Eleven years ago in September 2005, Indian Prime Minister Manmohan Singh attended the World Summit at the United Nations that reviewed progress towards the Millenium Development Goals. He came back with the lesson that maternal and child health status in India needed serious attention. Almost immediately, the fledgling Janani Suraksha Yojana got a budgetary boost and country intensified its call for hospital-based childbirth through improved ambulance services and other measures like free hospital stay and care for mother and infant. Ten years later our maternal mortality figures have reduced considerably.

Unfortunately this year, Prime Minister Narendra Modi did not attend the United Nations General Assembly and most of India’s concerns at the international forum were about terrorism. It is not clear whether India has brought back from the United Nations relating to the Sustainable Development Goals that replaced the Millenium Development Goals last year. One would hope so because a review of the indicators shows that India’s approach to healthcare needs to be recalibrated.

Among the 17 Sustainable Development Goals for the year 2030, health is an important domain. Goal three reads “Ensure healthy lives and promote wellbeing for all at all ages”. Lancet has reviewed the health-related goals for 188 countries and the news for India is not good.

The right indicators

The last 20 years are important from an Indian standpoint because they represent a period of rapid economic growth. The average annual growth rate has been around six percent or more and the per capita income has risen from $381.5 to $1,581. But while India is among the top ten global economies both in nominal terms and in terms of purchasing power parity, the health rank of India according to The Lancet report is a lowly 143. This rank is lower than all the other BRICS nations with Brazil and China being ranked 90 and 92 respectively. In the last 20 years India’s composite score has improved only 15 points and its rank has risen from 152 to 143. This is less than the progress of our sub continental neighbours like Bangladesh and Nepal who have improved from 18 and 17 points respectively with far less impressive economic growth. Clearly economic growth alone is not going to improve India’s health status in the future.

The 33 indicators on the SDG indicator list provide interesting areas for examination and comparison with other developed nations. Iceland, Singapore, Sweden, UK, Finland, Spain, Netherlands, Canada and Australia are among the first ten countries on this list with scores above 80. The health issues with the least scores in countries with that fare well on health relate to overweight, HIV, suicide, alcohol abuse and smoking. India, conversely, has done well on these grounds with high scores for overweight, alcohol and smoking along with family planning and neglected tropical diseases.

The problems that plague India are malaria, hygiene, water and air quality along with maternal mortality, neonatal mortality and mortality due to air pollution and water borne diseases and diseases due to particulate matter in air which causes obstructive lung disorders. It is necessary to understand the nature of these conditions if we have to understand how best to address them.

Even through maternal mortality has dropped considerable in the last ten years, the reduction is not uniform. There are many regions where the maternal death rates continue to be unacceptably high and compared to which our neighbours Bangladesh and Nepal have done better. The emphasis on maternal and child health needs to continue but the quality of care needs serious improvement and alternative approaches must be considered for marginalized and poorly served communities.

The urbanisation problem

The biggest emerging problems lie in rapidly urbanising India where malaria and its cousins dengue and chikanguniya, air pollution and water-borne diseases are surging. Nearly a third of our population lives in cities now and this proportion is set to increase rapidly in the coming years. Much of this increase will happen in smaller cities and among the poorer sections in the bigger cities. Sewage disposal, and treatment along with provision of safe drinking water are urban challenges for mosquito control. At the same time air pollution is causing more chronic respiratory disorders.

The review of the Swachch Bharat Mission, which is not a comprehensive solution to hygiene, sanitation and safe water, shows that it has yet to deliver the anticipated results. Even where the latrines have been built they are not being used, showing our current efforts are not adequate. Managing these problems requires more than photo-opportunity with a broom – it needs a public health approach with many more robust civic services.

The wrong direction

The Indian health policy architecture today is moving in the wrong direction. The medical education system has been producing “specialists” for a lucrative private sector. The departments of public health in most municipalities have dwindling staff and budgets. The overall investment in health by the government at about one percent of GDP is among the least among all countries in the world. Insurance based healthcare services by the private sector are being posited by the government, completely ignoring the fact that the formal private sector may not exist in any robust manner in very large number of districts in the country. Even in urban India, the five-star corporate hospitals are out of the reach of the average citizen, and in many urban settlements informal practitioners’ rule in the absence of a functioning regulatory system. The Medical Council of India has been found so deficient that the Supreme Court has mandated an oversight committee till a new mechanism for regulating medical care is devised by the government.

India’s poor status is repeatedly emphasised when any global report around health is released, however it seems to leave little impression among those classes who shape political interest, including the media or the middle class. Businesses see healthcare as a profit sector and India’s healthcare industry notably “medical tourism” is now a driver of growth. But this growth will not last long if we fail to grasp the ephemeral nature of our demographic dividend. It is true our youth are our greatest asset and India is a country with the world’s largest number of young people. Lacking opportunities in villages young people are migrating in large number to cities that are not safe. As we fail to provide adequate healthcare support their productivity will be seriously affected.

India is between many transitions – between the rural and the urban, between an agrarian and an industrial or service-based economy. The choices we make around healthcare will be very important for our country as it will determine whether we continue our trajectory economic growth.

The author is the director of the Centre for Health and Social Justice in New Delhi, clinical assistant professor in the department of global health at the University of Washington in Seattle, co-chair of the MenEngage Alliance and convener of the Community of Practitioners on Accountability and Social Action in Health.