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