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Now that the 2014 general elections are in the rear view mirror, Prime Minister Narendra Modi and his ministers face the challenge of expectations set by the media and all his supporters. One of the key challenges his team will be facing is: Healthcare.

With the World Health Organization’s 2000 World Health Report ranking India’s healthcare system at 112 out of 190 countries , some key questions in his mind should be: How should the country transform its healthcare system? What are its current pain points? What could be achieved during his tenure?

For those living in urban areas, healthcare is merely a political issue. They argue that the country faces bigger challenges such as economic development, infrastructure, jobs, and border disputes with Pakistan. I believe that the 2014 elections have presented India with a unique opportunity to take a fresh look at its healthcare landscape. I was happy to browse through the PM’s campaign website which had a section on his achievements in this sector.

But here are 5 things you should know about India’s healthcare system.

1. Rural Versus Urban Divide: While the opportunity to enter the market is very ripe, India still spends only around 4.2% of its national GDP towards healthcare goods and services (compared to 18% by the US) [2]. Additionally, there are wide gaps between the rural and urban populations in its healthcare system which worsen the problem. A staggering 70% of the population still lives in rural areas and has no or limited access to hospitals and clinics [3]. Consequently, the rural population mostly relies on alternative medicine and government programmes in rural health clinics. One such government programme is the National Urban Health Mission which pays individuals for healthcare premiums, in partnership with various local private partners, which have proven ineffective to date.

In contrast, the urban centres have numerous private hospitals and clinics which provide quality healthcare. These centres have better doctors, access to preventive medicine, and quality clinics which are a result of better profitability for investors compared to the not-so-profitable rural areas.

2. Need for Effective Payment Mechanisms: Besides the rural-urban divide, another key driver of India’s healthcare landscape is the high out-of-pocket expenditure (roughly 70%). This means that most Indian patients pay for their hospital visits and doctors’ appointments with straight up cash after care with no payment arrangements.  According to the World Bank and National Commission’s report on Macroeconomics, only 5% of Indians are covered by health insurance policies [3]. Such a low figure has resulted in a nascent health insurance market which is only available for the urban, middle and high income populations. The good news is that the penetration of the health insurance market has been increasing over the years; it has been one of the fastest-growing segments of business in India.

Coming to the regulatory side, the Indian government plays an important role in running several safety net health insurance programmes for the high-risk population and actively regulates the private insurance markets. Currently there are a handful of such programmes including the Community Health Insurance programme for the population below poverty line (like Medicaid in the US) and Life Insurance Company (LIC) policy for senior citizens (like Medicare in the US). All these plans are monitored and controlled by the government-run General Insurance Corporation, which is designed for people to pay upfront cash and then get reimbursed by filing a claim. There are additional plans offered to government employees, and a handful of private companies sell private health insurance to the public [3].

3. Demand for Basic Primary Healthcare and Infrastructure: India faces a growing need to fix its basic health concerns in the areas of HIV, malaria, tuberculosis, and diarrhoea. Additionally, children under five are born underweight and roughly 7% (compared to 0.8% in the US) of them die before their fifth birthday. [4] [5]. Sadly, only a small percentage of the population has access to quality sanitation, which further exacerbates some key concerns above.

For primary healthcare, the Indian government spends only about 30% of the country’s total healthcare budget [6]. This is just a fraction of what the US and the UK spend every year. One way to solve this problem is to address the infrastructure issue… by standardising diagnostic procedures, building rural clinics, and developing streamlined health IT systems, and improving efficiency. The need for skilled medical graduates continues to grow, especially in rural areas which fail to attract new graduates because of financial reasons. A sizeable percentage of the graduates also go abroad to pursue higher studies and employment.

4. Growing Pharmaceutical Sector: According to the Indian Brand Equity Foundation (IBEF), India is the third-largest exporter of pharmaceutical products in terms of volume. Around 80% of the market is composed of generic low-cost drugs which seem to be the major driver of this industry.

The increase in the ageing population, rising incomes of the middle class, and the development of primary care facilities are expected to shape the pharmaceutical industry in future. The government has already taken some liberal measures by allowing foreign direct investment in this area which has been a key driving force behind the growth of Indian pharma.

5. Underdeveloped Medical Devices Sector: The medical devices sector is the smallest piece of India’s healthcare pie. However, it is one of the fastest-growing sectors in the country like the health insurance marketplace. Till date, the industry has faced a number of regulatory challenges which has prevented its growth and development.

Recently, the government has been positive on clearing regulatory hurdles related to the import-export of medical devices, and has set a few standards around clinical trials. According to The Economic Times, the medical devices sector is seen as the most promising area for future development by foreign and regional investors; they are highly profitable and always in demand in other countries.

– By Vijay Ramnath Jayaraman (contact him directly @vijayramnath)