Health care in India faces several challenges including inadequate access, low insurance penetration and a growing chronic disease burden. At the same time, traditional business models have found it hard to show attractive returns on investment, except for a few large providers. Technology infusion — along with expanded infrastructure and efficiencies from process improvements — could help improve health care accessibility and affordability, according to experts who spoke about emerging trends in that industry at the 2020 Wharton India Economic Forum, held this month in Mumbai.
Despite its shortcomings, India’s health care sector has a lot going for it on several fronts. A government-led push to get health care providers to embrace electronic medical records is enabling artificial intelligence (AI) to extract insights from patient data to deliver better treatment. The availability of telecom bandwidth is making medical expertise reach underserved rural markets through telemedicine and tele-consulting programs, delivered over mobile phones.
The Indian government’s ‘Make in India’ initiative is encouraging domestic manufacture of medical devices and helping lower the prices patients pay for products such as stents and implants, which in the past were imported. At the same time, in India the policy environment and regulators need to accommodate technological interventions such as the growth of online pharmacies with the requisite controls in place, according to the panelists. Health care innovation in India could serve as a global model for a shift from treating the sick to preventive care and wellness, given the size of its underserved populations, they said.
Health care has the potential to lead to economic growth and to provide employment, but it also is a crucial sector in terms of “protecting the health and the wealth of the nation,” said Sangita Reddy, joint managing director of Apollo Hospitals, a chain of health care facilities, and president of the Federation of Indian Chambers of Commerce & Industries.
Health care offers the opportunity to find ways to make medical services “more understandable, affordable and accessible,” said Gaurav Agarwal, co-founder and chief technology officer at 1 mg, an online pharmacy and digital health care platform. The three-year-old firm, based in Gurugram in India’s northwestern state of Haryana, has already seen 85 million customer visits annually to its platform, which allows patients to not just buy medicines but also make bookings for lab tests or doctor consultations.
India’s health care industry is becoming more and more attractive for investors, with technology-led innovations helping penetrate second- and third-tier markets, said Puncham Mukim, managing director at Everstone Capital Advisors in Mumbai. The firm has investments across health care investment categories including hospitals and medical device makers, and has invested $400 million in the past couple of years, he said.
Changing the Dialogue
In laying out India’s health care challenges, Reddy noted that across the entire supply chain from the general medical practitioners to tertiary care hospitals and government-run facilities, “everybody is working on incremental access.” At the same time, she said the country has “high quality health care,” and that the private sector provides more than 76% of such care. She described that scenario as “islands of excellence in an ocean of inadequacy.”
“Care is shifting from the hospital to the clinic, from the clinic to the home and from the home to a 24/7, ubiquitous access to care, driven by the mobile phone.” –Sangita Reddy
A significant portion of the country’s population is underserved in health care, Reddy said. India has a doctor-to-patient ratio of 1:10,189, some 10 times lower than the 1:1,000 recommended by the World Health Organization, according to a report by The Center for Disease Dynamics, Economics and Policy, a Washington, D.C.-based research organization. The country’s doctor-to-patient ratio must see an increase with a doubling of the number of doctors; India needs three times as many nurses and five times the paramedics it now has, she said.
While these challenges are daunting, they provide “a tremendous opportunity to disrupt traditional health care models,” Reddy continued. She called for a shift from what has traditionally been “sick care” to wellness, and said that provides opportunities “to flip the health care paradigm and focus on prevention.” A two-pronged approach, “which is to grow the [health care] infrastructure, improve the methodology, the efficiency and the way we do things; and reduce the burden of disease” will address the supply-side constraints, she said. “If we do these things together, we might not just help solve India’s health care problems, but we will show a model for the world.”
Agarwal noted that India has a chronic disease burden or non-communicable diseases burden of almost 20% of its population, where nearly 200 million people have some chronic disease. Of that, just diabetes and hypertension afflict some 100 million people, and that patient population is growing by 13% a year, he said. To make matters worse, the rate of patient adherence to prescribed treatments is abysmally low, he added.
According to a paper by the All India Institute for Medical Sciences, patient non-adherence to medication ranges from 24% for cardiac patients to between 50%-80% for hypertension patients. The reasons include complex medication regimes, exhausted medication supplies and adverse drug reactions, it noted.
At the Tech Altar
Agarwal saw technology as the imperative to address some of the inadequacies, and listed a few of those. “Unlike the west, which has evolved into this massive care-driven health care ecosystem, India has a consumer-led health care ecosystem,” he said. “If you go to any hospital, you see patients walking around with their files. Insurance penetration in India is at 15%. There’s zero outpatient insurance, which means that when you go see a doctor for your day-to-day needs, there is no insurance available whatsoever. So from a cost improvement perspective, the payer as the patient is incredibly motivated to figure out how to reduce his or her disease cost burden on a monthly basis.”
At the same time, in India, the patient owns the health data, which Agarwal saw as “extremely fascinating” – it happened to be the germ of the idea behind founding his online pharmacy 1 mg. “In the U.S., my health care data was digital, but nobody had any access to that data,” he said, recalling his decade-long stint as an engineer in the San Francisco Bay Area. “But in India, we own our data and we are actually fairly okay with people having access to that data.” Such a data-rich country could provide the opportunity to do pioneering work on disease progression models and the like, and share them with the rest of the world, he added. “Health care will become consumer centric. India will drive that revolution.”
In September 2018, India launched its National Health Protection Mission called “Ayushman Bharat Yojana” with the aim of providing 100 million poor and vulnerable families (approximately 500 million beneficiaries) health care insurance coverage up to Rs. 500,000 each ($7,150 approximately) for secondary and tertiary care hospitalization. “From a large swathe of population that was hitherto untreated and undiagnosed, Ayushman Bharat [provides] large swathes of the population the opportunity to get diagnosed,” said Mukim.
Mukim noted, however, that sufficient capacity does not exist in terms of primary and secondary health care even in Tier 1 markets, or those with a population of 1,000,000 or more, which typically are large metropolises like Mumbai or Chennai (Tier 2 and Tier 3 markets are defined by progressively smaller populations). Most of the existing health care facilities are in those markets, and they attract most of the new investments in capacity as well, he added. Some pockets are coming up to speed with the need, though. Hyderabad and Chennai, for instance, are no longer “under-bedded,” he noted.
A major hurdle to expanding access to health care is a mismatch between the capital costs of building hospitals and the ability for those to generate sufficient returns for investors, said Mukim. Further, approvals and permits to build hospitals consume “a lot of time,” he added. The cost of setting up a hospital is not vastly different across markets, whether it is Tier 1, 2 or 3, he noted. But patients’ ability to pay gets progressively lower from urban to semi-urban and rural markets “because it’s all out-of-pocket” in the absence of insurance, he pointed out. “There has to be some help on that [front] to reduce cost of putting up capacity.”
To-do List for Technology
The first tier of technology-driven gains in productivity would come from efficiency enhancements, according to Reddy. Inventory management would be a prime focus area, since hospitals need to stock tens of thousands of different items, she said. The second tier is simplification of processes to improve accessibility for patients, she said. “Can they have the predictability of an appointment? Can you do basic scheduling for doctors? Can you minimize waiting time when you come in?” Her company’s app, AskApollo, facilitates about 7,000 appointments daily and guarantees wait times for a doctor of no more than 20 minutes, except in cases of emergencies.
“Around 20% of consultations on 1 Mg are actually done by an AI doctor. They’re just as accurate as a panel of six doctors.” –Gaurav Agarwal
The app helps bring an “efficiency layer across the spectrum” where, for instance, housekeeping staff could turn around rooms faster and the admissions desk knows which rooms are available at the press of a button, said Reddy. Electronic health records help its doctors “manage and move data” related to patients. The next layer is in establishing care protocols for hospital processes, she said. For example, such protocols allow “the newest doctor in Apollo to operate at the efficiency of someone with 20 years experience,” she explained.
Next, electronic medical records (EMR) make it possible to improve the quality of service, among other benefits, Reddy noted. “Once you have digitized [hospital processes] you can take the collated data, look at outcomes and build AI models that can be applied across the ecosystem,” she said.
The Three Bs of Health Care
Reddy identified “three Bs” that are changing health care. The first is “biology,” where technology could help lower the costs of genetic testing and facilitate new business models around targeted treatments, precision medicine and preventive care, she said. Her second ‘B’ refers to “bytes” or the steady drop in the cost of computing, driven by Moore’s Law (the number of transistors on a microchip doubles every two years while the cost of computing in that period is halved). The third front is “bandwidth” in digital communications, which along with India’s growing tele-density could expand health care access for rural India. It could facilitate tele-monitored surgeries, tele-education, tele-medicine and video consultations with doctors. Technology has also helped bring efficiencies in areas like CT (computed tomography) scans, such as better images and faster diagnosis, she said.
Other shifts are also underway thanks to technology. “I see care shifting from the hospital to the clinic, from the clinic to the home and from the home to a 24/7, ubiquitous access to care, driven by the mobile phone,” said Reddy.
Agarwal had his own technology war story where it helped 1 Mg overcome initial hiccups. As an online pharmacy, the company operated in a two-sided marketplace with patients requesting medicines on the one hand and retail pharmacies that dispense those medicines on the other. Barring the large retail chains, pharmacies had digitized their operations, which meant they had few records of the drugs they carried. India is a branded generic drugs market with between 80 and 100 brands “for each drug that has been discovered,” which translated into a monthly demand on the 1 Mg platform for up to 25,000 unique medicines each month, said Agarwal. “An average pharmacy stocks only 3,000 of those [25,000 medicines], and they didn’t know which 3,000 they stocked,” he added. “They knew the top 100 but they didn’t know anything after that.”
An AI-based predictive inventory model that 1 Mg developed found for it a way out of its frustrating experience in trying to match consumer demand with supplies from pharmacies. The model worked on two simple assumptions but worked well for 1 Mg. It assumed that if a pharmacy actually dispensed a certain drug in one week, it was likely to do so in the following week as well. Similarly, it also assumed that if a pharmacy did not dispense a certain medication in one week, it was unlikely to sell that in the following week. “That was a first use of AI and machine learning in our system, where we actually achieved 75% to 85% fill rates, based on zero inventory accuracy from our vendors,” said Agarwal.
When 1 Mg later added diagnostic testing services to its offerings, it again tapped technology in the form of a mobile app for patients to make bookings online. The phlebotomists it deploys to collect blood samples follow a specific protocol and use bar coded stickers with patient identification information that they stick on collection vials. Telemedicine is another tech-driven foray at 1 Mg, and it does nearly 5,000 of those daily, said Agarwal.
The firm also built an AI model for doctor consultations. The AI doctor comes up with a diagnosis and treatment plan that 1 Mg doesn’t share with the patient. Instead, it shares that with a real doctor, who then validates it or invalidates it. “Around 20% of consultations on 1 Mg are actually done by an AI doctor,” said Agarwal. “They’re just as accurate as a panel of six doctors that have varied levels of experience in [a given] field.”
Indian health care’s unique characteristics have called for custom solutions. For instance, handwritten doctor prescriptions are common, and 1 Mg uses an AI machine to decipher about half of such data, making it ready for further analytics. “A lot of the technology for health care in India was actually just in aping the west,” said Agarwal. “The challenge is that the ecosystem in India is very different. We’re now starting to see health care tech which is very India-centric.”
“The [Indian government’s] ‘Make in India’ campaign has actually worked for medical devices.” –Puncham Mukim
Notwithstanding the technology innovations by online pharmacies such as 1 Mg, regulators and courts in India have frowned on them, egged on by public interest litigants. The latest roadblock came last November from India’s drugs controller, who issued an order to stop online sales of medicines until regulations were put in place. “Every third day you have complaints against online retailers saying that they’re selling medicines without prescriptions, and that they should be shut down,” said Mukim. The reality is vastly different, he argued. “If you walk into any brick-and-mortar pharmacy in India, 50% of the time you would probably be able to get a medicine without a prescription. [However], if you try to buy from the larger online retail pharmacies, there is a 0.01% chance you’ll be able to get medicines without a prescription. The people who are flouting the rules are creating nuisance value for those who are following the rules — and the cost of following the rules is very high. There ought to be a policy framework to come into place [to regulate online pharmacies]; we’ve been waiting for long.”
Mukim batted for India’s nascent online pharmaceutical retail industry, saying that it has in three-four years achieved a market penetration that brick-and-mortar pharmacies have failed to do. “[Online pharmacies] have gone deep into Tier 2 and Tier 3 markets,” he said. “Medicine availability has been a huge problem in rural India and they’ve solved that problem.”
Elsewhere in the health care industry, regulators seem to have gotten it right. Three years ago, India’s drugs regulator brought price controls on coronary stents, slashing prices by some 85% (it has since accommodated marginal increases). “The cost of manufacturing a drug-eluting stent is Rs. 6,000 to Rs. 7,000 ($85 to $100), but it [was being] sold for Rs. 150,000 ($2,140) in India,” said Mukim. He blamed middlemen in the trade channels and “clinicians who were hand-in-glove with them in pushing the cost so high for patients.” The price cap on stents has given a great boost to domestic manufacturers of stents, and they are now supplying their products to some multinational brands as well, he added.
Mukim noted that the lower prices of health care in India relative to those in developed countries have made it attractive for international patients, especially those from the Middle East and Southeast Asia.
Investors such as Mukim appreciate the disruptive effect of price caps on stents, and see early signs of that mindset spreading elsewhere across the health care sector. Domestic stent manufacturers have begun supplying to Tier 2 and Tier 3 markets that were hitherto overlooked, he noted. More cath lab capacity is being added in the industry, as lower price points have resulted in a business boom for diagnostic services, he added. Furthermore, more and more higher-end technology in implants, and in drug-eluting stents, is starting to come into India, and foreign manufacturers of such devices are looking to set up capacity in India, he added. “The [Indian government’s] ‘Make in India’ campaign has actually worked for medical devices.” He slipped in a request to regulators to tweak the import duty structure for especially higher-end medical device equipment.
Pointers for Policy and Regulation
Data privacy is the next frontier for which Indian health care practitioners have to prepare. Health care data privacy is covered in the European Union by the GDPR (General Data Protection Regulation) that took effect in May 2018 and in the U.S. by the so-called HIPAA rules. Agarwal said India needs data privacy regulations, “but not at the level of say HIPAA or GDPR.” He suggested “something which is much more reasonable and takes into account the growing needs of the country.”
Reddy said “a modified level of data privacy [regulation] is not just good for health care companies, but is good for the country, and it’s essential.” Ideally, data privacy regulation must also recognize the advantages that analytics could offer. Reddy called for a focus on “standardization of data capture,” so as to avoid information sitting in silos across different organizations. “That lack of standards is what will impede us from collating our data and building new predictive models,” she said.
Join The Discussion
2 Comments So Far
Anumakonda Jagadeesh
Excellent.
Healthcare in India
The Indian Constitution makes the provision of healthcare in India the responsibility of the state governments, rather than the central federal government. It makes every state responsible for “raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”.
The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002, and then again updated in 2017. The recent four main updates in 2017 mentions the need to focus on the growing burden of non-communicable diseases, on the emergence of the robust healthcare industry, on growing incidences of unsustainable expenditure due to health care costs and on rising economic growth enabling enhanced fiscal capacity. In practice however, the private healthcare sector is responsible for the majority of healthcare in India, and most healthcare expenses are paid directly out of pocket by patients and their families, rather than through health insurance. Government health policy has thus far largely encouraged private sector expansion in conjunction with well-designed but limited public health programmes.
A government funded health insurance project was launched in 2018 by the Government of India, called Ayushman Bharat.
According to the World Bank, the total expenditure on health care as a proportion of GDP in 2015 was 3.89%. Out of 3.89%, the governmental health expenditure as a proportion of GDP is just 1%, and the out-of-pocket expenditure as a proportion of the current health expenditure was 65.06% in 2015.
Healthcare system
Public healthcare
Public healthcare is free and subsidized for those who are below the poverty line. The Indian public health sector encompasses 18% of total outpatient care and 44% of total inpatient care. Middle and upper class individuals living in India tend to use public healthcare less than those with a lower standard of living.[11] Additionally, women and the elderly are more likely to use public services. The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status or caste.[12] However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Much of the public healthcare sector caters to the rural areas, and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are long distances between public hospitals and residential areas, long wait times, and inconvenient hours of operation.
Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved. Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.[12]
Considering the goal of obtaining universal health care as part of Sustainable Development Goals, scholars request policy makers to acknowledge the form of healthcare that many are using. Scholars state that the government has a responsibility to provide health services that are affordable, adequate, new and acceptable for its citizens. Public healthcare is very necessary, especially when considering the costs incurred with private services. Many citizens rely on subsidized healthcare.[11] The national budget, scholars argue, must allocate money to the public health sector to ensure the poor are not left with the stress of meeting private sector payments.
Following the 2014 election which brought Prime Minister Narendra Modi to office, the government unveiled plans for a nationwide universal health care system known as the National Health Assurance Mission, which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments. In 2015, implementation of a universal health care system was delayed due to budgetary concerns. In April 2018 the government announced the Aayushman Bharat scheme that aims to cover up to Rs. 5 lakh to 100,000,000 vulnerable families (approximately 500,000,000 persons – 40% of the country’s population). This will cost around $1.7 billion each year. Provision would be partly through private providers.
Private healthcare
Since 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector. The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors.
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas. In terms of healthcare quality in the private sector, a 2012 study by Sanjay Basu et al., published in PLOS Medicine, indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare. However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure, which can be defined as health expenditure that threatens a household’s capacity to maintain a basic standard of living. Costs of the private sector are only increasing. One study found that over 35% of poor Indian households incur such expenditure and this reflects the detrimental state in which Indian health care system is at the moment. With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services. Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the World Bank, about 25% of India’s population had some form of health insurance in 2010. A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India’s population was insured. Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices. In Rajasthan, 40% of practitioners did not have a medical degree and 20% have not completed a secondary education. On 27 May 2012, the popular actor Aamir Khans program Satyamev Jayate did an episode on “Does Healthcare Need Healing?” which highlighted the high costs and other malpractices adopted by private clinics and hospitals. In response to this, Narayana Health plans to conduct heart operations at a cost of $800 per patient.
Medication
In 1970, the Indian government banned medical patents. India signed the 1995 TRIPS Agreement which allows medical patents, but establishes the compulsory license, where any pharmaceutical company has the right to produce any patented product by paying a fee. This right was used in 2012, when Natco was allow to produce Nexavar, a cancer drug. In 2005, new legislation stipulated that a medicine could not be patented if it did not result in “the enhancement of the known efficacy of that substance”.
Indians consumed the most antibiotics per head in the world in 2010. Many antibiotics were on sale in 2018 which had not been approved in India or in the country of origin, although this is prohibited. A survey in 2017 found 3.16% of the medicines sampled were substandard and 0.0245% were fake. Those more commonly prescribed are probably more often faked. Some medications are listed on Schedule H1, which means they should not be sold without a prescription. Pharmacists should keep records of sales with the prescribing doctor and the patient’s details.
Access to healthcare
There are 1.4 million doctors in India.[10] Yet, India has failed to reach its Millennium Development Goals related to health. The definition of ‘access is the ability to receive services of a certain quality at a specific cost and convenience. The healthcare system of India is lacking in three factors related to access to healthcare: provision, utilization, and attainment. Provision, or the supply of healthcare facilities, can lead to utilization, and finally attainment of good health. However, there currently exists a huge gap between these factors, leading to a collapsed system with insufficient access to healthcare. Differential distributions of services, power, and resources have resulted in inequalities in healthcare access. Access and entry into hospitals depends on gender, socioeconomic status, education, wealth, and location of residence (urban versus rural). Furthermore, inequalities in financing healthcare and distance from healthcare facilities are barriers to access. Additionally, there is a lack of sufficient infrastructure in areas with high concentrations of poor individuals. Large numbers of tribes and ex-untouchables that live in isolated and dispersed areas often have low numbers of professionals. Finally, health services may have long wait times or consider ailments as not serious enough to treat. Those with the greatest need often do not have access to healthcare.
Electronic health records
The Government of India, while unveiling the National Health Portal, has come out with guidelines for Electronic health record standards in India. The document recommends a set of standards to be followed by different healthcare service providers in India, so that medical data becomes portable and easily transferable.
India is considering to set up a National eHealth Authority (NeHA) for standardisation, storage and exchange of electronic health records of patients as part of the government’s Digital India programme. The authority, to be set up by an Act of Parliament will work on the integration of multiple health IT systems in a way that ensures security, confidentiality and privacy of patient data. A centralised electronic health record repository of all citizens which is the ultimate goal of the authority will ensure that the health history and status of all patients would always be available to all health institutions. Union Health Ministry has circulated a concept note for the setting up of NeHa, inviting comments from stakeholders.
Rural areas
Rural areas in India have a shortage of medical professionals. 74% of doctors are in urban areas that serve the other 28% of the population. This is a major issue for rural access to healthcare. The lack of human resources causes citizens to resort to fraudulent or ignorant providers. Doctors tend not to work in rural areas due to insufficient housing, healthcare, education for children, drinking water, electricity, roads and transportation. Additionally, there exists a shortage of infrastructure for health services in rural areas. In fact, urban public hospitals have twice as many beds as rural hospitals, which are lacking in supplies. Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities. Full immunization coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India. Inequalities in healthcare can result from factors such as socioeconomic status and caste, with caste serving as a social determinant of healthcare in India.
Rural south India
A 2007 study by Vilas Kovai et al., published in the Indian Journal of Ophthalmology analyzed barriers that prevent people from seeking eye care in rural Andhra Pradesh, India. The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).
The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care. Specifically, in one 2014 study conducted by Sherwin DeSouza et al. in a rural village near Karnataka, India, it was found that participants in community who owned a mobile phone (87%) displayed a high interest rate (99%) in receiving healthcare information through this mode, with a greater preference for voice calls versus SMS (text) messages for the healthcare communication medium. Some specific examples of healthcare information that could be provided includes reminders about vaccinations and medications and general health awareness information.
Rural north India
The distribution of healthcare providers varies for rural versus urban areas in North India. A 2007 study by Ayesha De Costa and Vinod Diwan, published in Health Policy, conducted in Madhya Pradesh, India examined the distribution of different types of healthcare providers across urban and rural Madhya Pradesh in terms of the differences in access to healthcare through number of providers present. The results indicated that in rural Madhya Pradesh, there was one physician per 7870 people, while there was one physician per 834 people in the urban areas of the region. In terms of other healthcare providers, the study found that of the qualified paramedical staff present in Madhya Pradesh, 71% performed work in the rural areas of the region. In addition, 90% of traditional birth attendants and unqualified healthcare providers in Madhya Pradesh worked in the rural communities.
Studies have also investigated determinants of healthcare-seeking behavior (including socioeconomic status, education level, and gender), and how these contribute to overall access to healthcare accordingly. A 2016 study by Wameq Raza et al., published in BMC Health Services Research, specifically surveyed healthcare-seeking behaviors among people in rural Bihar and Uttar Pradesh, India. The findings of the study displayed some variation according to acute illnesses versus chronic illnesses. In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased. Educational level did not correlate to probability of healthcare-seeking behavior for acute illnesses, however, there was a positive correlation between educational level and chronic illnesses. This 2016 study also considered the social aspect of gender as a determinant for health-seeking behavior, finding that male children and adult men were more likely to receive treatment for acute ailments compared to their female counterparts in the areas of rural Bihar and Uttar Pradesh represented in the study. These inequalities in healthcare based on gender access contribute towards the differing mortality rates for boys versus girls, with the mortality rates greater for girls compared to boys, even before the age of five.
Other previous studies have also delved into the influence of gender in terms of access to healthcare in rural areas, finding gender inequalities in access to healthcare. A 2002 study conducted by Aparna Pandey et al., published in the Journal of Health, Population, and Nutrition, analyzed care-seeking behaviors by families for girls versus boys, given similar sociodemographic characteristics in West Bengal, India. In general, the results exhibited clear gender differences such that boys received treatment from a healthcare facility if needed in 33% of the cases, while girls received treatment in 22% of the instances requiring care. Furthermore, surveys indicated that the greatest gender inequality in access to healthcare in India occurred in the provinces of Haryana, and Punjab.
Urban Areas
The problem of healthcare access arises not only in huge cities but in rapidly growing small urban areas. Here, there are fewer available options for healthcare services and there are less organized governmental bodies. Thus, there is often a lack of accountability and cooperation in healthcare departments in urban areas. It is difficult to pinpoint an establishment responsible for providing urban health services, compared to in rural areas where the responsibility lies with the district administration. Additionally, health inequalities arise in urban areas due to difficulties in residence, socioeconomic status, and discrimination against unlisted slums.
To survive in this environment, urban people use non-governmental, private services which are plentiful. However, these are often understaffed, require three times the payment as a public center, and commonly have bad practice methods. To counter this, there have been efforts to join the public and private sectors in urban areas. An example of this is the Public-Private Partnerships initiative. However, studies show that in contrast to rural areas, qualified physicians tend to reside in urban areas. This can be explained by both urbanization and specialization. Private doctors tend to be specialized in a specific field so they reside in urban areas where there is a higher market and financial ability for those services.
Financing
Despite being one of the most populous countries, India has the most private healthcare in the world. Out-of-pocket private payments make up 75% of the total expenditure on healthcare. Only one fifth of healthcare is financed publicly. This is in stark contrast to most other countries of the world. According to the World Health Organization in 2007, India ranked 184 out of 191 countries in the amount of public expenditure spent on healthcare out of total GDP. In fact, public spending stagnated from 0.9% to 1.2% of total GDP in 1990 to 2010.
Medical and non-medical out-of-pocket private payments can affect access to healthcare. Poorer populations are more affected by this than the wealthy. The poor pay a disproportionately higher percent of their income towards out-of-pocket expenses than the rich. The Round National Sample Survey of 1955 through 1956 showed that 40% of all people sell or borrow assets to pay for hospitalization. Half of the bottom two quintiles go into debt or sell their assets, but only a third of the top quintiles do In fact, about half the households that drop into the lower classes do so because of health expenditures.. This data shows that financial ability plays a role in determining healthcare access.
In terms of non-medical costs, distance can also prevents access to healthcare. Costs of transportation prevent people from going to health centers. According to scholars, outreach programs are necessary to reach marginalized and isolated groups.
In terms of medical costs, out-of-pocket hospitalization fees prevent access to healthcare. 40% of people that are hospitalized are pushed either into lifelong debt or below the poverty line. Furthermore, over 23% of patients don’t have enough money to afford treatment and 63% lack regular access to necessary medications. Healthcare and treatment costs have inflated 10–12% a year and with more advancements in medicine, costs of treatment will continue to rise. Finally, the price of medications rise as they are not controlled.
There is a major gap between outreach, finance and access in India. Without outreach, services cannot be spread to distant locations. Without financial ability, those in distant locations cannot afford to access healthcare. According to scholars, both of these issues are tied together and are pitfalls of the current healthcare system.
Initiatives to improve access
The Twelfth Plan
The government of India has a Twelfth Plan to expand the National Rural Health Mission to the entire country, known as the National Health Mission. Community based health insurance can assist in providing services to areas with disadvantaged populations. Additionally, it can help to emphasize the responsibility of the local government in making resources available. Furthermore, according to the Indian Journal of Community Medicine (IJOCM) the government should reform health insurance as well as its reach in India. The journal states that universal healthcare should slowly yet steadily be expanded to the entire population. Healthcare should be mandatory and no money should be exchanged at appointments. Finally, both private and public sectors should be involved to ensure all marginalized areas are reached. According to the IJOCM, this will increase access for the poor.
Public-private partnership
One initiative adapted by governments of many states in India to improve access to healthcare entails a combination of public and private sectors. The Public-Private Partnership Initiative (PPP) was created in the hopes of reaching the health-related Millennium Development Goals. It consists of three separate projects with different focuses: Fair Price shops which aim to reduce the costs of medications and treatment options; Rashtriya Swasthya Bima Yojana which reimburses those under the poverty line; and National Rural Telemedicine Network which assists with non-medical costs. This initiative was analyzed in the states of Maharashtra and West Bengal.
Fair Price Shops aim to reduce the costs of medicines, drugs, implants, prosthetics, and orthopedic devices. Currently, there is no competition between pharmacies and medical service stores for the sale of drugs. Thus, the price of drugs is uncontrolled. The Fair Price program creates a bidding system for cheaper prices of medications between drugstores and allows the store with the greatest discount to sell the drug. The program has a minimal cost for the government as fair price shops take the place of drugstores at government hospitals, thus eliminating the need to create new infrastructure for fair price shops. Furthermore, the drugs are unbranded and must be prescribed by their generic name. As there is less advertising required for generic brands, fair price shops require minimal payment from the private sector. Fair Price Shops were introduced in the West Bengal in 2012. By the end of the year, there were 93 stores benefiting 85 lakh people. From December 2012 to November 2014, these shops had saved 250 crore citizens. As doctors prescribe 60% generic drugs, the cost of treatment has been reduced by this program. This is a solution to affordability for health access in West Bengal.
The largest segment of the PPP initiative is the tax-financed program, Rashtriya Swasthya Bima Yojana (RSBY). The scheme is financed 75% by the central government and 25% by the state government. This program aims to reduce medical out-of-pocket costs for hospital treatment and visits by reimbursing those that live below the poverty line. RSBY covers maximum 30,000 rupees in hospital expenses, including pre-existing conditions for up to five members in a family. In 2015, it reached 37 million households consisting of 129 million people below the poverty line. However, a family has to pay 30 rupees to register in the program. Once deemed eligible, family members receive a yellow card. However, studies show that in Maharashtra, those with a lower socioeconomic status tend to not use the service, even if they are eligible. In the state of Uttar Pradesh, geography and council affect participation in the program. Those in the outskirts of villages tend to use the service less than those who live in the center of villages. Additionally, studies show household non-medical expenses as increasing due to this program; the probability of incurring out-of-pocket expenses has increased by 23%. However, RSBY has stopped many from falling into poverty as a result of healthcare. Furthermore, it has improved opportunities for family members to enter the workforce as they can utilize their income for other needs besides healthcare. RSBY has been applied in 25 states of India.
Finally, the National Rural Telemedicine Network connects many healthcare institutions together so doctors and physicians can provide their input into diagnosis and consultations. This reduces the non-medical cost of transportation as patients do not have to travel far to get specific doctor’s or specialty’s opinions.
The results of the PPP in the states of Maharashtra and West Bengal show that all three of these programs are effective when used in combination. They assist in filling the gap between outreach and affordability in India. However, even with these programs, high out-of-pocket payments for non-medical expenses are still deterring people from healthcare access. Thus, scholars state that these programs need to be expanded across India.
National Rural Health Mission
To counteract the issue of a lack of professionals in rural areas, the government of India wants to create a ‘cadre’ of rural doctors through governmental organizations. The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The NRHM has outreach strategies for disadvantaged societies in isolated areas. The goal of the NRHM is to provide effective healthcare to rural people with a focus on 18 states with poor public health indicators and/or weak infrastructure. NRHM has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff. The mission proposes creating a course for medical students that is centered around rural healthcare. Furthermore, NRHM wants to create a compulsory rural service for younger doctors in the hopes that they will remain in rural areas. However, the NRHM has failings. For example, even with the mission, most construction of health related infrastructure occurs in urban cities. Many scholars call for a new approach that is local and specialized to each state’s rural areas. Other regional programs such as the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India have also been implemented by state governments to assist rural populations in healthcare accessibility, but the success of these programs (without other supplemental interventions at the health system level) has been limited.
National Urban Health Mission
The National Urban Health Mission as a sub-mission of National Health Mission was approved by the cabinet on 1 May 2013. The National Urban Health Mission (NUHM) works in 779 cities and towns with populations of 50,000 each. As urban health professionals are often specialized, current urban healthcare consists of secondary and tertiary, but not primary care. Thus, the mission focusses on expanding primary health services to the urban poor. The initiative recognizes that urban healthcare is lacking due to overpopulation, exclusion of populations, lack of information on health and economic ability, and unorganized health services. Thus, NUHM has appointed three tiers that need improvement: Community level (including outreach programs), Urban Health Center level (including infrastructure and improving existing health systems), and Secondary/Tertiary level (Public-Private Partnerships). Furthermore, the initiative aims to have one Urban Public Health Center for each population of 50,000 and aims to fix current facilities and create new ones. It plans for small municipal governments to take responsibility for planning healthcare facilities that are prioritized towards the urban poor, including unregistered slums and other groups. Additionally, NUHM aims to improve sanitation and drinking water, improve community outreach programs to further access, reduce out-of-pocket expenses for treatment, and initiate monthly health and nutrition days to improve community health. (Wikipedia).
Pradhan Mantri Jan Arogya Yojana(PM-JAY)
Pradhan Mantri Jan Arogya Yojana (PM-JE) is a leading initiative of Prime Minister Modi to ensure health coverage for the poor and weaker population in India. This initiative is part of the government’s view to ensure that its citizens – particularly poor and weaker groups, have access to healthcare and good quality hospital services without facing financial difficulty.
PM-JAY Provides insurance cover up to Rs 5 lakh per annum to the 100 million families in India for secondary and tertiary hospitalization. For transparency, the government made an online portal (Mera PmJay) to check eligibility for PMJAY. Health care service includes follow-up care, daycare surgeries, pre and post hospitalization, hospitalization expenses, expense benefits and newborn child/children services. The comprehensive list of services is available on the website.
Dr.A.Jagadeesh Nellore(AP),India
Anumakonda Jagadeesh
Timeline of healthcare in India
This is a timeline of healthcare in India. Major events such as crises, policies and organizations are included.
Big picture
Year/period Key development
Prehistory The knowledge of the medicinal value of plants and other substances and their uses goes back to the time of the earliest settlers. Medical knowledge evolves through trial and error and exchange of know-how between diverse communities and regions.
Traditional medicine period Ayurveda, the science of life, has been the traditional system of healthcare in India for more than 5000 years. This medical system is well-established around 2500 to 600 BC, when it evolves into 2 schools: the School of Physicians and the School of Surgeons.
1600–1947 British colonial period. East India Company is established. Many British physicians assume broader scholarly roles and European medicine comes to be looked upon as the dominant medical knowledge system. British official colonial policy marginalizes indigenous medicine to secondary status. Notwithstanding European medicine becomes the official health care system, Ayurvedic colleges are still created. Ayurveda education becomes integrated with western concepts of healthcare.
1947 onward Post-independence period. The government of India makes efforts to recognize Ayurveda, Siddha and Unani as being on par with scientific medicine. Nevertheless, the general trend increasingly complies with the norms of modern medicine. In traditional medical schools the vocabulary and diagnostic tools of modern medicine replace traditional terms and techniques, and students increasingly become unfamiliar with classical references and methodologies.[1]
1980 onward Numerous government subsidies allow the introduction of private health providers. Also opening up of the market in the 90s further gives impetus to the development of the private health sector in India. Immunization programs increase.
21st century Today, the health status of India is still on a developing level. The private sector is the dominant healthcare provider. Private chains of healthcare providers are innovating very rapidly, offering high quality treatment at very low cost. As India incorporates world class technology and training, and low cost of service, a trend of medical tourism develops and strengthens in the 2010s.
Full timeline
Evolution of life expectancy in India for period between 1881 and 2005.
Year/period Type of event Event Location
7000 BCE
Origin Medical interventions such as dentistry and trepanation are practiced as early as this time. Indian subcontinent
5000 BCE Development Origin of Ayurveda medicine, when it originates as an oral tradition.
2500–1700 BCE Development Origin of Siddha medicine.
Tamilakam
600 BCE Development Ayurveda is branched into internal medicine; pediatrics; psychiatry; surgery; eye, ear, nose, and throat; toxicology; geriatrics; and eugenics/aphrodisiacs.
8th century CE
Development Texts called Nighantus dealing exclusively with the materia medica of Ayurveda are composed. Many of these works help to enlarge the repertoire of medicinal substances by incorporating knowledge of local practitioners and from foreign sources. A few well-known Nighantus are Madanapala Nighantu, Bhavaprakasha Nighantu, Dhanvantari Nighantu and Sodhala Nighantu.
1200s Development Unani medicine system is introduced in India via Rome. It integrates with other systems such as Ayurveda and Yoga.
1600s Development Introduction of western medicine in India. First medical officers arrive along with the British East India Company’s first fleet as ship’s surgeons.
1664 Organization (hospital) The Madras General Hospital is the first hospital opened in India. Chennai
1707 Organization (hospital) The Presidency General Hospital is formed.
Calcutta
1802 Organization (government body) A Superintendent General of Vaccination in India is appointed after the discovery of the smallpox vaccine.
1817 Crisis First cholera pandemic originates in the Ganges River Delta.
1823 Organization (medical school) The Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) is founded. It’s the oldest to teach European medicine in Asia. Today considered an Institute of National Importance.
Pondicherry
1829 Crisis Second cholera pandemic originates in the Ganges River Delta.
1835 Organization (medical school) The Calcutta Medical College is established.
Calcutta
1852 Crisis Third cholera pandemic originates in the Ganges River Delta.
1854 Development The government of India agrees to supply medicines and instruments to the growing network of minor hospitals and dispensaries. Government Store Depots are established in cities.[11]
Calcutta, Madras, Bombay, Mian Mir, and Rangoon
1858 Organization (asylum) Lunate asylums are established for insane persons.[11]
1860 Organization (medical school) The Lahore Medical School is established.[11][17]
Lahore (now in Pakistan)
1863 Crisis Fourth cholera pandemic originates in the Ganges River Delta.[14]
1869 Development A Public Health Commissioner and a Statistical Officer are appointed to the Government of India.[11]
1870 Organization (Mental Hospital) India’s first Western model mental hospital is opened in Oolanpara, Trivandrum.
Trivandrum
1870 Organization (government body) A central sanitary department is formed.
1873 Policy The Birth and Death Registration Act is passed.
1880 Policy An act is passed for the compulsory vaccination of children in municipalities and cantonments. Smallpox is the main target during this period, although vaccinations are also carried out for plague and other diseases.
1881 Crisis Fifth cholera pandemic originates in India. Bengal
1896 Organization (government body) The Plague Commission is constituted.
1896 Crisis The Bombay plague epidemic breaks out. It spreads across all of India and kills at least 2 million people.
1897 Policy The Epidemic Diseases Act is passed. The Governor General of India confers special powers upon local authorities to implement the necessary measures for control of epidemics.
1899 Crisis Sixth cholera pandemic originates in India.
1900 Organization (Hospital) The British Imperial Government opened the Trivandrum General Hospital in the princely state of Travancore.
Trivandrum
1912 Organization (government body) The Government of India sanctions the appointment of Deputy Sanitary Commissioners and Health Officers with the local bodies and releases funds for sanitation.[11]
1912 Policy The Indian Lunacy Act is passed.
1921 Organization (hospital) Sir Ganga Ram Hospital is founded. Lahore
1925 Organization which helped (medical institution) The National Institute of Mental Health and Neurosciences is established. Today it is listed as an Institute of National Importance.
Bangalore
1926 Organization (hospital) King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College is founded.
Mumbai
1930 Organization (health training) The All-India Institute of Hygiene and Public Health is established. Calcutta
1933 Policy The Medical Council of India is formed, with the purpose of establishing uniform and high standards of medical education in India.
1933 Organization (hospital chain, medical school chain) Excelsior Clinic is established in the town of Thodupuzha, which later became known as Chazhikattu Hospital, with the purpose of giving healthcare to the area, which until then had none. Thodupuzha
1938 Policy The Bombay Medical Practitioner’s Act is passed. With it comes the first legal recognition and registration for the Indian systems of medicine.
1939 Organization (health training) The first Rural Health Training Center is established near Calcutta. Singur
1939 Organization The Tuberculosis Foundation of India is established.
1940 Policy The Drugs Act is passed and drugs are made under the control of the government for the first time.
1946 Organization (medical school) Darbhanga Medical College and Hospital is established.
Bihar
1948 Program launch (healthcare coverage) The Employees’ State Insurance Scheme (ESIS) is launched with the objective of achieving universal health coverage. Targeted at employees with income less than Rs 15000/month and dependents.
1950 Policy The Insurance Amendment Act leads to the Government of India deciding to nationalize the insurance business.
1951 Organization (medical school) The Government Medical College, Thiruvananthapuram is established in Trivandrum, Kerala.
Trivandrum
1953 Organization (hospital chain, medical school chain) Manipal Hospitals is founded as a part of the Manipal Education and Medical Group (MEMG). Bangalore
1953 Policy The Delhi Nursing Home Registration Act is passed. Delhi
1954 Program launch (healthcare coverage) The Central Government Health Scheme (CGHS) is launched with the objective of achieving universal health coverage in government employees and families.
1956 Organization (medical college chain) The All India Institutes of Medical Sciences (AIIMS) are founded with a first college in New Delhi. These institutes are declared institute of national importance by the Act of Parliament. New Delhi
1962 Organization (medical and research institution) The Postgraduate Institute of Medical Education and Research is established. Today it is listed as an institute of national importance.
Chandigarh
1964 Organization (government body) A government body for setting norms for the manufacture and the control of the quality of traditional medicinal preparations is formed.
1970 Program launch (nutrition) The Government of India launches the Balwadi Nutrition Programme to provide food supplements at Balwadis to children of the age group 3–6 years in rural areas.
1970 Organization (medical school) Anugrah Narayan Magadh Medical College and Hospital is founded.
Gaya
1970 Policy The government of India passes the Indian Medical Central Council Act to standardize Ayurvedic teaching institutions, their curriculum and their diplomas.
1971 Organization (medical school) Jawaharlal Nehru Medical College and Hospital is founded. Bhagalpur
1975 Program launch (nutrition, child health) The Integrated Child Development Services (ICDS) scheme is launched with the purpose of improving nutrition and health status in children.
1976 Organization (hospital chain) Aravind Eye Hospitals chain is opened by Dr. Govindappa Venkataswamy as a network of eye hospitals. Having a major impact in eradicating cataract related blindness in India, today the model of Aravind Eye Care hospitals is highly recognized and has won multiple awards. Tamil Nadu, Madurai, Theni, Tirunelveli, Coimbatore, Pondicherry, Dindigul, Tirupur, Salem, Tuticorin, Udumalpet
1978 Organization (hospital) Lilavati Hospital and Research Centre is established.[20][37]
Mumbai
1981 Organization (Hospital) The Regional Cancer Centre, Thiruvananthapuram is established in Trivandrum, Kerala.
Trivandrum
1983 Policy The National Health Policy is endorsed by the Parliament of India.
1983 Organization (hospital chain) Apollo Hospitals opens its first facility. It is the first hospital to be registered as a publicly listed company in India. Chennai
1985 Program launch (immunization) The government of India launches the Universal Immunization Programme, consisting in massive vaccination for nine diseases: tuberculosis, diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, measles, Hepatitis B, Diarrhoea, Japanese Encephalitis and Pneumonia.
1990 Organization (hospital) Pharmaceutical company Wockhardt opens its first medical center. Kolkata
1992 Organization (hospital) Fortis Malar Hospital is established. It is considered among the best in the country. Chennai
1994 Crisis 1994 plague. Bubonic and pneumonic plague break out.
South-central and southwestern India
1994 Crisis Pneumonic plague epidemic in Surat breaks out.
Gujarat
1995 Organization (government body) The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) is created as a governmental body in India purposed with developing education and research in ayurveda, yoga, naturopathy, unani, siddha, homeopathy, and other alternative medicine systems.
1995 Program launch (immunization) Pulse Polio program is launched by the government to eradicate poliomyelitis by vaccinating all children under the age of five years.
1996 Organization (hospital chain) Fortis Healthcare is founded. Delhi
1997 Program launch (immunization) The Revised National Tuberculosis Control Program (RNTCP) is launched by the government with aims at achieving universal access to tuberculosis control services.
2000 Policy (healthcare coverage) The Insurance Regulatory and Development Act (IRDA) opens up the market with the invitation for registration applications.
2000 Organization The Krishna Heart Institute is founded as a high-end medical facility, specializing in heart diseases.
Ahmedabad, India
2000 Report The World Health Organization’s global healthcare profile ranks India’s healthcare system 112th out of 190 countries.
2000 Organization (medical school) The Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) is established. Listed as an Institute of National Importance
Thiruvananthapuram
2000 Organization (hospital chain) Narayana Health system is opened as a multi-specialty hospital chain by Dr. Devi Shetty under the guidance of the Asian Heart Foundation. Today it has 31 hospitals in 19 locations. It is one of India’s largest and considered the world’s most economical healthcare providers with a reputation for high quality. Bengaluru, Ahmedabad, Davangere, Dharwad, Bellary, Berhampore, Jaipur, Jamshedpur, Katra, Kolar, Kolkata, Mahuva, Mysore, Palanpur, Raipur, Shimoga, Durgapur, Guwahati
2002–2005 Program launch (lifestyle diseases) The Tobacco cessation clinic program (later renamed as Tobacco Cessation Centers) is launched by the World Health Organization (WHO) and the Ministry of Health of India. Until 2005, 18 facilities are created. The services offered at the clinics include individual intervention in the form of behavioral counseling, medication, and nicotine replacement therapy[52]
Anand, Bhopal, Bangalore, Chandigarh, Chennai, Cuttack, Delhi, Goa, Jaipur, Lucknow, Mumbai, and Patna, Mizoram, Guwahati, Kolkata, Hyderabad and Trivandrum
2004 Program launch (healthcare coverage) The Deen Dayal Antyoday Upchar Yojna scheme is launched by the government of Madhya Pradesh to provide free health care to poor families. Madhya Pradesh
2005 Program launch (healthcare coverage) The National Rural Health Mission (NRHM) is launched by the government of India.[54]
2005 Program launch (healthcare coverage) Accredited Social Health Activist (ASHAs) is launched as a program of community health workers instituted by the Ministry of Health and Family Welfare.
2005 Program launch (child mortality) The Janani Suraksha Yojana scheme is launched by the Government of India with aims at decreasing the neonatal and maternal deaths happening in the country by promoting institutional delivery of babies.
2007 Program launch (healthcare coverage) The Government of Andhra Pradesh launches the Aarogyasri program in order to provide no cost coverage of hospitalization for all those below the poverty line. Andhra Pradesh
2008 Organization (hospital and research center) Ford Hospital and Research Centre is founded.
Patna
2008 Organization (hospital) Hospital chain Columbia Asia establishes a referral hospital. It is considered among the best hospitals in India. Bangalore
2009 Program launch (healthcare coverage) The Rashtriya Swasthya Bima Yojana (RSBY) scheme is launched with the objective of providing affordable healthcare to the poor.
2010 Organization (hospital) Kokilaben Dhirubhai Ambani Hospital is founded.
Mumbai
2011 Program launch (healthcare coverage) The National Programme for the Health Care of the Elderly (NPHCE) scheme is launched with the objective of providing the elderly an easy access to primary healthcare.
2012 Organization (medical college chain) All India Institute of Medical Sciences expand to six locations. Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh
2014 Crisis Odisha jaundice outbreak. Mainly Hepatitis E and also Hepatitis A kill at least 36 people. Odisha, Bolangir district, Cuttack, Khurda and Jajpur
2014 Program launch (immunization) Mission Indradhanush is launched by the Ministry of Health and Family Welfare with the purpose of immunizing all children against seven vaccine preventable diseases, namely diphtheria, pertussis, tetanus, polio, tuberculosis, measles and hepatitis B by 2020.
2014 Program launch (immunization) TB-Mission 2020 is launched by the Government of India with the purpose of eliminating tuberculosis from the country in 2020.
2017 Rural Health Care In April 2017, IFFCO bought 26% stake in Gramin Health Care to offer affordable and easily accessible healthcare services for farmers at tier III and tier IV rural hubs by setting up primary care centres at its IFFCO Bazar outlets.
Wikipedia
Dr.A.Jagadeesh Nellore(AP),India