population explosion

India is set to become the world’s most populous country by 2024. But is it ready?

India needs to fill the gaps in public healthcare, improve its sex ratio and infant mortality rates and address family planning concerns to sustain its growth.

By 2024, India will slip past China to become the most populous country and must rapidly prepare for a fast-changing economy.

India will likely hold that rank throughout the 21st century. Its population is 1.34 billion, nearly a fourfold increase since independence 70 years ago. China’s population, at 1.41 billion, roughly doubled over the same period. The pace of India’s population growth, now at 15 million per year, is the world’s largest. The two nations alone have more than a billion people and their population gap is projected to widen to 500 million by 2100. By comparison, the third and fourth most populous countries in 2100, Nigeria and the United States, are projected to have populations of nearly 800 million and 450 million, respectively.

Global growth: India is on track to be the world’s most populous nation (Source: UN Population Division medium variant projections)
Global growth: India is on track to be the world’s most populous nation (Source: UN Population Division medium variant projections)

Fertility factor

The long-term growth of India’s population, largely a function of fertility rates, is less certain. UN population projections indicate a range of possible scenarios. For example, if India’s current fertility of 2.3 births per woman remains constant, its population would grow to 1.8 billion by 2050 and 2.5 billion by 2100. Even under the instant-replacement fertility variant, with the country’s fertility assumed to fall immediately to 2.1 births per woman, India’s population would reach 1.9 billion by the century’s close.

The frequently cited UN medium projection assumes Indian fertility will decline to below replacement by 2035 and remain at 1.8 births per woman in subsequent decades. As a result, India’s population is projected to peak at 1.7 billion in 2060 before declining to 1.5 billion by 2100. The low projection assumes more rapid fertility decline to well below replacement level – about 1.3 births per woman – resulting in India’s population peaking at 1.5 billion around 2040 and falling to 900 million by 2100.

While India’s fertility has declined to about half the level of the late 1980s, that trajectory may not continue. In the past eight years, contraceptive use fell by almost 35%, as abortions and use of emergency pills doubled. More specifically, reliance on oral birth control pills fell 30%, reliance on condoms declined by 52% and vasectomies by 73%. This year, the Health Ministry launched a campaign to expand use of modern contraception with a focus on population stabilisation in 146 high-fertility districts across seven states. With India’s contraceptive prevalence rate at 52%, abortion has become a “proxy contraceptive” for many women, especially those from poorer households.

For decades, India relied on female sterilisation as the primary contraceptive method, funding about four million tubal ligations annually, more than any other country. In 2016, the government took major steps towards modernising that system, introducing injectable contraceptives free of charge in government facilities.

A relatively young age structure also contributes to India’s population growth. The median age in India is 27 years, compared to 38 years for China. Children under age 18 account for one-third of India’s population as compared with one-fifth of China’s.

However, due to fertility declines to near replacement levels, India’s population is also aging. The proportion of elderly aged 65 years and older is expected to double to 13% by 2050, and the number of working-age adults per elderly person is projected to fall from 11 to five.

India has achieved notable progress in reducing mortality rates. Life expectancy at birth increased from 44 years in the mid-1960s to 68 years today. India’s child mortality rate at 38 per 1,000 births still lags behind China’s rate of 11. Early marriage and pregnancy still contribute to excessive maternal deaths, and life expectancy of Indian women is eight years less than their counterparts in China.

Taking turns: Individual choices and government policies influence population growth (UN Population Division)
Taking turns: Individual choices and government policies influence population growth (UN Population Division)

Skewed sex ratio

India and China, unlike most other nations, have significantly more males than females. In both countries, infant mortality was higher for females than males in the 2000s. Skewed sex ratios are due in part to use of prenatal ultrasound scanning to abort female fetuses. The practice of sex-selective abortion, while prohibited, is difficult to eliminate. In coming decades, number of “surplus males” who can’t find brides in India could reach 40 million by some estimates. Contributing to son preference: expected care for elderly, traditional departure of daughters to husbands’ households after marriage and expectations for a bride’s parents to pay a dowry to prospective in-laws.

Such traditions linger in India, where the population is predominately rural in contrast to China’s urban population of 57%. Urban populations generally transition more rapidly to lower fertility rates.

India’s rate of urban population growth is expected to climb, partly due to migratory flows, especially youths seeking jobs. By mid-century, half of India’s population, about 830 million people, is expected to be urban dwellers, which will challenge government capacities to provide basic services and infrastructure. About one-fifth of the population lives without electricity.

Big if: India’s population may vary by as much as 1.5 billion by the end of the century, depending on whether the fertility rate falls to 1.3 children per woman or remains at the current 2.3 children (Source: UN Population Division, 2017)
Big if: India’s population may vary by as much as 1.5 billion by the end of the century, depending on whether the fertility rate falls to 1.3 children per woman or remains at the current 2.3 children (Source: UN Population Division, 2017)

Healthcare challenges

Healthcare also lags, with about half of Indian children reported to be undernourished. About two-thirds of them are immunised for diphtheria/pertussis/tetanus, compared to nearly all in China. Tuberculosis in India accounts for over a quarter of reported new cases worldwide, the highest of any country. Another public health challenge: the lack of sanitation facilities for more than half of India’s rural population

More than half of India’s population lives in areas vulnerable to calamities such as earthquakes, floods, cyclones, droughts and tsunamis, and the government continues to develop early-warning systems and promote community preparedness.

International migration plays a negligible role in India’s population growth. Nevertheless, India has the largest emigrant population, with approximately 16 million Indians living abroad and millions more planning to emigrate. India is the world’s largest remittance recipient, receiving on average close to $70 billion annually in recent years. The country implements strong enforcement measures to prevent illegal entry of immigrants, especially from Bangladesh.

Despite high rates of economic growth, forecast to exceed 7% for 2017, the benefits do not trickle down to most Indians. Despite India’s relatively large middle class, many struggle to secure basic daily needs. About 25% of Indians live on less than $2 a day and the country accounts for one in three of the global population living in poverty.

India struggles to create enough jobs for its growing working-age population. Over the coming two decades, the working-age population is projected to increase by more than 200 million. Over 30% of Indians aged 15 to 30 years are neither in employment nor in education and training, more than double the OECD average and nearly three times that of China. At the same time, Indian businesses report shortages of qualified skilled workers. In addition to its efforts to making labour regulations friendlier for job creation, the government must invest in education and vocational training.

Wary about automation and new technologies transforming workplace productivity and redefining the role of workers, education and business leaders recommend a major rethink of curricula and university training programs. India ranks sixth in publications on AI research, between 2011 and 2015, but lacks strategic policies.

India accounts for more than one-sixth of humanity. If the nation’s fertility rates remain unchanged, the population may double to 2.5 billion by 2100. Even if replacement-level fertility were achieved today, the population would still reach nearly 2 billion by 2100. The government must emphasise family planning while improving public health and the status of girls and women – or be hard-pressed to sustain high rates of economic growth and meet mounting aspirations of its billion-plus inhabitants.

This article first appeared on Yale Global Online.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.