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India @ 100: Old and Unhealthy

The year is 2047 and India is basking in its centenary year of freedom from British Rule. The most populous country is ecstatic. There is joy and pride among its 1.5 billion-plus citizens. And why not? The country has come a long way from its years of infancy. Like an infant dependent on others for care and nutrition, the initial years of the nation were import-dependent, and it achieved self-sufficiency in food and nutrition in its adulthood (the decades of 20s and 30s since independence) through green and white revolutions. It took a bold decision to open itself and become a market-driven economy in its 40s and made its presence felt globally through its 50s and 60s and was the cynosure of all eyes. Age was merely a number as the nation began to make rapid strides and continued to rise the fastest it ever had. And finally came the moment when the nation made its entry into the big boys' club (breaking into the top 10 economies globally). And continued to rise up the ladder gradually. The Indian economy today is the third-largest, after the United States and China (not necessarily in that order). The BSE Benchmark Index, SENSEX is at 500,000 and the market cap of all BSE listed companies is more than twice the size of the Indian economy (we will come to this later). India is today well-established startup capital of the world, with a maximum number of unicorns, the majority of whom continue to be registered outside India, most notably Singapore and financed with foreign capital. India, today is a middle-income country (and may not move up any further).


Today, its not just about the size of the economy. Its also about its people, its soul. From a predominantly rural country at the time of independence, India today is an urban-centric nation with more than half of its population residing in cities and towns. New Delhi, Mumbai and Bangalore are among the most populated cities in the world with extremely high population densities. This migration of the population from rural to urban centres indicates the upward mobility of the populace but it needn’t necessarily indicate improved quality of life. Most of the population continues to stay in tiny homes (most of which have either been slum rehabilitation or the redevelopment of old housing like the chawls). Owning a home in these glitzy metros continues to remain a piped dream for millions. The development in the rural economy can be seen through pucca houses, potable tap water for all, all-terrain roads, and a network of schools and primary care centres, broadband connections among others.


The average life expectancy of the population has improved significantly, from 32 years at birth in 1947 to upwards of 75 years today. But there is a stark difference within the states. Kerala continues to be the torchbearer and is in fact, healthier and lives longer than some of the most advanced economies, whereas Bihar is just about to reach the 70 years mark. The erstwhile BIMARU states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh along with Uttarakhand) are getting healthier too and thus propelling the nation forward. The child mortality and infant mortality rates are well within the World Health Organization's (WHO) prescribed limits, thanks to sustained efforts on child immunization and nutrition programs. The literacy rate is on the right side of 95 per cent with Kerala yet again leading the way with almost 100 per cent and Bihar, with maximum improvement, leapfrogging to the 90 per cent plus club.


While the nation gained strength and became stronger overall, there are deep pockets of frailty as evident from the wrinkles across the body. There are serious concerns too. The most populated country in the world is not young anymore. Literally and figuratively. And the advancing age brings along its own sets of problems and challenges. The fertility rate is well below the replacement rate and the median age of the population is touching 40 and the number of senior citizens increasing with each passing day. There are more people above 40 than under it. And with the fertility rate being well below the replacement rate, the median age will only increase going forward. The population growth has stabilized. And it will start to decline (if not declining already, the next round of census will confirm this). And with a declining population, comes the risk of falling economic growth as is being witnessed in Japan, Italy, Greece, Spain and other countries in the EU region.


Apart from some of the problems witnessed in the aforementioned countries due to falling population and economic growth, India has a prevalence of many more acute issues. All through its growing years, India was a very divided and unequal society. The gulf between the haves and the have-nots continued to expand and progressed at its most rapid pace through the middle years of the nationA mid-life crisis of sorts. The market capitalization of a handful of listed companies is equivalent to the size of the nation’s GDP, thus indicating the huge disparity. This inequality was not only with regards to income and wealth but also inequality of opportunities, inequality in access to basic services, access to healthcare, and inequality in representation to list a few. And over the years, these inequalities have exacerbated the problems plaguing Indian society. While India is a middle-income country (a trap that is very difficult to break out of), a large portion of the population continues to languish at the lower end of the economic spectrum.


The average literacy of the population improved but the skills didn't match the industry's needs. The opportunities were far and few and they dried up faster than an ordinary rivulet in the Indian summer. Millions who entered the job market with degrees were greeted with a rude shock. For years it was oft-repeated that education is the key to success and better life. Families strived, the education of the next-gen raised hopes and aspirations, but not necessarily their fortunes. The rapid urbanization in the early part of this century signalled upward mobility but soon the dream crashed for many with the cost of living and lack of opportunities adversely impacting the quality of life. The stress levels are at their highest ever. There seems to be no balance between work and life for a majority of the population. Mental health issues are a serious concern and thankfully receive due consideration and are no more a stigma in society.


The change in the climate from years of burning fossil fuels, mining of minerals, rapid urbanisation, and consumerism has made the planet hot. What a large segment of the global population either called a hoax or was in denial, is a reality today. The ocean surface temperature is up leading to changing wind directions and El-Nino and La-Nina occur frequently. Summer months are hotter and drier, and the season has expanded. Rain is scarce but torrential. Cities are increasingly reporting instances of flooding. Cyclones in the Bay of Bengal and the Indian ocean are a regular phenomenon. Central India and the plains of Ganges are like a baking oven. Instances of daytime temperatures crossing 50 degrees Celsius are increasingly becoming frequent. Health concerns have risen sharply and productivity levels are declining again. And the migration phenomenon has started again, this time to escape the disastrous effects of climate change.


For decades, India has officially been the diabetes capital of the world by some distance. Now, it is also in the lead for the incidences of poor cardiovascular health coupled with cancer (ranging from oral to lung to breast to cervical to prostrate to name a few). Breathing issues through the years of inhaling poor-quality air have added to the disease burden. The share of Non-Communicable Diseases (NCDs) in the overall health burden is upwards of 80 per cent and rising. And the NCDs are costly, both in terms of the actual treatment as well the loss of productivity and healthy life years.


After remaining stagnant at around one per cent of the Gross Domestic Product (GDP) for many decades, the health care spending has only managed to breach the two per cent mark around 2030, the year in which the country was expected to achieve the goal of Universal Health Coverage. The Covid-19 pandemic in the 2020s was a big financial setback for the nation and the country took nearly a decade to recover from the situation to be where it was pre-covid. The failing economic situation of many through large parts of the 21st century adversely impacted the health profile as people avoided treatment/care owing to poor financial health. Covid-19 pushed nearly 100 million people back into extreme poverty. It had taken decades of high growth and sustained social sector spending in the early twenty-first century to pull out millions from below the poverty line. Covid-19 wiped years of gains in a flash. The Disability-Adjusted Life Years (DALYs) have increased manifold in the past three decades, thus impacting the overall productivity in the country. The catastrophic health expenditure continues to impact a few million households every year and some of them get pushed below the poverty line again. And the cycle continues.


With healthcare spending continuing to remain below par, the health outcomes cannot be above par. The prevalence of diseases among the population and its financial burden on the economic health of the nation has increased sharply. Owing to commitments at the United Nations for Universal Health Coverage (UHC) and the Agenda 2030 for Sustainable Development Goals along with its newer siblings and the popular mandates and electoral pressures, the government of the day kept widening the net of Ayushman Bharat to include more people under its ambit but the allocation continues to remain sub-par to meet healthcare requirement for all. Insurance penetration and density have improved significantly and are inching towards the global average but continue to lag peers. The Insurance and Regulatory Development Authority of India (IRDAI), the governing body for the insurance sector in the country, borrowed a leaf out of its regulatory peer (the Reserve Bank of India) and experiences of other developed and developing economies and has opened doors to other forms of insurance institutions (namely, Mutuals and Cooperatives) apart from the conventionally known Joint Stock companies.


While the insurance coverage has improved, so has the risk and incidence of diseases. The country is on the verge of providing UHC to all its citizens, but there remains a substantial protection gap. This gap between the desired and actually available coverage will continue to plague both the economic as well the actual well-being of its citizens. With the increasing disease burden, primarily the NCDs coupled with advancing age and not so desirable economic situation for a large chunk of the population, it is very likely that India will become old before it gets rich. And in all likelihood, it will be an uphill task to arrange for foster care to look after its people in their advanced years. Both, arranging for caregivers and financing required for meeting the needs will be a big challenge. Probably for the first time in the history of independent India, a smaller segment of the population (those below the median age) will be expected to support and provide for a larger section of the society (those above the median age). And this support base will only keep on shrinking.


An ageing population is a fact and cant be avoided. What certainly can be controlled (to a reasonable extent) is good health and a stable economic position. Let us wish and strive for when the nation approaches its centenary, it does so in good health and sound economic position. And along with our prayers and best wishes, there is a need for a manifold increase in investment in healthcare and managing macro-economic stability. It’s easier said than done, but do we have an alternative?


On a personal note: In 2047, this author, if still alive, will also be on the other side of the retirement age and would wish to see most of the above predictions (on likely poor health and economic outcomes) being false and the nation is truly independent of the economic and health shackles of today and is blooming like a fresh daisy on a usual morning in the spring. May the nation be in its best position ever. That will be true independence.


Happy 100 Years of Independence. May the new century turn a new leaf and infuse fresh life into the soul of this great country.

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