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The Hindu
2 days ago
- Health
- The Hindu
Vital gains in the health of citizens
In 1947, if a child was born in India, the average life expectancy at birth, or the number of years a newborn would live, was a mere 32 years. In 2022, that rose significantly, to 70.19 in 2022, and is currently 72, just a year short of the world life expectancy, pegged at 73.4. Life expectancy is a key indicator of a population's health, and is considered a valuable tool because it encapsulates both mortality rates and the impact of health conditions on the lifespan. This is the story of Indian health care in the past 80 years, one of slow, but steady progress for the first 50-odd years, and then, thanks to a clutch of policies that specifically targeted improving access to health care services for the people, bringing in cutting-edge technology to research and practice of medicine. That era also saw the rise of a parallel health sector in the private realm, which came as a boost, but also with its own set of disadvantages. But then, we get ahead of ourselves. As the country was born anew, independent, soon to be a republic, the new government exhorted people to be proud of the Independence Struggle that facilitated the transfer of power, but on the health indices front, pride would not have been an appropriate emotion. As Sanjay P. Zodpey, and Preeti H. Negandhi summarised in a paper in the Indian Journal of Public Health, according to the '1951 Census, India's population was 36.1 crores, at independence... The overall life expectancy was 32 years. The infant mortality rate (IMR) was 145.6/1000 live births. Maternal mortality ratio (MMR) in the 1940s was 2000/100,000 live births, which apparently came down to 1000 in the 1950s. There were only 50,000 doctors across the country. The number of primary health-care centers in the country was only 725.' Fatal infections At the time of Independence, the litany of health challenges would fill several volumes and spill over: the country was battling widespread prevalence of infectious diseases that had a fatal effect — including malaria, tuberculosis, smallpox, and cholera. As already discussed, maternal and child mortality was also very high. The focus, naturally, was on addressing these communicable diseases. India clearly had a lot of work to do, to improve health services, even as it set about the task of nation building. In retrospect, much of the progress that India has seen today was thanks to the foundations laid during this intense period, though policies kept changing over the years, as they indeed do, and must. Retrospect is a wonderful teacher, and it is clear today, where the investments in the health sector should have been in, 80 years ago. Would that have fast-tracked improvements, reduced mortality and morbidity, and improved quality of life? No doubt. Incremental measures, not only in the health sector, implemented over the years, have pulled the nation to a situation that has of course dragged it to a modern century. The first such measure to make a difference was the Bhore Committee report, in 1946. In fact, this visionary document would go on to build the scaffolding on which Indian health care would continue to go on, and retain, even seven decades down the line. The Bhore Committee laid the foundation for a state-led healthcare model, emphasising universal access and preventive care. As a consequence, the basic building blocks of the Indian health care system — the Primary Health Centres (PHCs) and sub-centres were set up. This network has remained, and grown, over the years, taking access to more people at the very lowest rung. As mentioned, the government was busy fighting infectious diseases, and key moments, also to be replicated later, included the launch of interventions in a programme mode at the national level. The National Malaria Control Programme was instituted in 1953, followed by the National Tuberculosis Programme and the Expanded Programme on Immunisation. Significant milestones It was the focus on immunisation that enabled the country to mark two significant milestones that also ensured fewer deaths and a better quality of life for its citizens. The first significant milestone was the eradication of smallpox in 1980, along with the rest of the world. Smallpox was a highly contagious and disfiguring disease, and with a high fatality rate, with about 30% of those infected dying. The second came at least 25 years later in 2014 with the WHO certifying that the country had eliminated polio. Interestingly, these campaigns were executed as mass public outreach programmes, with the effort of several players including the state and non-state actors involved in massive immunisation work, besides extensive awareness and communication activities explaining the importance of such vaccination. Advances have since been made in reducing maternal and infant mortality with Kerala leading the country in achieving targets in the these parameters, and Tamil Nadu following in its footsteps. Certain Northeast States have enviable single-digit numbers for IMR. Overall, infant mortality fell from around 161 per 1,000 live births (1947) to about 26 per 1,000; maternal mortality dropped from over 2,000 per lakh (100,000) live births to around 103 in 2024. However, even today, with the advancements, large regional variations contribute to increasing the national mean, in both infant and maternal mortality gains. Intra-country and intra-State variations are still high in many parts of India, both with IMR and MMR. The roll-out of the New Economic Plan in the 1990s was to leave a lasting impact on health care services in the country, and change it, fundamentally. Pegged on the concepts of liberalisation, privatisation, and globalisation, the NEP made the private sector a significant player in the health care scenario, hoping to level the playing field, and increase access, efficiency and quality of services. While these ramped up service delivery, contributed massively to India's position as a destination for affordable, quality medical tourism, they indeed did queer the pitch — issues of increased out-of-pocket expenditure, and access for only those who could afford it cropped up. These continue, in some ways, till date. This period also gave impetus to the pharmaceutical industry to grow into one of the largest in the world, supplying generics globally. Simultaneously, a significant factor was the growth of medical colleges across the country. This helped increase the number of trained medical professionals available in India to serve the people. However, a great urban-rural divide still exists, with urban centres faring better than their rural counterparts. ASHA's entry But it was later, in 2005, with the launch of the National Rural Health Mission, that a true attempt was made to improve health care delivery in rural areas. Among its successes we must count the ASHA (Accredited Social Health Activist) — a cadre of female health care workers working with the community was created to take health awareness and health services directly to the doorsteps of the people in the villages. The National Health Mission, later, zeroed in on a clear mandate to improve access to healthcare even in urban areas. With an epidemiological shift occurring in the country, over the years, India has come to accumulate a huge burden of non communicable diseases — diabetes, hypertension, cardiovascular diseases — as a result of changing lifestyles and eating habits, and a strong genetic component. The government has also shifted track to addressing these issues through national programmes launched across the country, and in the meantime, with the threat of infectious disease outbreaks still remain alive. In fact, the threat from tuberculosis, which was among the first few national health programme started, is still virulent, with further assaults from resistant strains derailing progress on the front. Investments in health care research, in the public and private sectors, have ensured that the lag on that front is also being addressed. Research into newer molecules, vaccine platforms, and rare diseases will provide the country an edge in the future, the challenge would be to ensure that these state-of-the-art therapeutics and diagnostics are available to, and accessible by all. At this juncture, India is poised on the edge of a demographic transition. While fully geared to take advantage of the youthful population, it also needs to provide for a future that will be largely grey. As it nears the final stages of reaping its demographic dividend, the nation will also have to plan to take care of the health requirements of an ageing population. The task ahead is by no means simple, there are no magic bullets, but India has learnt that ensuring health for all, consistent delivery of a standard of care to all segments of the population, irrespective of their ability to pay, is the only steady way ahead.
The Hindu
28-07-2025
- Health
- The Hindu
The medical boundaries for AYUSH practitioners
The recent controversy on X between a hepatologist and an Indian chess Grand Master, on whether practitioners of traditional medicine can claim to be doctors, has sparked much commentary on the role and the status of practitioners of traditional Indian medicine systems such as Ayurveda and Unani, in India. Committees, governments, perspectives The burning issue here is not merely whether practitioners of Ayurveda can refer to themselves as doctors, but rather the scope of medical activities permitted under Indian law. This is an issue which has consequences for public health. A starting point for this discussion is to understand the framing of the debate over the last 80 years, beginning 1946, when the Health Survey and Development Committee, better known as Bhore Committee, batted in favour of modern scientific medicine based on evidence. The committee had pointed out that other countries were in the process of phasing out their traditional medicine systems and recommended that states take a call on the extent to which traditional medicine played a role in their public health systems. The Bhore committee's lack of enthusiasm for the traditional medicinal system did not go unnoticed by practitioners of traditional Indian medicine who mounted a vocal protest. They managed to convince the Government of India to set up the Committee on Indigenous Systems of Medicine, which submitted its report in 1948. This committee unabashedly wrapped up its conclusions in communal language, framing the issue in terms of Hindu nationalism by linking Ayurveda to the Vedas and its decline to 'foreign domination'. While the Nehru government took no action to formally recognise these practitioners of traditional medicine, the Indira Gandhi government in 1970 enacted a legislation called The Indian Medicine Central Council Act recognising and regulating the practitioners of Ayurveda, Siddha and Unani. This law was replaced in 2020 with a new law called The National Commission for Indian System of Medicine Act. The syllabus for aspiring practitioners of Ayurveda is an absolute mish-mash of concepts that span everything from doshas, prakriti, atmas (which includes learning the difference between paramatma and jivatma) with a sprinkling of modern medical concepts such as cell physiology and anatomy. These are irreconcilable concepts — the theory of tridosha attributes all ills to an imbalance of doshas, while modern medicine locates the concepts of some diseases such as infections in 'germ theory', among others. There is no middle ground between both systems of medicine which is why concepts such as integrative medicine make no sense. Point of friction Nevertheless, the legal recognition of this new class of practitioners led to questions on the exact boundaries between the practice of traditional and modern medicine. The major point of friction has been the prescription of modern medicines by the practitioners of traditional medicine. Ayurvedic practitioners, in particular, while claiming the superiority of their art over modern medicine, have consistently demanded the right to prescribe modern medicines developed by evidence-based modern science. Pertinently, this dispute revolved around the interpretation of Rule 2(ee) of the Drugs and Cosmetics Rules, 1945 which defined the class of 'registered medical practitioners' who can prescribe modern medicine. This definition is complicated since it is not limited to doctors with a MBBS degree. It delegates a certain amount of power to State governments to pass orders declaring medical practitioners on their State medical registers as persons 'practising the modern scientific system of medicine for the purposes of ….' the Drugs & Cosmetics Act, 1940. Many State governments have used this power under Rule 2(ee) to allow registered practitioners of Ayurveda and Unani to prescribe modern medicine such as antibiotics. The constitutionality of these orders was challenged before the courts and the first round of litigation concluded in 1998 with the judgment of the Supreme Court of India in Dr. Mukhtiar Chand & Ors vs The State Of Punjab & Ors. The Court concluded that 'the right to prescribe drugs of a system of medicine would be synonymous with the right to practise that system of medicine. In that sense, the right to prescribe allopathic drug cannot be wholly divorced from the claim to practice allopathic medicine'. Simply put, Ayurvedic practitioners had no right to prescribe modern medicine. That judgment never stopped the lobbying by Ayurvedic and Unani practitioners with State governments for the promulgation of orders under Rule 2(ee) allowing them to prescribe modern medicine. Several State governments have continued passing these orders in defiance of the Court's judgment. This inevitably leads to litigation before the High Courts, usually by the Indian Medical Association, which often wins these cases. Unsuspecting patients too have often sued practitioners of Ayurveda before consumer courts on the grounds that they were deceived into believing that they were being treated by a doctor with a MBBS degree who can prescribe modern medicine. While much of the litigation has revolved around the right to dispense modern medicine, there is also the issue regarding the medical procedures that can be conducted legally by practitioners of Ayurveda and Unani. For example, can a registered Ayurvedic practitioner 'intubate' a patient? This is an important question to ask since it is an open secret that many hospitals purporting to practise modern medicine are hiring Ayurvedic practitioners with Bachelor of Ayurvedic Medicine and Surgery (BAMS) degree at lower pay in place of graduates with a MBBS degree. Further, a notification by the Indian government in 2020 has allowed Ayurvedic practitioners (post graduates) to perform 58 minor surgeries, including the removal of the gall bladder, appendix and benign tumours. The constitutionality of this notification is pending before the courts. If the notification is upheld, the question that arises is whether these Ayurvedic practitioners can now use anaesthetic agents and antibiotics required to conduct surgeries. The stakes are high for public health in India since the likely strategy of Ayurvedic practitioners will be to argue that these surgeries were known in traditional Indian medicine. In these times of heady Hindutva, it will be difficult to find a judge who will ignore these claims. The political factor The larger political backdrop to this entire debate regarding Ayurvedic practitioners is 'Hindu pride', which has fuelled claims of fantastical achievements by ancient Indian civilisation, be it the pushpaka vimana or the claims of the Kauravas being test tube babies. When a policy issue such as Ayurveda is cynically draped in the language of 'Hindu pride', it is not just the Bharatiya Janata Party but also the Indian National Congress which feels compelled to support an obviously dangerous approach to public health. The last election manifesto of the Indian National Congress, in 2024, promised that the party would 'support' all systems of medicines instead of a promise to support only rational, evidence-based medicine. This blind faith in traditional medicine is going to cost every citizen in the future since the government is actively considering the inclusion of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) treatments under the Ayushman Bharat insurance scheme funded by tax-payers. This is in addition to approximately ₹20,000 crore of tax-payer money spent on research councils functioning under the Ministry of AYUSH with a mandate to research AYUSH. They have very little to show for in terms of scientific breakthroughs. Twitter outrage notwithstanding, the joke at the end of the day is on the tax-payer. Dinesh S. Thakur is the author of 'The Truth Pill: The Myth of Drug Regulation in India'. Prashant Reddy T. is the coauthor of 'The Truth Pill: The Myth of Drug Regulation in India'
Time of India
21-04-2025
- Health
- Time of India
Empowering Nurses in Rural India: Training for Primary and Preventive Healthcare
Access to quality healthcare continues to be a major challenge in rural India, as the uneven distribution of healthcare professionals has led to gaps in primary and preventive care. Nurses, who form the backbone of the healthcare system, are in the best position to bridge these gaps, particularly in settings where doctors are not available. Boosting their training and providing them with necessary skills can make a great impact on improving the delivery of healthcare in underserved regions in the country. The Role of Nurses in Rural Healthcare Nurses have always been an integral part of the healthcare system in India. The Bhore Committee in the 1940s recognized the need to expand their roles and suggested utilizing nurses to deliver healthcare services to remote and underserved areas. In the last few years, the Government of India (GOI) has fortified this vision through the introduction of initiatives like the National Health Mission (NHM), which created the role of Community Health Officers (CHOs). Nurses, being the first preference for CHOs under the National Medical Commission (NMC) Bill 2019, are now better positioned for professional development and broader public health responsibilities. Bridging the Skills Gap Through Specialized Training Although they play a crucial role, most nurses get limited exposure to community health nursing , midwifery, and sickness care in their General Nursing and Midwifery (GNM) and Bachelor of Science in Nursing (BSc Nursing) courses. To address this, the GOI introduced the Bridge Programme of Certificate in Community Health for Nurses (BPCCHN) in 2017. This program aims to enhance nurses' knowledge and skills, enabling them to deliver comprehensive healthcare services in primary health centers and community settings. Training initiatives like BPCCHN are essential for equipping nurses with the expertise required to handle preventive and primary healthcare needs in rural areas. The National Sample Survey Organization (NSSO) 75th round (2017-18) reported that 7.5% of the Indian population (9.1% urban and 6.8% rural) experienced health ailments during the 15-day reference period of the survey. Strengthening primary healthcare through well-trained nurses can help address this growing healthcare burden. Technology and Data Science in Nursing Education The infusion of technology and data science in healthcare education is imperative in gearing nurses up for the future of healthcare. Artificial intelligence (AI) and predictive analytics can help with early diagnosis, preventive medicine, and patient monitoring, thus improving the delivery of healthcare. Training programs need to center on preparing nurses to possess digital literacy competencies, enabling them to leverage AI-enabled tools to monitor patients in real time, predict diseases, and develop treatment plans. Collaboration between data scientists and healthcare professionals across disciplines can further improve patient care and enhance health outcomes. Strengthening Rural Healthcare Through Community Engagement A people-centered approach is pivotal to upgrading rural healthcare. Nurses, being at the forefront of healthcare, can play a significant role in community health initiatives, focusing on disease prevention, maternal and child health, nutrition, and sanitation. Through data-driven practices, they can identify high-risk populations, introduce targeted interventions, and monitor health progress effectively. Engaging nurses in community work can also close the gap between healthcare facilities and rural communities. Training programs should incorporate communication and leadership skills to empower nurses to educate communities regarding preventive healthcare practices and enhance health-seeking behavior among rural residents. The Need for Policy Support and Institutional Backing To ensure the success of nursing-led primary healthcare in rural India, policymakers need to invest in workforce planning, retention strategies, and financial incentives. Offering competitive remuneration, career progression opportunities, and a healthy work environment will improve job satisfaction and lower nurses' attrition rates. Healthcare facilities should also work with educational institutions to revise nursing courses from time to time so that they remain aligned with emerging healthcare trends. Public-private collaborations can further support training programs, equipping nurses with the latest medical knowledge and technological skills. Conclusion Empowering nurses through specialized training, integration of technology, and community engagement is key to boosting primary and preventive care in rural India. Closing the gaps in workforce availability, motivation, and performance will lead India toward a more equitable and efficient healthcare system. As the healthcare paradigm shifts, the nurses need to be provided with lifelong learning and development opportunities so they remain at the helm of providing high-quality care. With the right policy support and institutional backing, nurses can lead from the forefront of transforming rural healthcare and making quality healthcare accessible to all. This article is written by Dr. Sunil Khetarpal, Director at AHPI (Association of Healthcare Providers India) (DISCLAIMER: The views expressed are solely of the author and does not necessarily subscribe to it. shall not be responsible for any damage caused to any person/organisation directly or indirectly)
