This Article is From Nov 25, 2013

The NDTV Dialogues: Why is India's healthcare in critical condition?

New Delhi: India's health parameters are amongst the worst in the world right now and a child born in India today has less chances of survival than in Nepal or Bangladesh. On The NDTV Dialogues, Dr Srinath Reddy, Kiran Mazumdar Shaw, Dr Binayak Sen and Dr Ashok Seth join NDTV's Sonia Singh to look at why India's healthcare is in a critical condition.

Following is the full transcript of the discussion:

NDTV: Good evening and welcome to the NDTV Dialogues. A dialogue of ideas, different perspectives on key issues that seem to have disappeared from our political and media discourse. Tonight in the NDTV dialogues we look at why India's healthcare is in critical condition. Joining me tonight, Dr Srinath Reddy, Kiran Mazumdar Shaw, Dr Binayak Sen and Dr Ashok Seth. Thank you all for coming in tonight. Dr Reddy, I think everyone agrees that our health parameters are amongst the worst in the world right now and in fact a child born in India today has less chances of survival than in Nepal or Bangladesh. How do we look at addressing even just this aspect, going forward?

Dr Srinath Reddy: Well it's true that we had an increase in our life expectancy, from the time of Independence, from 35 years to now 65 years plus. But even this is very unevenly distributed. The life expectancy in Madhya Pradesh is 56 years, whereas in Kerala it is 74 years. And the girl baby born in Madhya Pradesh is six times more likely to die before her first birthday as compared to a girl baby born in Kerala. When you look at multiple health indicators there is huge inequity within the country. But certainly in comparison with other countries, immediate neighbourhood, of course Sir Lanka is way ahead of us. But even in comparison with Nepal and Bangladesh, and in comparison indeed with some of the Sub Saharan African countries, we are lagging far behind in terms of our health indicators. We need to do a lot more in order to ensure firstly, that the living conditions in which our people will build up their health and not have their health threatened are improved, because health lies beyond healthcare. But when they do fall ill or even for preventive and promotive services, we need the services to have outreach, efficiency and an equity perspective. And if all three are deficient then we are going to have serious problems in terms of our health indicators, which will also affect that development, because we have a huge human resource loss because of untimely death and disability. And keeping in mind that our growth in the population over the next two decades is going to be in the 15 to 59 years segment, if we do not invest adequately in our human resources, we are never going to harness them for development. And even aside from that, health is a human right and we have to treat it as a right of every individual citizen. And therefore it is absolutely imperative, whether it is child health or maternal health or even elderly care, we need to look at health as an important attribute that we must ensure and protect across the entire life course.

NDTV: Ms Shaw, the right to health. This comes; of course we talk about how 66 years after Independence it seems almost, whether tragic or comic, how do you describe it, but the fact is that it comes in the context of various, the debate over rights. Because we talk about right to food, right to education, there's been a furore about when we talk about giving rights, this is about elections around the corner, what about the delivery system? If we haven't been able to do this after 66 years, do we need to change our whole method of delivery, the method of thinking or have we actually left a large part of India behind in this whole obsession with growth, as some would say?

Kiran Mazumdar Shaw:
Well I think you know, what we are really looking at is how do you build a viable sustainable model, that provides access to every citizen, in terms of delivering a decent quality of healthcare? And as you know Srinath said, it's not just about healthcare, it's about just creating a healthy environment. So for instance, when you talk about public health, sanitation plays such an important role in healthcare. Now if you looked at it, 50per cent of our population defecates in the open and we need to address that. So I think, you know, building you know, toilets for our people is a very important part of public health. Now when you look at how we are going to address right to healthcare, certainly I think it is a right. I think we cannot let our people fend for themselves when they fall ill, certainly not the poor. And today, as we know, 80 per cent of healthcare spend happens out of pocket. How can we sustain such a model? Today the whole debate in the US is about Obamacare, because they also can clearly recognise you cannot leave, exclude people in society to fend for themselves at time of illness. We know in our country that rural illness and rural indebtedness are directly linked. So we can't allow this. We have to develop a proper sustainable economic model that does provide proper health care to all. That is the essence of health care. Now it is challenging you know, it is a big challenge for the country, it is a huge economic burden.

And how do you sustain this financial burden in terms of delivering good healthcare? So it does start with, you know, preventive healthcare. It does entail, you know, one of the things is we have got a lot of ingredients to develop a good universal good health care model. You know because when you look at intervention in terms of healthcare delivery it's about drugs and we are the world's lowest cost producers of generic drugs. So that is a good you know starting point for us. Then we do have a large number of primary healthcare centres already setup although they all are not efficiently functioning. But that is good infrastructure to start with. We do have tertiary care structures but then we are not connecting the primary health care structure system with the tertiary healthcare system adequately. So that's where technology comes in. How do we use telemedicine to connect them? And telemedicine today, you know, is possible with just a handheld device, a tablet, and you don't have to have a dedicated room or something. You can, actually a doctor sitting anywhere can communicate with any doctor, with a tertiary care hospital very effectively, so how do we create this whole ecosystem? What is the insurance model, so the reimbursement model? What is the drug? Essential drugs are something, which all we've been talking about, that is being setup very effectively in certain aspects. And one of the important things in healthcare is not just something that happens through a union policy, it is to be delivered at the state level, so states also get involved in health delivery.

NDTV: Dr Sen as someone who has spent his professional career in areas of Chhattisgarh, dealing with children there, when we talk about issues of primary healthcare etc, we often talk from an academic perspective. You have actually been there, seen how it actually functions on the ground. Do you think, what do you think needs to actually change the most? It is about sending more funds? We had even the President of India saying that it's spending the ratio GDP and health's spending must rise. Is it about changing the mindset? We talked about healthcare or policy? Do we look too often at healthcare for the rich? What actually needs to change?

Dr Binayak Sen:
Well, the committee on the social determination of health, I think Dr Srinath Reddy already mentioned this, talked about equity and said that inequity is killing people on a grand scale. That is absolutely true for India; inequity is killing people in a grand scale. Before we come to healthcare, when we are talking about health we have to look at the fact that there are large sub sects of the Indian population which are permanently existing in a state of chronic, stable famine; that the malnutrition is existing constantly, not only among children, but also among adults. In children among all the deaths that occur below the age of five years, half of the deaths are associated with or have to do with malnutrition. In adults, if you look at the proportion of the population, according to the National Malnutrition Monitoring Bureau, the proportion of the population that exist below a body mass index which is 18.5, which is commonly held to be indicative of chronic malnutrition. If you look at the tribal areas more than 40 per cent of the men and 49 per cent of the women have a body mass index below 18.5. Overall the Indian population, the adults, 36 per cent of the total Indian adults have a body mass index is below 18.5. World Health Organisation says that any community in which 40 per cent of the people have a body mass index below 18.5 should be regarded as a community in famine. By that criterion the large sections of the Indian population are living in a state of famine, chronically living in a state of famine. Now that has important consequences for the entire healthcare system. Because for instance, if you look at the number of deaths from tuberculosis annually, the number of deaths occurring due to tuberculosis have gone up five times in ten years, okay. Now this is something that has very bad portents for the future of the Indian population. I think my colleagues here are trying to do that, but the point is that we are not able to make sufficient allocations. I think that the idea that we don't have, the Planning Commission has reneged on the commitment of the recommendation of its own committee high level experts group, for universalization of healthcare, because on the grounds...

NDTV: Headed by Dr Reddy?

Dr Binayak Sen: ...headed by Dr Reddy; which on the ground we didn't have enough resources. That's a useless argument because we are giving tax breaks of 5 lakh crore rupees, we are giving non-performing assets, in the corporate sector to the scale of, and we can't afford healthcare to go from 1per cent of the GDP to 3per cent of the GDP. This is ridiculous.

NDTV: No in fact I will come back to Kiran Shaw. I think this whole fighting under what GDP, which part, how much spending we should raise. But what I wanted to ask Dr Ashok Seth, because that point raised just now, of course that 80per cent of Healthcare now comes from the private system. Yet, we talked of public private partnership in this area, but there is some level of disconnect. And activists say almost obscenely disconnected when you have breakthroughs in the field of say cancer, breakthroughs in the most complex surgeries in the world. Yet the number of people of who are dying of tuberculosis, the fact that over 200 children died of encephalitis, who die in badly staffed hospitals, hospitals where there is not even basic facilities. Yet for dengue, here, or an issue, or even if its foot mouth disease, there will be a much more outcry, whether it is national media or whether its resources of our doctors. How do you reconcile this?

Dr Ashok Seth:
You see there they are not mutually exclusive and I think we want to understand this very clearly. Let me just give you my perspective of this before we move forward. Even when I was in medical school you would be surprised to know, that at that time you are taught, this is 35 years ago, that one Australia was getting added to India every year. And we therefore developed into a nation of 1.2 billion. So we start looking bad on every parameter of healthcare delivery, whether you call it doctor per thousand and ten thousand patients or bed per thousand patients, just because we have this. We look worst in terms of emerging economies even including Brazil and so forth. But the real issue is that this universal healthcare for all is a lovely by-line, it's a lovely motto. But I always start thinking that when 80 per cent of our population lives in the villages, at least not in the urban areas, then sanitation, hygiene, food, proper water supply is all that is required to upgrade the health, so they don't even come to the health status issues, and even that is not being provided. So let alone our whole discussion on numerous issues about this by-line of universal healthcare for all, because then, we just talked about it, it is not just universal, it has to be quality healthcare for all. It's got to be value medicine for all and that is far away from what we visualise. There are numerous hurdles in its way. Coming to the role of private and public is a much bigger issue and I will tell you why I think it's not mutually exclusive. If we understand healthcare delivery in this country, now I am talking about healthcare, not health of the country, which I think government should be taking care of, food, sanitation and doctors, as well, even if we have upgraded those basic amenities to our poor in the villages we would upgrade health. But when we come to the single fact that while 70 per cent of the population lives in villages, and there are only 30 per cent beds and that's, and there is 70 per cent of beds available to 30 per cent population of the country. We are looking at private being a partner to what is provided, a healthcare provider in this country. When we think that only 1.5 per cent GDP came from the government and the remaining 4 per cent came from the private players, when we talk about what sorts of facilities exist in the public versus private hospitals, then we know...

NDTV: So subsidised land came from public...

Dr Ashok Seth: Yes, in many instances, but in many instances it did not. But the same government hospitals, which developed, were not unfortunately able to provide numerous of those facility where quality healthcare should come in. So when we talk about say a district hospital, which has all the government proposals to it, all the government facilities to it, is it actually providing quality healthcare? And quality healthcare is not expensive healthcare. It's a process driven health care. It's an ethical healthcare. It is based on evidence-based practices and it is auditable healthcare and there does not lie any expertise. So when we talked about a quality healthcare unfortunately it's one of the easiest healthcares to deliver in terms of expertise, which is moderate level of expertise in terms of actually having processes, in terms of having evidence based medicines, in terms of having value medicines and value medicine is cost efficient medicine. And that's why the patient benefits and the government benefits and yet we don't see that existing. So I think we can keep on discussing these two sides, but I actually find it very odd that private healthcare providers are not seen as partners, but as people who are actually fleecing the population away and yet we must not forget, that if only the trust lay between the government and the private players, we would actually create the milieu, at least one of the milieu, which could help delivery of universal healthcare.

NDTV: How can that actually happen? Because there is level of distrust and there's of course the court case also, specifically in Delhi over this public land being used and free beds not being given. But how do we create that trust? And we know of course hospitals, AIIMS, many private hospitals hire doctors from AIIMS because you got good quality doctors, and they paid them higher salaries and they went, so how do we create that trust?

Dr Srinath Reddy: Firstly let me correct Ashok on a particular point. If we are talking about 5.45 per cent GDP being spent on health and 1 per cent comes from the government, the remaining 3.5 per cent is out of pocket expenditure. People are paying for it and they are getting impoverished in that process. 60 million Indians are crushed into poverty each year because of unaffordable healthcare costs. And the private sector is a significant contributor to that problem. Even in a well-developed...

Kiran Mazumdar Shaw: But government is also abdicating responsibility...

Dr Srinath Reddy: Sure, sure, sure, sure, I am not saying that, It is a responsibility of the entire society.

Kiran Mazumdar Shaw: Yes

Dr Srinath Reddy: And even in a well-developed state like Gujarat. There was a survey done between 2001 and 2010, Anirudh Krishna from Duke University, 88 per cent of those who became poor attributed it to unaffordable healthcare costs. So it's a major cause of impoverishment. And apart from looking at water, sanitation, nutrition and the environment as the key social determinants, we have to strengthen primary healthcare. And in primary healthcare the private sectors has not shown much appetite for entry. The government has taken up the responsibility but it has not delivered effectively. We do need the private sector but as a responsible partner. You see, we cannot think of controlling tuberculosis and multi drug resistance tuberculosis in this country without engaging the private doctors, because they are the people actually seeing the largest number of patients. On the other hand the private sector has to come and responsibly, through contracted arrangements, to deliver a setup, well-defined services for which they can get paid, but with accountability. See when we talk of public private partnerships let us not forget the public purpose. I would like to redefine the PPP as the partnership with the public purpose. Then both the sides, or even any number of partners are engaged in it, should have their deliverables clearly defined, and accountability affixed. So we need a regulatory framework in which all the resources are available to society, whether it is the public sector, the private sector, the voluntary sector, all of them should be able to work together in order to deliver the services that are required. But first and foremost primary health services must be strengthened both in rural and urban areas. It is no use boasting that we have wonderful tertiary care services we are getting medical tourism, if our primary services are abysmal.

Dr Ashok Seth: I would say that the primary and the secondary care services

Dr Srinath Reddy:
Primary and secondary too

Dr Ashok Seth: And I think that's only going to have, the trust is still the biggest issue. And I totally agree with Dr Srinath Reddy, accountability on either side, but yet creating a milieu, which is positive and a win-win at the end. The winner is the patient and yet the stakeholders have to get sit around and understand where are the reservations, where are the apprehensions, and what are can be done in a transparent manner, to create the best for everyone together.

NDTV: I'd like to just bring in Ms Shaw on, an aspect that's most specific to the industry you work as in well and that's, you just mentioned, generic drugs. Now the Supreme Court verdict wasn't welcomed by many manufacturers, because it felt that it hindered the cause of research, yet world over India has being hailed. Countries like Africa, even countries like America hailed India for that Supreme Court judgment. Do you think that was a judgment, which is actually progressive and needed, when you are looking at regulating costs in the health industry?

Kiran Mazumdar Shaw:
See I think we have to look at this ruling in a very different way. One is there is no doubt about it, generic drugs are actually helping the whole world address this whole challenge of unaffordable healthcare. And India is playing a very key role in helping countries to actually address these financial challenges that health care systems have and today even a country like America actually finds that 80 per cent of its prescription are generic drugs, and India alone enjoys 30 per cent of that share. Now generic drugs per se are extremely important for this country. And I think the debate we are having is drugs that were basically allowed by Supreme Court, in terms of patent aspects that the drug enjoyed. Basically we are looking at compulsory licencing. I think India has done very well to say we will not recognise ever-greening of the patent, because that basically delays the genericisation of drugs. But I think to suddenly usurp the patent rights of companies on the basis of affordability, when many of these drugs we are talking about are really not drugs that most poor people can afford, even at the prices at which they are selling. So I think merely to look at the affordability, as the reason for invoking compulsory licencing, is not quite fair on the companies who have actually spent a lot of money developing them. Government also can be a responsible player in this particular aspect by actually bulk procuring these drugs and then giving it and making it available, so the kind of patients who really needed to be treated with such drugs are fewer. That's what the larger disease, the metabolic diseases are all about.

NDTV: But for instance, Bill Gates recently said in that conference when of course when he released those mosquitoes in front of a whole packed delegation, it seemed that, you know that the drug, international drug industries look more at say anti-baldness drugs rather than looking at developing of a cheap affordable anti-malaria drug. The issue of priorities, whether it comes from the drug industry, whether it comes from the private hospitals, whether it comes from NGOs, when we look at how to look at the healthcare problem for India, as not divided into say rural India, urban India, but looking at holistic system, do you think we all fail on that, whether its in media discourse, whether it's in public discourse?

Dr Binayak Sen: I think that there is one aspect of the overall culture in India, which impacts directly on health, which we are not; which is prior to much of the discussions that have happened, and that we had earlier talked about. The equity, inequity and about, and about, what is getting left out is violence. I think violence is one aspect of this situation. India is, what we do not, I don't know how many of us realise it, but India is one of the most violent societies in the world. And there is an idea that women and children and old people only become victims of violence by the process of collateral damage. That is not true. Much of the people are the hungry people who might be talked about. Who might talked about, these people are unable to survive because of their access to common pool resources, and when the access to common pool resources is compromised then their survival is put at risk. And in India is a situation. The Indian, the state in India is in a massive process of expropriation of common pool resources, handing these resources over to corporate entities, okay. And now, when, so the women, the people who suffer most as a result of these factors are not the competents. The people who suffer most are the vulnerable sections of the population. That is women, children and old people. We also need to look at female foeticide and infanticide. I mean these female foeticides and infanticides are taking on demographic proportions. These are not individual criminal acts anymore, these are you know demographic.

NDTV: So the Prime Minister called it a national shame, the female foeticide.

Dr Binayak Sen: Yes, so this is an important aspect that we need to address. Once we put those aside, if we look at health care, see the corporate. You see we had this very eminent cardiothoracic surgeon in the Planning Commission the Steering Committee, who said that in the 20th century industry was the engine of the economy, in the 21st century healthcare is going to be the engine of the economy. Now, so corporate entities have a different logic from the logic of public provisioning...

NDTV: The socialist aspect of public provisioning

Dr Binayak Sen: Public provisioning has to; you know primary healthcare can only take place as a result of public provisioning. Now we can have, you know, we can take it as part of the democratic functioning at the, you know at the peripheral level. Half of our population, almost half of the population, at least 40 of our population is today urban. So this rural urban distinction has now become an artificial one. We have to look at the entire population as a whole, and we have to develop patterns of primary healthcare including patterns, you know, including mandatory, standard treatments, standard treatment protocols, which would have the force of law

NDTV: In that aspect, when you say an atmosphere and trust needs to be built up, what would corporate healthcare or what would hospitals like yours do to induce that trust? I mean there are so many proposals, so why don't private doctors actually go and voluntarily volunteer in areas where there are no doctors? How does this private healthcare build up that trust, that which is not seen as fleecing patients?

Dr Ashok Seth: Right, and on the other side, how does the private healthcare have a trust in the government, so that they don't see them as a red-tapism or slow or inefficient services? In fact when you look at the primary healthcare, we just discussed the primary healthcare, we pointed out that the primary healthcare is a huge area to be strengthened. We know that can happen, through numerous; again regulations, the problem is that the stakeholders, all the stakeholders don't come in and sit around the table to actually discuss and finalise the proposals, which actually have continuous input of everyone. Decisions are made arbitrarily through groups of people, without actually thinking through who is actually going to be the stakeholder, and how they execute this stakeholder and therefore create trust. For example, when I think of primary healthcare and we talked about doctors going to the primary healthcare, yes, legislation can actually be put forth, what we are actually talking about, literally in equal number of private medical collages versus the government medical colleges, which produce doctors. And yet one thinks that the loads of fee which are charged by the private medical collages should all be abolished into uniform, standardised methodology, whereby government says okay, lets actually just make sure that there is a medical education in this system at a particular cost, but then a legislation that every doctor would spend time out in the community, in the primary care centers. But also at the same time upgrade the primary care centers, so these doctors who've actually studied on their own, can actually practice there a level of care, which transfers into somebody getting better. Unfortunately those services do not exist, so we are not. We just come strengthen it by doctors. We have equal number of ayush workers that we produce every years, 30 thousand ayush workers and we have to rely on systems of medicines which have been traditional and which have been sound. Let us try and use them again in the primary services. The private sector is keen on coming into this secondary care service. That's also being seen much more recently. And again guidelines and frameworks have to be developed where specific costs, and specific charges for treatments can certainly be put down, on an infrastructure which when we created both together. So that at the end of the day if we are creating value medicine for the patients, and the value medicine is not the top most techniques and expertise and equipment, it relates to what do you actually give that patient. Most cost efficient care at what cost; and the government would be very happy if the partnerships revolve around cost efficient care in the best possible manner, so that the patients get better. Models can be numerous, but the framework is no profit making. Profiteering to the extent that it becomes a viable option and the patient benefits.

NDTV: In fact that, Dr. Reddy, that may be one interesting proposal. But just also to present two case studies for instances, one is of course the recent tragedy in Bihar where we had children dying of food poisoning, also because they didn't getting medical treatment in time to save their lives, over twenty. Then you have a recent order passed which says bureaucrats can go abroad under CGHS and get facilities abroad, when we have people coming in from abroad here to India to get facilities, we know it was already have available for politicians. The way we look at healthcare and what's available, the contrasts, forget about the inequity existing in the system, but inequity of what different kinds of people, the right to care that they can get, is that really part of the issue when you argue universal healthcare? Did you buy the government turning down as a lack of funds?

Dr Srinath Reddy:
Well I do not accept the lack of funds as an excuse because I think there is a great opportunity to increase the amount of funds available for healthcare. The numbers of other subsidies, which have been given, which can actually be curtailed, and funds should flow into healthcare and that is something that health and healthcare, I mean, all the social determinants as well. But coming to the specific instances that you cited. Firstly I think it is absolutely unacceptable that our primary healthcare services should function poorly. We need geographical access, we need adequate infrastructure, we need appropriate staffing, availability of the drugs and equipment round the year and for this I think...

Dr Ashok Seth: Round the clock as well...

Dr Srinath Reddy: Round the clock as well

Dr Ashok Seth: Yes

Dr Srinath Reddy: ...and for this not only the Centre should spend but also the states should start spending much more. And both of them should actually ensure together the primary health services are strengthened. There should be local accountability as well. I was in Rwanda just a month ago. There the primary health centres are staffed and supervised by nurses, doctors are not needed and the whole bevy of community health workers are actually spread out, one community health worker for every 500 people. And interestingly, the mayors, members of the Parliament, the local administration are all held accountable for infant mortality, maternal mortality, for also immunization coverage rates. Now that is the level of community monitoring and accountability that's really required if you want our services to function effectively. And we need to build a continuum of care between primary, secondary and tertiary. Ashok is absolutely right. Secondary is also the missing the element. We need to strengthen our district hospitals as well as bring in private sector as a responsible partner where required. But the whole continuum is dead. Because unless primary health services are strengthened and act as a gate keeper, you will get a lot of potentially preventable diseases spilling over into expensive secondary and tertiary care and our healthcare costs will keep piling up. So I think there is a great opportunity of looking at resource mobilisation through increased taxes on cigarettes, beedis are not taxed for example at the rate they should be. There are a number of ways of resource mobilisation and also increase the allocative and expenditure efficiency to improve primary healthcare services and building this continuum. Secondly I think it's totally unacceptable, when the Prime Minister of this country can choose to get operated in the All India Institute of Medical Sciences for a second bypass surgery, that we should have our civil service going abroad. I mean that is something that I personally find rather surprising as a concession being made. But the point that you underline is there is huge inequity and the inequity must be bridged. And even in urban primary healthcare, now that urban health mission is there, we must ensure the primary healthcare is strengthened and it need not be doctor dependent. We know from global experience and even some Indian experience that much of the primary healthcare functions can be performed by the trained nurses, trained community health workers and intermittent physician's supervision, if available, is good, but you don't have to have the whole primary healthcare hostages to the availability of a reluctant doctor.

NDTV: In fact Kiran Shaw just look, I think nobody would argue about, we would all want universal healthcare for all. But there are still huge, huge questions about whether the government putting in more funds is really the answer, because of the fact that the delivery mechanism has been so poor in the recent, has been so poor wherever we see. Some states work of course, like Tamil Nadu has done well, Kerala has done well, but do you believe that another right to health is the answer?

Kiran Mazumdar Shaw:
Well you know you can't debate the fact that everyone needs right to health. I mean that's, that's absolutely not up for debate at all. But I think what we need to understand is look, you know there are several, you know, reports that tell you that if you have a healthy country, you know if the people are healthy, it actually will add to GDP and economic development. You know just now I think Dr Sen said that, look, if you really look at health and nutrition per se and if you actually address just that, then you know that this has a direct impact on economic development, because you don't want under nourished people who can't perform. Now that is a big, big challenge that we have.

NDTV: Where corporate India doesn't say raise funding for health?

Kiran Mazumdar Shaw: No but...

NDTV: And this, well any other demand, but we've never had corporate India saying raise funding for health

Kiran Mazumdar Shaw: No I think there is a certain, you know recognition that right to health is as important as all the other rights that we are addressing. So I think that is, I think as someone from corporate India, I would clearly say that right to healthcare is a very important right for this country. I think it's also very important that we look at the resource allocation to this very, very important sector. And this resource allocation for healthcare starts with public health, sanitation, nutrition; all the way up to the healthcare that we are talking about. And I think here there is a model that has to be developed, where private sector can be enrolled into delivering healthcare. Now I think we do need to make sure that there is a political will to ensure healthcare for all. That is still missing. I think that the state has a very important role to play. The Centre has a very important role to play. Some states actually have made it happen. You know if you look at what Tamil Nadu has done with its healthcare, you know system, and how it has delivered on health for all. Compare it to what Kerala has done, even what states like Rajasthan has done. But many states have not done that; they don't even bother to invest so much in healthcare. So I think there is inequity all around. There are, you know, there is an inequity in terms of how we look at delivering health to our people. There is inequity in terms of how different states are delivering healthcare to its people. So I think we need to replicate models that are working. I mean if you think that the Tamil Nadu healthcare model is working very well, then why not try and scale that up. If you think that the Kerala healthcare system is a very good model to follow or if there is a combination that you need to do between what different states are doing, do it, but scale it up. You can't suddenly have one state totally, you know, denied access to healthcare and the other state providing a very good healthcare system for its people.

NDTV: The final round of the Dialogues tonight. Dr Binayak Sen, the issue of political will, why is it that healthcare is not in the political agenda of say the key stakeholders in this next election? You just saw Narendra Modi saying toilets over temples; Jairam Ramesh said that I have being saying that for a while. You may hear these stray references to sanitation, health etc. but what wins elections still seems to be about religions caste etc. Why? You have come from the state like Chhattisgarh, you worked there, why do you think health is not a major issue, not then an election issue?

Dr Binayak Sen: I think that health is not a major issue because people don't see it as an issue, which it can be articulated by...

NDTV: ...voter

Dr Binayak Sen: ...the sections of the voters who count, count within inverted, within...

NDTV: ...inverted commas

Dr Binayak Sen: ...within inverted commas. Sections of those, sections of the voters who count, who can articulate their entitlements in the face of overall demand patterns. I think that is not happening and so health is being seen as a kind of concession that is being made by the government. You know, among the all the other important functions that they perform, this is another function which you know, a welfare function, that government is you know performing as a kind of, you know, as a kind of a concession to the demands of the people. I think that people have to realise that; that with these patterns of inequity and violence that we have talked about we cannot have a viable sustainable society, in which these patterns of inequity and violence are perpetuated. I think that is something that people need to realise and that there is no way out of this of recognising these entitlements, that we, it's not just a matter of votes or a matter of whose forces are stronger in the market. Unless there is equity, unless there is justice, unless there is peace, we will not be able to survive as a society. I think this is something that we need to understand.

Kiran Mazumdar Shaw: Even today if you look at the political rhetoric, not one says healthcare being mentioned, so far. Yet there are states that have won elections based on promises on healthcare.

Dr Srinath Reddy: In fact in Andhra Pradesh Rajashekhar Reddy attributed his re-election to his healthcare initiative. But let me give you one positive news. It's being shown that in panchayats, which are headed by women, the expenditure on water, sanitation and health is much better, in terms of actual allocation and utilization, than in panchayats which are traditionally headed by men. Therefore the 33 per cent reservation has paid off in some ways. I think we do need more women, less foeticide and more women and more women leaders, but I think the lesson is also decentralisation. We need more decentralisation on local accountability.

Dr Binayak Sen:
We need to, in fact, decentralization I agree totally with that. But we also need to give more recognition to the democratic processes at the periphery, rather than just looking at you know legislature and what they do.

Dr Ashok Seth: Lets, the doctor says one important point that, that I believe is very important and its getting missed out in all our discussions, is that while there's a section of our population that requires free healthcare, that advancements of science and technology which are happening, when I said earlier on that these are not mutually exclusive, that while we look at malaria and malnutrition, we can't forgo the fact that advancement and science and technology have to be made available. The issue is that every advancement of science and technology, as we see it, comes at a cost. And our job now in the countries, how thus it becomes available to the common man, at affordable costs. And we're missing out this affordable cost business. Because while we may talk about free healthcare, we know the free healthcare for all, in a quality based manner, taking into an account investment of science, also is not practical. United States, UK, all withered under the issue of free healthcare and yet even in our teaching institutions, like All India Institute of Medical Sciences and GB Pant, there is an issue about affordable. There are patients who are charged some amount of money, which is affordable to them. We need to scale down from the private sector to a mid-path, which says, let's get around the table and talk about affordable healthcare. There's this is the whole population of middle class, who is okay for them to actually pay for, say a complex angioplasty technique, 50 thousand. But what would be impossible for them is to pay 3 lakhs. Now there are ways to get to that. And the way to get that is to create a milieu of innovations, create a milieu of frugal innovations, create a sector, who develops innovative technologies.

Kiran Mazumdar Shaw: No economy as a scale itself, is an option for us

Dr Ashok Seth: Yes create sectors, which actually develop these, gives these important advantages in milieu of creation, of research, of academic, of thought processes. Let's have what they do in the West right here, and let's create an encouraging milieu for every aspect. Be it low cost innovation strategies, be it zones, which are tax free zones, of creating these very technologies from outside within this country. Let us actually believe that we could actually do it together to provide affordable healthcare. And if the motto is affordable healthcare to all, it is achievable. If we actually talk about free healthcare for all then even the government will not be able to sustain any form of business model and that is what my biggest concern about all this, this is all...

Kiran Mazumdar Shaw:
I totally agree

Dr Binayak Sen: I don't agree with that...

Kiran Mazumdar Shaw: No, I think there is a tiered system

Dr Binayak Sen: ...because I think that we need to get into, we need to get into a; you see the high level expert group talked about universalise, universal access to healthcare. And it's important that it should be universal. Let it mean, it should be available to everybody on cashless basis. See this, I think that we do have enough resources as a country, we do have enough resources to fund universal healthcare.

NDTV: But may be those who afford it why should...

Dr Srinath Reddy:
Let me put it here this is way. Not only the World Health Organisation chief, but the World Bank chief, Jim Kim, in the World Health Assembly in May said, user fee is both unfair and inefficient and it punishes the poor, it shuts the door on poor. The question is if you are actually efficient in collecting your taxes, and the government has not been, then the taxation itself is a progressive measure in which everybody contributes, through the taxes, to their own healthcare. But employer-provided insurances also can be additional element. But at this point in time, primary services, emergency services, at least much be ensured to every single citizen and nobody should be able to really search in his pocket before approaching for an important healthcare need. So that is where we actually said, universal is a principle, in which everybody is entitled to a certain level of services; because services that are designed only for the poor, as a matter of charity, will never actually be properly designed or delivered. Everybody should have a stake in this system. And the reason why United States is actually in trouble is because, before Obamacare, their costs were escalating. And why did they actually introduce it, because 15 per cent of the GDP was going into healthcare. General Motors was bankrupted because of healthcare costs of the workers. It was more of a healthcare industry, with automobile as ancillary. So that is the reality, we can't afford our healthcare costs to pileup. We have to contain them. And the answer is strengthen primary healthcare, secondary and tertiary care and I agree with Ashok that we need modern science. Modern science and basic health services are not in mutual expulsive. But the reality is, in terms of healthcare, India exists simultaneously in five centuries. We must ensure that the 20th century is a century where we all unify in one century, rather then spread across five centuries.

NDTV: Well I could think to end this dialogue with tonight. Thank you very much for joining me. Hopefully this will be a political issue in these elections and top priority for the next government as well, thank you very much, all of you, for joining me tonight. Thank you.