Several challenges face nation states while addressing the issue of providing adequate healthcare for their populations. Over the last half a century, the landscape of health and diseases have considerably changed all over the world and not necessarily for the better. While modern medical system has enabled elimination of certain diseases, notably small pox and polio, new diseases are emerging globally and with increasing movement of people all around the World, diseases and even epidemics can no longer be contained to certain geographies where they originate. Resistance to life saving antibiotics have threatened favourable prognosis of many infections. The ageing population with average life expectancy even in a country like India reaching 69 years has created fresh socio economic problems. Altered life styles and environmental factors have led to increased incidence of coronary diseases, metabolic disorders, respiratory diseases, gastrointestinal diseases , stress and non stress related mental disorders and cancer. In fact, in most countries,’ including the poorest of the poor, life style related, non-communicable diseases, many of them of a chronic nature, needing life long treatments, are growing at a faster pace than communicable (infective) diseases. As a result, developing countries with scarce resources are finding it increasingly difficult to cope with issues of ill health arising out of a plethora of diseases both communicable and non-communicable, among their people.
Spending on healthcare
The US, the world’s richest country, spends on an average, $8,000 per capita per year on healthcare which works out to over 16% of its GDP. In contrast, India spends only 4.1% of her GDP on health. In fact US spending on health estimated to be around $2.6 trillion is one and half times the entire GDP of India .Modern healthcare services in India reach only 40% of the country’s population, the number of beds, the number of doctors and the number of nurses per 1,000 people in India are lower than even in some of the neighbouring countries, Sri Lanka or Bangladesh. In terms of ranking, only countries of Sub Saharan Region and Bhutan are perhaps below India in per capita spending on health. Additionally even this low spending is generally concentrated in the urban and semi urban areas with the rural areas where > 60% of the population reside being neglected.
Compulsions to develop an equitable healthcare model
The compulsions to analyse the current healthcare model as a major instrument for the development of a healthy nation are obvious since sustainable healthcare for a nation’s population is the prime determinant to ensure economic and social development. As early as 1977 at Alma Atta, the World Health Organisation proclaimed as a clear objective, ‘Health For All by 2000 AD’. The world organisation also defined health as ‘not absence of diseases’ but ‘a state of physical, mental and social well being’. From the very beginning, it was obvious that ‘HFA By 2000’ was fallacious, impractical and unachievable even in theory since health as defined by WHO can never be guaranteed to all people at all times. On the other hand in an utopian world it is possible to consider providing ‘Healthcare For All’ (Universal Healthcare) in a defined time frame. While many nations have put universal healthcare as a priority in their planning process, very few have a clear idea even about the possible approaches to achieve such an objective.
To put things in the proper perspective, provision of healthcare needs a multi pronged approach involving all stake holders, the governments, hospitals, medical and para medical personnel, pharmaceutical companies, health insurance systems and practices and of course the beneficiaries, the patients and the public at large. It also entails understanding the current status of efforts in the healthcare field and what are the inherent deficiencies and roadblocks which stand in the way of progress.
Healthcare is more disease centred than health centred
For the last two centuries, since the modern system of medicines (largely based on the allopathic system) became the major provider of health care by providing drugs and surgical interventions, healthcare has been synonymous with attempts to alleviate if not cure diseases. Management and maintenance of health was largely based on curative medicine rather than preventive medicine. So much so, all systems and practices were designed to cater to post-disease intervention rather than preventing the incidence of diseases in the first place. The only exception was the use of vaccines which helped to prevent many preventable diseases. The contribution of vaccines to prevent small pox and polio (both eradicated) and prevent a series of other diseases have helped reduce infant mortality in most countries by effective immunisation programmes. Many bacterial and viral infections, some transmitted through vectors have been under control such as diphtheria, pertussis, tetanus, mumps, measles , rubella, hepatitis B, haemophilus inflenza etc. Apart from these infectious diseases, a major breakthrough has been the development of a Human Papilloma Virus (HPV) vaccine, the first ever vaccine which can prevent the incidence of a cancer, in this case cervical cancer, the second largest cancer in women.
Apart from vaccines, all the other medicines discovered and developed for therapeutic use except anti-infective agents, notably antibiotics treat the symptoms of the disease and hardly ever cure them. So much so, they are required to be consumed life long, a situation which leads to several unwanted consequences including many serious adverse effects apart from the heavy economic burden on the patient.
Components of healthcare costs
Various factors contribute towards the high and unaffordable costs of healthcare. They include hospitalisation charges, physicians’ and nurses’ charges and surgical and medical interventions which include costs of diagnostic procedures, devices, prosthetics and drugs . In all these areas continuous innovations to improve current and available products and services and make them available and affordable are necessary imperatives.
Search for new medicines
Drugs constitute a major component of overall healthcare costs to the patient. And efforts are on continuously on to discover and develop new drugs for diseases for which available drugs are not satisfactory or no drugs are available.
Over the last several years the costs of discovering and developing a new drug has galloped with figures for 2015 being quoted as high as $2 billion for every new molecular entity (NME) put into the market. Investments of that order of magnitude are deemed responsible for the high prices of new drugs. The private sector R&D based pharmaceutical companies in US alone spend over $50 billion on drug research, while the US government through the National Institutes of Health (NIH) spends $30 billion. Over the last five years the number of NMES approved by US FDA have been around 25-30 an year, many of them belonging to the ‘me-too’ category with little major advantages over the existing therapies. In fact it has been stated that of all NMES launched in 2011, only less than 30% could be deemed to be first in class with respect to their structural types or pharmacological action.
Emergence of biologicals
New drug discovery has moved away from natural products and synthetic chemicals to a new breed of biologicals, based on two new technologies, the recombinant DNA and monoclonal antibody technologies. Already 40% of the new drugs approved by US FDA in 2014 belonged to these classes. While these drugs are eminently more effective and specific to the disease and therefore better, they are effective only in limited number of patients and therefore modern medicines are moving into an era of personalised medicines. Industry efforts have moved from the blockbuster era to development of low volume high cost personalised medicines. Average monthly treatment costs with most of the top dozen biotechnology based products are above $40,000, clearly not within the reach of most of the patients in developing countries. The entry of bio-generics which would have reduced the prices of these drugs post patent expiry is also restricted due to several regulatory hurdles.
What is the future?
It is obvious that the current models of healthcare involving both products and services need a radical change, since the trend of increasing costs continue to threaten economic sustainability of this sector, regardless of where the funding comes from.
Healthcare programmes need to ensure adequate, timely, appropriate and effective interventions at all times for all people. It also needs to take into account the basic needs of public health, sanitation, safe potable water, clean and nutritious food and most importantly healthy lifestyle. Hence many factors outside the medical system also play an important role in the maintenance of health. The responsibility of ensuring all these rest not only on governments, healthcare providers, pharmaceutical companies and insurance agencies, but also on individuals who need to adopt healthy life styles, food habits and adequate exercise. Endearing social and family connectivity and interactions also help reduce stress and enhance quality of life.
It will be very prudent to take an integrated holistic view on all these aspects and develop and implement an equitable doable health policy and action programme. Every country has to design its own system keeping in mind its developmental status, disease incidence and prevalence, medical needs and availability of resources.
(The author is a senior research scientist and industry expert based in Chennai)