terms of deaths from road traffic accidents, and has the second largest (and growing) number of people with diabetes worldwide.

What is especially disturbing is that NCDs are affecting people in India at younger ages, and costing society and the country economically by imposing health costs and lost productivity during peak years of life. Yet, a high proportion of NCDs are potentially preventable by tackling tobacco, improving diets and physical activity, reducing excess alcohol consumption, reducing air pollution, and by investing in evidence based preventative clinical medicine. Addressing NCDs in an integrated manner—based on data and evidence gathered from India—is an urgent priority. Some lessons from other countries may be useful for India, but, for the most part, the country will need to invest in its own science and innovations to come up with locally and contextually relevant solutions—with potential for global applications—for the massive and growing NCD challenge.

3) Invest in healthcare reform. India’s healthcare systems require modernization to be able to proactively deal with new health challenges, which have been largely brought about by the rapid growth of NCDs, superimposed on the ongoing challenges of infectious diseases, maternal and child health, and undernutrition. Systems that work for chronic NCDs are often different than those that worked for infectious diseases. The country needs to strengthen its primary healthcare system, emphasize prevention, and retrain and expand its workforce to address NCDs. There is a huge shortage of health personnel— especially trained primary care physicians—and non physician health workers, such as nurses, community health workers, chronic care coordinators, diabetes educators, and lifestyle coaches.

Innovatively addressing these shortages through public and private partnerships would offer huge opportunities for improving healthcare, while also providing employment to millions. The challenge before India is to develop and implement models of healthcare that are of a high quality, yet affordable in cost. Some great examples exist: Devi Shetty’s approach to the delivery of high technology cardiac treatments or the Aravind Eye Care System’s model of eye health for millions, are just some of the innovations to learn from.

Beyond these, good integrated models of primary care for NCDs are greatly needed, and it is also important for India to develop mechanisms that guide and monitor healthcare quality, and to introduce accountability and consumer participation in healthcare. A large part of healthcare costs in India are met directly out of pocket, which can often discourage prevention or, worse still, mean that huge financial burdens are associated with catastrophic illnesses. Innovative approaches to healthcare financing are very much needed, and this could be through a mixture of public and private funding mechanisms.

4) Invest in health research infrastructure. For the size of its population and disease burden, India lags woefully behind in health research. For example, although India is about 15% of the world population, she contributes to roughly only 0.5% of the world’s research productivity in several health areas (such as diabetes). This needs to change rapidly if India wishes to harness her human potential, and become a “Knowledge Power” in the 21st century.

Developing high quality research from within India would require serious action at several levels. Firstly, the country’s education system remains largely stuck in a rote learning model, which may have worked in the years gone by, but is completely out of sync with the creative and innovative needs of a 21st century economy. Research skills and training need to be inculcated within the education system at all levels, starting from middle school and beyond, and examination systems should move away from pure testing for knowledge to including original analytical and research projects. India’s system of doctoral training needs to be reformed in a manner that promotes independent investigators, who are encouraged and supported to take risks.

Secondly, the country needs to build a large network of well supported clusters of excellence for health research and innovation across several thematic areas. This model is working for China, and India could learn from that country in this regard. Such clusters of excellence can soon become the bugle call for change and for active collaborations between academia and industry. Furthermore, such clusters will help India retain her top talent, and also attract talent to India from elsewhere.

Lastly, India needs to drastically cut the red tape that holds back research in general, and which is also a huge impediment to healthy international collaboration. Some of the recent regulations concerning clinical trials are death knells to innovation. While human subjects’ protections are important, and ethical frameworks and infrastructure towards that end are much needed to ensure compliance, it is equally important to develop clinical trials’ policies in a way that does not kill investment in science.

Similarly, India still practices several protectionist policies that impede global research collaboration (for example, huge delays with health ministry clearances for foreign grants or disallowing the transfer of specimens in collaborative global studies using standardized methods). Modifying some of these policies to facilitate healthy and dynamic global collaboration would help Indian science hugely, and also make Indian science more globally competitive.

Prime Minister Modi, you have indicated that the 21st century will be “India’s century.” That is such an inspiring and compelling vision. I humbly offer to you that attention to health should be an urgent priority for India to achieve that tall and exciting vision.

K M Venkat Narayan is director of Emory Global Diabetes Research Center. He is also Ruth and O.C. Hubert chair of global health and professor of epidemiology and medicine at Emory University, Atlanta. He is a product of three continents, having lived and worked in India, the United Arab Emirates, the United Kingdom, and the United States of America.

Competing interests: The author has no competing interests to declare.

Read The BMJ‘s Feature: Expert views: what the next Indian government should do for health and healthcare

  • Dr Rahul Chandavarkar

    Very well written article. Poor healthcare threatens India’s future development and the aspirations of the future generations. In a country where the WHO reports 0.6 to 0.7 doctors per 1000 population, the Indian government should empower the Medical Council of India to create and enforce stricter ethical standards within the medical profession.

    Corruption, nepotism, bribery and fraud can cause economic stagnation and deepen poverty.

    Battling corruption in healthcare will be a long-term battle, but it is vital for the good of India’s people and the country itself.

    The new government has got the golden opportunity and the majority mandate to make a genuine change and improvement in India’s much maligned and ailing health care system .
    Lets hope that Mr Modi can make it all happen , where there is the will there is always a way !!.

  • A very hopeful piece about Modi, I must say. But, when I hear his thoughts on the next steps for health, the emphasis seems to be too much on the for-profit private sector. I think the coming days are crucial and many of us public health professionals need to underscore the importance of robust public healthcare delivery systems. I am not sure if the latter is his focus though…

  • Wg Cdr P K Narendran ( Retd )

    An open letter to Shri Narendra Modi

    Dear P M
    Sri Narendra Damodardas Modi,

    Congratulations,
    well begun!

    I am more
    than happy to hear the phrase GOOD GOVERNANCE very often these days!

    More than
    being the silver lining a large majority of desperate Hindustanis sees in the
    bleak future of India, you and the B J P can and must prove there is much more
    to good moral governance than Patriotism,
    equality, non- corrupt administration and Material development. You can do it
    if you WILL and I shall tell you how. Please be patient and read this letter
    with a calm and cheerful mind.

    Like
    thousands of human beings on this planet; from my childhood onwards, I was also
    trying to find out the right answer to the question “ how to LIVE ”. The
    answer, obviously depends on “ what is the purpose of human life ”. My research
    has lead me to this conclusion: The aim of human life is to assist and hasten
    the process of positive evolution which will ultimately lead to the creation of
    a better species.

    Continuous
    improvement with the aim to create a better species is actually, the JOURNEY
    towards GOD in religious jargon.

    In the
    past 8000 or so years, at various places and times, SELFLESS thinkers had
    explained and shown by their own lives, how to live moral and just lives to ensure
    sustenance and improvement of human societies, whether they were clans, tribes,
    communes or kingdoms.

    At
    present, human beings have reached a station in their evolutionary journey
    where in they have grouped themselves
    together as Nations. And these nations are being governed by individuals or
    groups of human beings called Government. These governments are supposed to
    ensure the nations sustain peacefully and make progress, both moral and
    material, in the true sense of the word.

    Perhaps
    the moral and natural purpose of governance consists of assuring, on behalf of
    those governed, a worthy pattern of good while avoiding an undesirable pattern
    of bad. The ideal purpose, obviously, would assure a perfect pattern of good
    with no bad. A government comprises a set of inter-related positions that
    govern and that use or exercise power, particularly coercive power.

    A good
    government, following this line of thought, could consist of a set of
    inter-related positions exercising coercive power that assures, on behalf of
    those governed, that a worthwhile pattern of good would result while avoiding
    an undesirable pattern of bad circumstances, by making decisions that define
    expectations, grant power, and verify performance.

    Politics
    provides a means by which the governance process operates. For example, people
    may choose expectations by way of political activity; they may grant power
    through political action. Governance may also be defined as the exercise of political authority and the use of
    institutional resources to manage society’s problems and affairs.

    Efficient
    moral governance can not only provide the best administration but also help
    each person to achieve the aim of his life.

    It
    is obvious that moral governance is the single most important tool for the REAL
    and LONG- LASTING improvement of any nation and its people. In simpler
    terms, we need individuals with moral integrity, patriotism, relevant knowledge,
    experience and above all missionary zeal to run the government. This alone can
    lead a nation and its people from progress to progress.

    Towards
    this aim, we should have a SYSTEMATIC PLAN to select young candidates with
    in-built qualities of moral integrity, patriotism and a set of positive traits
    ideally suited for moral governance. We need to impart formal education on good
    governance to these candidates. And then we should strive to make them the
    peoples’ representatives which will ensure the best governance.

    Dear Narendra Bhai Modi, what Bharat ( or any
    other country ) needs NOW is such a system of national governance. Believe me
    you, I have worked out a basic Five – year –
    project- plan for this purpose. If you can appreciate the real meaning of
    my view, we can take this idea forward.

    Wishing you all the best and with respectful
    regards,

    Yours sincerely,

    Wing commander P K Narendran ( Retd ).

    pknarendran@gmail.com

  • Giridhar

    Agree with all these points here. I had raised some pointers for the parties before Shri.Narendra Modi was unanimously elected. Here is the link to the blog: http://blogs.bmj.com/bmj/2014/02/20/giridhara-r-babu-health-for-indians-who-cares-about-it-anyway/