Can current Indian health system achieve health related SDG’s?

Introduction: India has committed to Sustainable Development Goals and Universal Health Coverage by 2030. National Health Policy 2017 is in place with a Goal of The attainment of the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face fi nancial hardship as a consequence.


Introduction
Achieving Sustainable Development Goals (SDGs) set up by United Nations [1], is the commitment of India. Over the next fi fteen years, with these new Goals that universally apply to all, countries will mobilize efforts to end all forms of poverty, Fight inequalities and tackle climate change, while ensuring that no one is left behind [1]. The SDGs build on the success of the Millennium Development Goals (MDGs) and aim to go further to end all forms of poverty. The new Goals are unique in that they call for action by all countries, poor, rich and middle-income to promote prosperity while protecting the planet. They recognize that ending poverty must go together with strategies that build economic growth and addresses a range of social needs including education, health, social protection, and job opportunities, while tackling climate change and environmental protection [1]. India has aligned its National Health Policy 2017 [2], to achieve these goals. It had launched National Health Protection Scheme (Ayushman Bharat) [3], a health assurance scheme on 25th September 2018 to cover the health expenses of secondary and tertiary care of over 500 million poor benefi ciaries and Jana Aushdhalaya's [4], -chain of pharmacies to improve the access to essential drugs at an affordable cost, Both these initiatives confi rm the Indian government's commitment. As a reconfi rmation their commitment Indian government has recently raised their 2019 healthcare spending by 13.6% YoY to US$8.9b from US$7.45b in 2018 [5].
In September 2015, the United Nation's General Assembly established the Sustainable Development Goals (SDGs) which specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. The Sustainable Development Goals (SDGs) have been criticized by some as "senseless, dreamy, garbled", as compared to the Millennium Development Goals India has a healthcare system, with inequitable coverage and quality. The glaring defi ciency is the lack of well-equipped public health system. Public health is most impactful if it promotes policy, analyzes the social determinants of health, If policy makers show their will by increasing public outlay, as low outlay so far has made it impossible for the public sector to respond to the growing health needs of the population. India has the skills & resources to provide sustainable development goals. Financial resources cannot be cited as a constraint nor fragmented as we are seeing in standalone Swachh Bharat taxes to raise resources for sanitation or Ayushman Bharat the health assurance scheme. What is needed is transformational initiative in health fi nancing, public private mix in service delivery & strengthening Primary Health Care to take it to people's doorsteps and a viable referral mechanism and system to link to the secondary and tertiary care facilities. The health system should prioritize interventions for preventions of untimely deaths, diseases, disability limitation & rehabilitation and not just reproductive, maternal and child health plus as being done now. A robust public health system acts as fi rst defense by preventing outbreaks, if occur controlling the spread soon and limit the damage of endemic diseases.

Burden of illness in Rural and urban india [8]
National Sample Survey Organization (NSSO) report for January-June 2014 indicates that, 1) About 12% of urban and 10% rural population reported prevalence of some ailment during last 15-day reference period of the survey. It had increased from 54 to 118 in urban areas compared to 1995-96 survey and the same had gone up from 55 to 89 in rural area in the same time gap. Among the urban females it had gone up from 51 to 101 whereas for rural females it had gone up from 58 to 135 during the same period clearly indicating that rural women sickness rate had increased more than urban females.

Public Health Care System
The Public Health care system in India has two clear divides 1. Rural India, that is reasonably well organized over last 6 decades and 2. Urban India-that was neglected by Health ministry and the nodal ministry -the Department of Municipal Administration for very long.

1)
Indian public health system has a three-tier system of health care servicePrimary health care consisting of i)

Village /community level link workers called Accredited Social
Health Activists (ASHAs) with short trainings for every 1000

Urban Health Care Providers
Public Sector Health Services in Urban areas: Urban health care services are mainly dominated by Private facilities ranging from Jhola Chhap (mobile quacks-door to door service provider) unregistered care provider (RMP) to superspecialists. The complexity increases as the size of the town/ city increases. Public sector service providers include municipal dispensaries, maternity homes, infectious diseases hospitals  Others (1%), In terms of service providers Medical & Dental constitute (52%), AYUSH Doctors (10%), Diagnostic Labs, ISM hospitals (14%), Nursing & Physiotherapy (2%) and Others (2%) [8].
What is unique about urban population in the context of health? [11] The urban population is unique in some determinants of Health.
1) Population composition: The urban populations have no urban genotype; genetic characteristics interact with environmental conditions to produce urban phenotypes with health resiliencies and vulnerabilities. Changes in urban population composition over time because of urbanization, aging immigration and fertility decline have a profound impact on health 2) Economic conditions: Heterogeneous economic conditions are explicit as on one side we have some fi lthily rich or infl uential people having access to both private and Government facilities, and on another side we have urban poor that include homeless, Jhuggi-Jhopri (JJ), relocated from JJ, Dalit Basti's, Nomadic, construction site camps, unauthorized slums, regularized slums and registered slums, approved colonies, transient population who need health services most and generally have either geographical or fi nancial diffi culty in accessing.
3) Social Conditions: The migrated population from different rural background from certain districts /states settle together in any city. This leads to continued gender inequity, poor educational & skill background, socio-cultural practices, Alcoholism & drug abuse 4) Living Environment: The slums have insecure land tenure and poor housing standards, overcrowding and having poor access to water supply, sanitation and sewerage system that dd to the health problem.

5) Unlisted slums with Rapid mobility:
Almost all the slums are unregistered for initial 5-1o years with temporary migrants. Therefore, they are denied access to health and other development services. They are compelled to commute long distances to go for work and are exposed to additional risk of road accidents, sound and smoke pollution in addition to commuting pain. 6) Multiple Disease burden: Since people come from different background, bring various area specifi c infections, chronic diseases and mental health conditions and expose other for the risk of transmission 7) Collective Capacity: They lack collective efforts or organizing the community for Fighting against civil authorities as people would have come from different background and takes time to build mutual trust, 8) Environmental Pollution: Since most of these slums are built on land fi lls many of them would not have faced in their rural life the challenges of air, water and Noise pollution adding to health risks 9) Access to use of Public Health Facilities: The public health facilities like dispensaries, Anagnwadi centers are far away and provide low quality of services, that might discourage them seeking early care or go to private sector and get exploited leading to getting trapped into poverty.

National Health Programs [12]
The Government of India, Ministry of Health and Family Welfare is responsible for planning and State governments for implementation of various programs of prevention and control of communicable and non-communicable diseases.
These programs provide an additional opportunity to the states by sharing standard case management protocols, supplies, diagnostics, human capacity building, apart from Primary health care set up ( Figure 4) in India provide the essential preventive and curative care required to address the most prevalent conditions, including reproductive and maternal health, child health, nutrition and diagnostic and treatment services for most common conditions. It is also from these PHC facilities that we run public health programs and community-based programs using community health workers like Strengthen the capacity: Of all Countries for Tobacco control, early warning, risk Crucially, the national and State health communities need to move beyond assessing individual health-related SDGs to investigating the links between different goals. The issues like reduction of Poverty (SDG-1), Hunger/Nutrition (SDG-2) education (SDG-4), gender equality (SDG-5), access to clean water and sanitation (SDG-6) peace, justice, & strong civil institutions all have a profound impact on health. Sanitation has already been made national priority with Swachh Bharat Mission. Many studies have indicated that Education contributes for increasing the number of trained health workers at the community level, who in turn will help change the behaviors and habits of people that have a positive impact on an individual's health. Everybody knows that the Children who complete basic education eventually become more capable parents for providing quality care for their own children and better users of health and other social services available to them. Evidence indicates that when girls with a basic education reach adulthood, are more likely to manage the size of their families according to their capacities and are more likely to provide better care for their children and send them to school than those without an education. Better nutrition efforts like Ending hunger by employment generation and Nutrition (macro & micronutrients: under & over) programs have direct infl uence on the health status and resistance to many infections. End poverty in all its forms everywhere especially during natural calamities like Floods, Fire, Famine, Earthquakes & Accidents and disease disasters (outbreaks) are the basic needs for maintaining health. Gender inequality in seeking health care is the most glaring phenomenon we see and neglected by people and Government. It needs a social revolution and better behavior from service providers.
Other Key Health Related Initiatives that will contribute to Health may be challenged and, in some case may not be true but no one can take away the improvement in sanitation across the country. Not everything is perfect, a lot more needs to be done, but Swachh Bharat is a remarkable achievement, that has been acknowledge by the international community [17].    Therefore, individual care centers must have to struggle to get back the clients by not only providing available services, but also advising referral to appropriate facilities so that these customer-centric recommendations help lock in the clients for long as effectively as the quality of services themselves On the other hand, Private sector is moving towards Customer Centric [19], Strategy. Customer Centricity is a strategy that aligns the corporate hospitals deliver their product and services with current and future needs of their patients of a select customer in order to maximize their long-term profi t. It is based on an understanding that not all customers are created equal. Patient centricity develops sustainable profi t on the long term. The three key areas that helps are i) Customer acquisition ii) Customer retention iii) Customer development. It involves investment in the technologies, and human capacity necessary to collect and analyze data of their customers to meet the needs of their core customers. The other customers are also serviced but for short term, such much more numerous other clients will probably generate more profi ts than right customers, as they don't have to put much effort to make that profi t happen [19]. Most of the corporate hospitals especially in major cities of India are investing in such strategies i. Recognizing fundamental and inevitable differences among their customers ii. There is a quantifi able value to be found in individual clients to focus on long term marketing efforts iii. By working to quantify each customer they gain valuable insights as to how much they are willing to spend to keep existing customer and to acquire new clients iv. By doing this they serve better and in a personalized manner than their competitors [19]. By following these norms, the private health Industry is attracting lots of health tourism and some of the institution make more profi t from international clientele. There is already growing concern about some of these facilities treating the local clients as other short-term benefi ciaries and giving more importance and better services to the foreigners.  create an updated individual, family and population health profi le. They will also help the local team to generate periodical reports required for monitoring at higher levels.

Use of Telemedicine: IT Platforms -A long term dream
is to promote at all levels, teleconsultation to improve referral advice, seek clarifi cations, and undertake virtual training including case management support by specialists located in regional super specialty hospitals.   and to enable dispensation of medicines for chronic illnesses as close to communities as possible continued availability of essential medicines and diagnostics to support the expanded range of services will be ensured. diagnostic and management facilities to the expanded range of services at every district headquarters. As of now referral services are available in private sector for secondary care in most of the districts towns and the super specialty hospitals at regional levels. Bharat-The NHPS) is a government-sponsored health insurance program, riding piggyback on similar schemes that are in practice in some of the southern states. It may be the extension of the existing Rashtriya Swasthya Bima Yojana (RSBY) with the sum assured now a raised to Rs fi ve lakhs as against RSBY's Rs 30,000. The coverage has enabled expansion to include tertiary care making provision for purchasing it from the private sector where the such services are not available in public sector. As many as 1,393 benefi t packages are offered under the Ayushman Bharat. "In the fi rst 100 days, 685, 000 patients were provided hospital treatment. 51,00,000 lakh claims settled by the scheme. This averages 5,000 claims per day for the fi rst 100 days15, the scheme provides INR 500,000 per family annually, benefi ting more than 107 million poor families for secondary and tertiary care hospitalization. A network of 16,000 government and private hospitals are involved in this "game changer" initiative.

The National Health Protection Scheme (Ayushman
The Centre fi nances 60 per cent (90% for north eastern and hill states) of the costs incurred on the target benefi ciaries in the states. The state governments fund 40 per cent of the scheme cost and bear the responsibility implementation. The Health and Family Welfare Ministry (Govt. of India) is held accountable by the Parliament and the Comptroller and Auditor General (CAG) for outcomes and results for the money released to states. The National Health Agency (NHA), charged with the responsibility of implementing the Ayushman Bharat is building an institutional framework right down to the district levels to closely monitor. The NHA has, already come up with comprehensive and detailed guidelines for the contracting and outsourcing of the job to commercial companies that function as third-party administrators (TPAs). Mechanisms to detect fraudulent claims are also in place. The mechanism involves State Health Societies to enhance the implementation and institutional capacity for monitoring and administering several aspects of the program at decentralized levels and also keep a close watch on the utilization of the funds released and the performance in terms of depth and quality at the district level in accordance with the guidelines. Some of the national public health experts do see a disadvantage in this approach as it standardizes and brings in uniformity in a country that is highly diverse, unequal and disparate. It might stifl e innovation and local thinking in designing, implementation strategies for accommodating local conditions, preferences, and costeffective solutions they accuse. Standardization may help Govt. to monitor the scheme, but it is costly. The TPAs are commercial companies, highly infl uential with political connections and therefore the local health administration might fi nd it diffi cult to control them over data and their manipulations can harm the building of a balanced health system [20].

Service Delivery Framework
The services envisaged at the HWC level , which were hitherto entrusted with preventive services and minor ailment in subcenter clinic once a week or on demand will now include early identifi cation, basic management, counselling, ensuring treatment adherence, follow up care by running a regular outpatient 6 hours each day. They will also ensure continuity of care by appropriate referrals, optimal home and community follow up, and health promotion and prevention for the expanded range of services. The HWC would also undertake public health functions in the community leveraging the frontline workers and community platforms. Thus, the HWC team will assist people in navigation of the health system and mobilizing the support for timely access to specialist services when required. All facilities will follow care provision as per clinical pathways and standard treatment guidelines. This arrangement is expected to decongest the secondary and tertiary care facilities to improve the quality of services provided there.

Challenges in Operational Strategy Guidelines
Comprehensive Primary Health Care with interventions that account for high proportions of morbidity and mortality closer to the community is expected to reduce out of pocket expenditures. They are ambitious in their scope and scale and aspire to achieve the goals through guidance on physical and fi nancial requirements, service packages, IT requirements, monitorable targets and payment packages including teambased incentives [21]. The delivery of Comprehensive Primary Health Care is not without challenges. The NHM has laid the path for effective implementation, but the entire world will watch if the states leverage this learning for effective implementation of HWC.
Operationalization of any policy depends upon the budgetary provision. Historically budgets have been hovering around 1.1% to 0,9% of GDP, with the Union Government's contribution to public health expenditure around 15% and that of the State's 85%. It is heartening to note that the Indian government has raised its 2019 healthcare spending by 13.6% YoY to US$8.9b from US$7.45b in 2018 [5], but most of it goes for implementing National Health Protection scheme, the health systems' gain for infrastructure will still be a challenge to meet.
The other key issue is the low community ownership of Govt. public health programs, that impacts the effi ciency, accountability and effectiveness in outcomes. Vertical health and family welfare programs such as Immunization (UIP), AIDS are limiting the synergizing effects for other interventions at implementation levels. There is a strong need to synchronize services such as sanitation, hygiene, nutrition and drinking water with health services. In urban India the challenge is more of providing healthy environment for living and working.
The health services can be easily organized but Air pollution, Safe water scarcity, Sewage system and Commuting pain Index are the issues that need to be addressed. Above all, population explosion remains a challenge, in northern and central states. to know what the left hand is doing [19].

What can be Expected by 2030
Having reviewed the health system's strengths, weaknesses, opportunities and threats we now turn to look at what results can be expected by 2030. This is done on two parameters, fi rst on expected outputs, outcomes and impact and secondly on agreed domain-wise commitments of achievements by national Government in NHP 2017. As the table 1 indicates, Outputs like HWC data base and Health cards and family folders stabilization in next 12 years appear to be too optimistic to achieve given the experiences under different vertical program initiatives in the past 50 years. Similarly, increased access to services of the existing services may be feasible but the expanded services like individual care in HWCs and PHC to the last individuals is diffi cult to achieve basically due to a) ability to empower the existing fi eld health functionaries for the newly added interventions like NCD, VBDs, and counseling for enabling families for selfcare b) New staffi ng policies in last 2 decade which recruits skilled persons on temporary basis with security of job and pay packages of much lower level than open market, that does not attract the best in the open market c) Near collapse in supportive supervision of fi eld functionaries as there is no long term solution being thought or considered as a policy issue d) State Governments inability to recruit staff such as male health workers, epidemiologists basically due to low pay packages and lack of training plans. Outcomes of Improved population coverage and reduction in out of pocket expenditure and catastrophic health expenditure and decongestion of secondary and tertiary health facilities are feasible to achieve. But the outcome of Risk mitigation appears to be failing due to the limitation of existing health promotion strategies and ability of communication teams at various levels to empower the community. The country is witnessing this type of challenge under high profi le immunization program known as Mission Indradhanush and strengthening routine immunization (The author led this assessment in Sept-2018-January2019 and the report is yet to be published) , where in through GAVI health system support project (HSS-1, & HSS2) since 2012, where communication and social mobilization strategies for reaching near 100% coverage of routine immunization in general and in urban and tribal population are yet to see the light of the day. The impact in terms of Improved availability, access and utilization may contribute to equitable health outcomes. But measuring such outcomes through periodic populationbased surveys for key indicators is going to be diffi cult given the size of the country, number of districts (being the units of program implementation and monitoring) and operational and fi nancial challenges. Better responsiveness based on dignity and respect for individuals and communities especially for the marginalized is also going to be diffi cult to reach in 12 years' time. Intersectoral collaboration, community system strengthening, encouraging peoples participation, information sharing and willing to take feedback and allow community monitoring that lead to increased trust building, and comfort in seeking care and addressing social and environmental determinants appear to be the biggest challenges the country will face given the socio-political differences.
In terms of the domains of SDGs to be achieved, as shown in table 2, the mortality rates are achievable by the country as whole and in urban India. Some rural districts and desegregated urban poor pockets may lag. There are large inequities in U5 mortality across states and districts and between social and economic groups. The good news is that there is some evidence of reduction of social and economic inequalities over the past two-three decades. Bad news is that of continued presence of several risk factors like low levels maternal education, early childbearing and inadequate birth spacing that will impede the child mortality reduction in some pockets if such pockets are not identifi ed and special efforts are made. Given the fact  ii. iii. ii.

Outputs:
The HWC data Base: Population enumeration and empanelment implies the creation and maintenance of database of all families and individuals in an area served by a HWC. This is planned such that every individual is empaneled to a HWC. This also involves active communication to make residents aware of this facility.
Health Cards and Family health Folders: These are made for all service users to ensure access to all health care entitlements and enable continuum of care. The health cards are given to the families and individuals. The family health folders are kept at the HWC or nearby PHC in paper and/or digital format. This ensures that every family knows their entitlement to healthcare through both HWC and the Pradhan Mantri Jan Arogya Yojana or equivalent health schemes of state & central government.
Increased access to Services: HWCs would provide access to an expanded range of services indicated in Box 2. The availability of services would evolve in different states gradually, depending on three factors-the availability of suitably skilled human resources at the HWC, the capacity at district/sub-district level to support the HWC in the delivery of that service, and the ability of the state to ensure uninterrupted supply of medicines and diagnostics at the level of HWC. States will also have the fl exibility to expand the range of service to address local health problems as defi ned by disease prevalence.

Outcomes
Improved population coverage: Active empanelment and HWC database will improve the population coverage. The HWC database would enable HWC staff to monitor and identify the left-out population and improve coverage of national health programs.
Reduced out of pocket expenditure and catastrophic health expenditure: Improved access to expanded services closer to the community, assured availability of medicines and diagnostic services and linkages for care coordination with Medical Offi cers/specialists across levels of care will reduce fi nancial hardships faced by community.
Risk factor mitigation: Health promotion efforts by primary health care team would support in addressing the risk factors for diseases.
Decongestion of secondary and tertiary health facilities: A strong network of HWCs at the sub district level would facilitate resolving more cases at primary level and reduce overcrowding at secondary and tertiary facilities for follow up cases as well as serve a gate keeping function to higher level facilities.

Impact
Improved population health outcomes: Improved availability, access and utilization will in turn contribute to equitable health outcomes measured through periodic population-based surveys for key indicators Increased responsiveness: Provision of care by primary care team will be based on principles of family led care including dignity and respect for individuals and communities with focus on marginalized, information sharing, encouraging participation, including intersectoral collaboration that will lead to increased trust building, comfort in access to care and enable addressing social and environmental determinants. i. Yes would increase the population coverage but population in remote rural, tribal areas and some urban slums and transient will continue to be underreached.
ii. Yes there will be reduction in out of pocket expenses on health care for most of primary care services, but referral linkages may not be fully established with quality services in the timeline iii. The interpersonal communication skill development among fi eld staff to the extent of addressing risk factors appears to be too optimistic iv. This will depend upon the secondary and tertiary care facilities in each district hospital. Given the present situation as of 2018, this is unlikely to happen in at least 10% of the remote districts in the country.
i. Improved utilization of public health services is subject to commitment of the staff, that depends upon the district authorities to keep them motivated, skill development and monitoring accountability and ability to provide on job support that is lacking ii. Health services provision may be addressed adequately but the intersectoral coordination especially for marginalized population like urban poor, transient, rural remote may fail. Addressing the urban environmental determinants appear to be bleak in next 12 years.

Essential elements of a Health System to work efficiently
Effective Program Managers for, MCH, FP, TB, NCD, VBDs, HIV/AIDS etc. and Superintendents for all level hospitals at national, state & district and sub-district levels. Public Health oriented personnel to manage PHCs and CHCs, leaving the doctors to take care of clinical work.
Tools for program managers to manage resources to achieve outcomes Effective Standard Operating Procedures for clinics, hospitals and community-based services to be delivered consistently according to quality standards.
Ayushman Bharat's successful implementation to reach the last person unreached so far to get secondary and tertiary level care especially from private sector with no fi nancial burden Effective health professionals that have the training, tools and job aides to deliver these services while also enjoying their work.
Aggressive implementation of the defi ned program

Conclusion
Low public outlay so far has made it impossible for the public sector to respond to the growing health needs of the population. If policy makers have the will to provide adequate resources Indian health system has the skills & resources to provide UHC and achieve SDG with the support of departments responsible for providing healthy living conditions. Financial resources can no more be a constraint nor fragmented as seen in Swachh Bharat Cess to raise resources for sanitation and additional funds for special organizational set up or to purchase services from private sector under Ayushman Bharat.
Government has realized that a robust public health system acts as fi rst defense by preventing outbreaks and if they occur controlling the spread as soon as possible and limit the damage of endemic diseases. I am sure Govt. will go for a transformational initi ative in health fi nancing, public private mix in service delivery & strengthening Primary Health Care to take to people's doorsteps. The health system will prioritize interventions for preventions of untimely deaths, diseases, disability limitation & rehabilitation not just RMNCH+A as was done until recently. Approaches to health care will take comprehensive view and pay attention to broader determinants of health such as sanitation, safe water, air & noise pollution, roads and transport.
The country has realized that accountability is the n eed of the time. It will be enforced through clear chain of command and by inculcating the discipline seen in medical tourism for its high quality, low cost advanced care, in public sector. India has emerged as the global pharmacy for inexpensive drugs and vaccines and is determined to make them available in every village and urban community in the next decade. Last but most important is India will make all out efforts to involve people in deciding health priorities, own interventions and monitor progress to lower inequities.