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Universal health coverage Single payer Disparities Self-harm Portable INTRODUCTION Canada’s population is 33 million people. The land area is 3,854,082 square miles (Infoplease, 2010). Eighteen percent of Canada’s population is under 15 years old (UNO, 2004), and 17% of the population is over the age of 60 (WHO, 2004). The primary languages spoken in Canada are English and French. The largest ethnic groups are British, French, and other European groups. The largest religious groups are Roman Catholic with a strong presence of Anglican and other Christian religions (who.intl/profiles_countries). Canada is ranked 25th out of 31 countries in the literacy rate. Because demand for health services is so high, Canadians often must wait a long time for appointments to see the doctor, especially in the province of Quebec. In the words of Frogue (2001, p. 10), “everything is free but nothing is readily available.” HISTORICAL Dating back to 1867 Canada’s Constitution assigned most of the healthcare responsibilities to its ten provinces and three sparsely populated northern territories. These provinces vary widely by size and fiscal capacity. For example, in 2001, Prince Edward Island had a population of 135,000 while Ontario had 11.4 million. Canada, unlike the United States, provides universal health coverage, a national health insurance program provided by the Medical Care Insurance Act of 1966. Universal coverage provides health care to all members of its society, combining mechanisms for health financing and service provision (WHO, 2008). Health care in Canada is funded through general taxes and Medicare. The National Medical Care Insurance Act operates on the basis of four principles: 1) it is comprehensive, covering all medically necessary services provided by physicians, 2) universal coverage is available to all legal and illegal residents, 3) it is publicly administrated, either directly by provincial government or by an authority directly responsible to it, and 4) it is portable. The Canada Health Act, passed in 1984, established a fifth core principle, accessibility, which sought to force provinces to forbid extra billing and cost sharing. It called for the Canadian government to deduct the amount of such charges from its payments to any province. During the early 1990s there were growing concerns about the perceived notion that the country was approaching physician saturation, even the potential for a surplus. This led to policy decisions such as enacting a 10% cut in first year medical school admissions, contributing to a drop in physician supply. STRUCTURE Canada has a readily available supply of physicians, and less availability of nurses. Levels of nurses practicing in Canada are comparable to those in the United States and include registered nurses, nurse practitioners, nurse midwives, and LPNs. However, nurse practitioners and physicians assistants are relatively new to Canada and are not yet widely utilized. Other health professionals in Canada include dentists, pharmacists, medical and radiology technicians, chiropractors, and physiotherapists. In 2004, workforce aging became a significant challenge in that health professionals were aging more rapidly than the Canadian population with the average physician being 49 and the average RN being 45. Between 1990 and 2005, the number of nurses practicing in Canada decreased from 11.1 to 10 nurses per 1,000 population, with the lowest point occurring in 2003, at 9.6 per 1,000 (OECD Health Data, 2007). Also, increasing numbers of women are entering the medical workforce. According to OECD (2007) data, 24% of Canadians live in rural areas, yet only nine percent of the physician workforce practices in rural Canada. Although Canada has a stable supply of physicians, in 2008 approximately 14% (5 million) of Canadian adults did not have a family physician. Between 2002 and 2006, permanent migration of physicians to other countries tripled and temporary migration increased over 10%. Permanent migration of nurses increased by 40%, and temporary migration increased by 35%. In 2006, 9% of all nurses and 19% of physicians born in Canada were working in other OECD countries. Physicians also move freely among provinces, in fact 62.3% of the physicians in Canada are concentrated in the two provinces of Ontario and Quebec. Although the number of male registered nurses almost tripled from 1985 to 2006, from 5,000 to 14,000, they make up only 6% of Canada’s nursing workforce and more than half the male nurses in Canada practice in Quebec. Physicians from South Africa, and nurses from the Philippines also are part of the Canadian workforce (OECD, 2007). Many of the nurses working in the United States in the travelling nurse program were Canadians. Canada regulates physician supply, physician and hospital budgets, and technology. The government also coordinates financing, insurance, and payment function. Unlike the American healthcare system, because the Canadian healthcare system is government run there is no need for employer involvement in health care except, of course, for supplemental catastrophic additional coverage. The role of payers is limited to the government and individuals. The role of insurers in Canada is minimal. In the Canadian healthcare system the physicians, through their medical associations, have a great deal of autonomy. Medical associations negotiate with provinces for fee schedules. There is centralization at the province level although activities vary among provinces. There are more general practitioners than specialists demonstrating the emphasis on promoting healthy communities and preventing disease. Generally, medical specialists earn more than family practice physicians with the largest variance being in Ontario, where specialists earn on average 1.68 times more than family physicians, whereas in Quebec the variance is smaller, amounting to 1.22 times more. Major differences in nurse salaries differ among provinces. Most nurses work on union contracts negotiated by the Canadian Federation of Nurses Association. The maximum wage ranges between 70,000 Canadian dollars (C$) in Ontario, 51,000 C$ in Quebec, and the minimum ranges from 53,000 in Manitoba and 34,000 in Quebec. However, some nurses in Canada make over 500,000 C$ (OECD, 2007). FINANCING During the 1970s physicians commonly billed patients for additional costs that were already covered by the government plan. In 1984, the passing of the Canada Health Act prevented medical providers from billing patients for services if they had also billed the public insurance system. A reaffirmation of the government’s stance that they were committed to health care that was, “comprehensive, universal, portable, publically administered, and accessible,” was issued by the Prime Minister in 1999. Portable means coverage continues when patients travel or move between provinces. Single payer is used to primarily describe a system that is government funded and controlled. Canada has a single payer system, complemented by insurance and direct out-of-pocket payments. There are global budgets for hospitals and physicians, negotiated fees for services, and consumer co-payments. Hospitals and physicians must operate within a set budget with which they must strictly adhere. In order to finance Canadian health care, provincial funds are gathered from a mix of federal transfers that favor poorer provinces, general provincial revenues, employer payroll taxes, and insurance premiums. In provinces like Alberta and British Columbia where premiums exist, there are special provisions for assistance to people with low incomes. Residents of each province receive insurance cards, which they present when being seen in a hospital or physician office. They must produce this card for care because benefits vary slightly among provinces. There is typically no general dental coverage, but most provinces provide some pediatric dentistry, and all provinces cover in-hospital oral surgery as part of hospital coverage. Many provinces provide limited optometric, chiropractic, and physical therapy coverage. Financial support for pharmaceutical expenses is included in separate programs, generally for seniors and other categories of the needy. Contraception is available to all women in Canada free of charge as birth control is also covered under the public insurance plan. Every provincial plan insures all medically necessary physician and hospital care. Private insurance is allowed for what is referred to as non-core services. Private insurance plans are prohibited from billing patients for core services, or any service covered by the standard public insurance plan. An estimated 80% of Canada’s population has supplementary coverage for items such as private rooms, dental care, and other non-core services (Irvine, Ferguson and Cackett, 2002, p. 17). This is financed primarily through employers, and, as in the United States, is treated as a business expense for tax purposes. INTERVENTIONAL The social and economic conditions experienced by a people have a definite influence on their health status. Any proposed interventions must be geared toward addressing health issues within the realm of these conditions. Despite problems with access, and language challenges that are closely related to cultures other than French, there is a high user satisfaction with health care in Canada. Canada places less reliance on technology and there is greater access to health providers in urban settings. However, there are often long waits for appointments and services. In 2005, on average, Canadians waited 12.3 weeks for an MRI, 5.5 weeks for a CT scan and 3.4 weeks for an ultrasound (Fraser Institute, 2005). Almost half of the Canadian public, when surveyed by Pollara polling in 2005, reported their willingness to pay out-of-pocket for faster access to services (Irvine et al., 2005, p. 59). Absenteeism and turnover rates for nurses are also high. For example, absenteeism rates for full time RNs was 83% higher than it was for the general labor market. The Canadian government paid 962 million C$ in absentee, overtime, and replacement wages among nurses in 2007 (Drebit, 2010). Health care for older adults in Canada is plagued by major long-term care challenges, lengthy waits to gain admission into nursing homes, and poor quality of care. PREVENTIVE Approaches to addressing health promotion and disease prevention in Canada are perhaps as diverse as the population. Indigenous to Canadian society are the Francophones that include the Mètis, Native American and European descendants, and the Acadians, descendants of the early French colonists. Canada, with its multiethnic, multilingual, and cultural mosaic is a melting pot of diversity (Coutu-Wakulczyk, Moreau, and Beckingham, 2003, p. 160). Despite Canada’s nearly perfect literacy rate (approximately 99%), illiteracy is high among the Francophones and the elderly. In fact, in some communities, Canada’s high school drop-out rates exceed 40%, highest in poor and rural areas, especially for Aboriginals and Francophones, and among boys (Office of Francophone Affairs of Ontario, 2000). Another problem is obesity and obesity related hypertension especially among women. Pausova et al. (2000) believe these are attributed in great part to the TNF-α gene locus. There has been a steep decline among Francophones in fertility rates from 4.95 children for the period 1956–1961, to 1.57 from 1991–1996 leading to the concern about long-term viability of Francophones outside Quebec especially since they have very little access to healthcare services where providers speak French (Office of Francophones Affairs of Ontario, 2001, Chung, 2009). Ansen (2000) found among Francophone women, the more educated the women the lower the fertility rate. Edwards and Rootman (1993) reported the responses of Canadians aged 15 and older who were asked about practices for improving health. In order of importance they identified smoking cessation 81%, increased relaxation 69%, exercise 65%, income security 45%, quantity of time spent with family 45%, weight loss 42%, better dental care 27%, job changes 22%, reduced drinking 16%, moving 14%, and reduced drug use 9%. Canada’s government-focused initiatives to address promotion of health and prevention of disease include specific programs to address obesity and the dissemination of health information via hard copy and online, keeping in mind that if the information is not disseminated in minimally English and French it will not likely be beneficial. Education always appears to be a key indicator in preventing illness. RESOURCES Men appear to be the hallmark of the Canadian society. They are typically viewed as the moral authority, and the one responsible for providing for, and protecting the family. Women, on the other hand, are charged with responsibility for running the household, child care, and caring for family members when ill (Langelier, 1996). For childbearing women, midwives and maternity centers are commonly used. In some segments of Canada’s population, family, extended family, and clergy are particularly supportive in the care of persons at or nearing the end-of-life. For example, African Canadians account for more than half (52%) of Nova Scotia’s visible minorities (Statistics Canada, 2003). According to Clairmont and Magill (1970), years of poor living conditions, racism, hostile treatment, and a widespread lack of acceptance and integration into Nova Scotia society has led to the creation of a Black community that has been oppressed. Rather than seeking help from the healthcare system, many persons of African descent draw heavily on each other for support when challenged by an illness. Crawley et al. (2000) describe the rich religious tradition among African Americans in explaining some of the behaviors of African Canadians. The authors explain that in considering the omnipotence of God, if they do not receive a healing miracle, they often welcome death as a “home going.” MAJOR HEALTH ISSUES Canadians are plagued by troubling diseases that often result in death, with cancer leading the way. Although the incidence of smoking is trending down, lung cancer is still the leading cancer killer in Canada for men and women (The Canadian Cancer Society, 2007). Heart disease and stroke rank as the second and third leading causes of death in Canada. The WHO (2010) record of the top ten diseases causing death in Canada are as listed in Table 5-1. DISPARITIES The top three diseases, cancer, heart disease, and stroke, in Canada are treated similarly to the United States. There are many similarities and differences in treatment approaches among Canadian provinces. Whether health outcomes are positive or negative they are influenced by social determinants such as population, poverty, age, race/ethnicity, and gender. Table 5-1 Top 10 causes of death (all ages) in Canada, 2002, with the number and percent of years of life lost by disease. Source: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls SUMMARY There are many more strengths in the urban healthcare area than rural among Canadian provinces. It is important for Canada to build a workforce that is more sustainable and effective at meeting the needs of its residents both rural and urban. Recruitment and retention incentives may be effective ways to address these two important workforce issues. Discussion Questions 1.  Technology is not a major part of Canada’s approach to health care. In your opinion, how does the limited application of technology impact the quality of patient care? Describe how technology affects patient care in your work setting. What technological interventions are critical to service delivery? What technology does your work setting need? Explain why this technology is important. 2.  Edwards and Rootman (1993) identify a prioritized list of health issues Canadians are attempting to address. How does this list compare to your own observations of health problems in the community you serve? What are the similarities? What are the differences? How would you rank order the list of health concerns that require preventive measures and health promotion in your community? What preventive activities are taking place in your community to address these health issues? 3.  For some segments of Canada’s population, family, particularly women, serve in important caregiver roles, and religion is a strong therapeutic element of support in healthcare situations. Describe what you have observed along these lines. In your opinion, what are the advantages of family as participants in the cycle of care, and what might be some drawbacks. As greater numbers of women join the workforce, how do you think the caregiver role of the family will change? What are the implications for healthcare providers? Discuss your views of religion in relation to health care? In your opinion, to what extent does a person’s religious beliefs help or detract from efforts to improve a patient’s health status? 4.  Canada has more GPs than specialists. Discuss the advantages of this situation in relation to providing quality health care? Are there any drawbacks? 5.  Education is an important determinant of health. Considering Canada’s high school drop-out rate, particularly in the poor rural areas, what preventive and health promotion strategies should be undertaken to ensure positive health outcomes for the drop-out segment of the population? How would you approach this challenge? Are you facing similar issues in your work setting? What are the most frequent health issues of this population? What interventions are in place to address their health issues? 6.  Canada is facing challenging staffing issues in terms of high absenteeism and turnover rates of nursing staff. What might account for this situation? Have you observed similar staffing problems in your workplace or are you aware of this issue in other healthcare settings? How does nursing turnover and absenteeism impact healthcare delivery (e.g., continuity of care, staff relations, healthcare costs)? What can be done to reduce the incidence of high turnover and absenteeism among nursing staff? Case Scenario Mrs. Carisse: Crossing the Border Mrs. Carisse, a 48-year-old married mother of three, is recovering from brain surgery after suffering a major bleed in a vessel in her head. She is on a medication that costs over $400 a month. She has been unable to work for almost four years, as she is unsteady on her feet and at risk for falls. Her husband, Peter, has just learned he is losing his job and insurance benefits due to major profit losses at the small company where he works. The Carisses’ are both concerned because without insurance they will be unable to pay for her medications. If she skips the medication for one day she will experience serious side effects and her health will rapidly decline. Peter has a co-worker who travels to Canada to purchase pain relievers because he can get them cheaper and without a prescription. He has convinced him to try to get the medication his wife needs in Canada.

Activities of daily living Ayurvedic medicine Caste Dalits Fatalistic Harijans Shundras Telemedicine Unani Vaisyas INTRODUCTION The population in India has grown over the past decade. Today, there are 1,205,073,612 (CIA World Factbook, 2012) people in India. India’s land area is 2,973,192,059 square km (CIA World Factbook, 2012). There is an under 5-year-old mortality rate of 85:1,000 and life expectancy of 62 years. India’s largest ethnic groups are Indo-Aryan, and Dravidian. Its major religions are Hindu, Muslim, Sikh, and Christian (WHO, 2005). India has a low literacy rate, and, as is true of most developing countries, it has a high infant mortality rate. Similar to Ghana, India is devastatingly poor but the economy is improving as a consequence of the United States’ overseas cheap labor employment opportunities. India is a male-dominated society. Women are subservient to males. Many women do not aspire to work outside the home, (or are content with remaining home, or not working outside the home). Men have traditionally had first priority for attending school. India’s Ministry of Health has a poorly managed and funded National Health Care System. Residents receive acute care only. True of much of the developing world, many chronic, infectious diseases due to major public health problems like contaminated water and poor sanitation plague India. India’s endemic problems include cholera, and CR-Malaria. There are incentives (money and prizes) given for voluntary male sterilization. The predominant religion is Hindu, which accounts for approximately 83% of those native to India. Approximately 11% are Islamic Muslim. It is not uncommon for Indians to take the fatalistic view of health and view sickness as God’s will. Death is welcomed as natural, cremation is preferred, and there is an anticipation of reincarnation. HISTORICAL Indians practice what is called Ayurvedic medicine (also called ayurveda) a traditional medicine utilizing the healing arts that balances the use of herbal remedies and medical practices. Many rural and urban poor rely on alternative treatments such as acupuncture, Ayurvedic, and Unani medicine. According to Spector (2009), Ayurvedic medicine, a 4,000 year old method of healing the body, is one of the oldest systems of medicine in the world. It is accredited with laying the foundation for Chinese medicine. It is similar to CAM in that herbs, specialized diets, and natural therapies are used to integrate and balance the body, mind, and spirit. Similarly, Unani medicine is based on the humoral theory that presupposes the presence of four humors; Dum (blood), Balgham (phlegm), Safra (yellow bile), and Sauda (black bile). The body, when in balance, has the power to maintain balance of these humors (unanidoctors.com, n.d.). Universal health enjoys a long history in India. In similarity to other developing countries, during the mid-80s with healthcare expenditures varying greatly among states and union territories, Indian leaders committed to health for all by 2000. There has been a growth in the health industry of about 12% per year in the last four years (moneycontrol.com, 2007). STRUCTURE There is a serious health provider shortage in India. Forty percent of the primary health centers are understaffed. According to the WHO (sero.who.int, n.d.) India produces over 25,000 physicians annually in the modern system of medicine and more than 400 a year in the Indian system of medicine and homeopathy (IM&H). Yet, there remains a tremendous shortage of not only physicians but nurses and paramedics. India licenses approximately 18,000 new physicians every year, as many migrate to more prosperous, developing countries to practice. According to the Planning Commission Government of India (2002–2007), in 2000, there were approximately 1.25 million doctors and 0.8 million nurses in India; one doctor for every 1,800 people. When counting the indigenous doctors and homeopaths this ratio is one doctor for 800 people. The overall ratio of doctors to population in rural area is almost six times lower than that in the urban population (Central Bureau of Health Intelligence, 2001). It is difficult to determine the accuracy in physician numbers because, although doctors are registered to practice in India, many have emigrated to other countries to practice and some are left in the system even after they have died (Medical & Tourism). Despite the existence of well-funded healthcare centers of excellence, India has poor health outcomes. These state of the art centers are too few and inadequate to meet the healthcare needs of the masses. The number of hospital beds in India grew from 11,174 (57% private) in 1991 to 18,218 (75% private) in 2007 (Central Bureau of Health Intelligence, 2001). India also has a large gap in the availability of hospital beds to serve the people in rural areas. Its infrastructure has failed to keep pace with the growing economy. India also does over a 260 billion (INR) pharmaceutical business, exporting a significant amount of the drugs manufactured (Ministry of Chemicals and Fertilizers, 2001–2002). FINANCING India spends a total of $14.8 billion annually on health care. This equates to approximately 5.2% of its GDP. It is predicted that India will spend $33.6 billion by 2012, which accounts for 8.5% of the GDP (WHO, 2007). India’s healthcare system is a system that is grossly inadequate and underfunded. According to WHO (2003) “only five other countries in the world are worse off than India regarding public health spending” (Burundi, Myanmar, Pakistan, Sudan, and Cambodia). Despite relatively low overall spending on health care, state expenditures are even lower, only (0.9%) of the GDP (Deogaonkar, 2004). The state government contributes approximately 15.2% to the financing of health care, the central government contributes 5.2%, third party insurance companies and employers contribute 3.3%, and municipal and foreign donors contribute an additional 1.3%. The World Bank suggests that nearly 59% of this money goes to fund primary health care (curative, preventive, and health promotion). Another 39% is spent on secondary and tertiary inpatient care. The government run General Insurance Company (GIC) along with four subsidiaries are the major providers of insurance. Out-of-pocket expenditures are high and account for 98.4% of the total health expenditures by household. The private sector accounts for more than 80% of total healthcare expenditures in India. “Eighty-two percent of health expenditure in India is made as out of pocket payments by the user of the service,” (Deogaonkar, 2004, p. 4). The per capita expenditure on public health is seven times lower in rural areas than urban areas (Central Bureau of Health Intelligence, 2001). INTERVENTIONAL According to the Indian Institute of Medicine (2005), private firms provide approximately 60% of all outpatient care in India, and approximately 40% of all inpatient care. Approximately 70% of the hospitals in India are private sector owned and operated. One of the most significant attempts at providing quality care interventions in India is the promotion of the use of primary health centers in delivery of care. However, these centers are understaffed, personnel are underpaid, and equipment and supplies are lacking (Deogaonkar, 2004). Approximately one million Indians die each year because of the insufficient treatment facilities and lack of personnel to meet the care demands of the country. Another major interventional consideration is that the northern areas of India have the greatest healthcare needs yet this area tends to have the most difficult access challenges. There is also an urban/rural divide reflected by the significantly fewer hospitals and services in the rural Indian communities as compared to the urban areas. For example, in 2005 there were 178 hospitals and 3.6 clinics in urban areas compared to 9.85 and 0.36 in rural areas. The federal government funded program called the National Rural Health Mission 2005–2012 works to improve rural health. In India, long-term care and care of older adults are regarded as better than in many other countries. In fact, individuals are beginning to retire to India in search of better long-term care options. India is not only a top destination for medical tourism for persons searching for low cost surgery and other treatments but it is becoming a popular destination for retirement. According to Chicago Tribune reporter Kidd Stewart (2007, p.3) outsourcing ill parents to India costs considerably less than caring for them in the United States. In India, $2,000 a month covers a nursing home stay in a resort-like plush facility on the coast of India for two persons. This cost also covers food, utilities, medications, telephone, 24-hour staffing by very low paid, but good staff. Medications are about 20% less than the same drugs in the United States. Although there appears to be substantial accommodations for older adults in the Indian system of health, these facilities are not available to older people who have mental and/or physical disabilities. It is suspected these individuals would require assistance in carrying out activities of daily living (Dey, 2006), which includes such things as bathing, dressing, meal preparations, and light housekeeping. In regard to medical tourism, it has become a big business in India. It is estimated that medical tourism made an estimated $350 million in 2006. It is predicted to grow into a $2 billion industry by 2012 (Confederation of India Industry, 2006). India proposes that it delivers the best treatment, often at less than one-tenth the cost of the same treatment in the United States and other industrialized countries. Its private hospitals excel in cardiology, joint replacements, orthopedics, gastroenterology, ophthalmology, transplants, and urology (India Brand Foundation Report, 2007). For example, according to the Brand Foundation Report, cardiac surgery in the United States costs $50,000; it costs $14,200 in Thailand and $4,000 in India. A liver transplant costs approximately $500,000 in the United States, $75,000 in Thailand, and $45,000 in India. It is believed that medical tourism leverages India’s well educated, English speaking medical staff, and its state of the art private hospitals and diagnostic facilities. Many western tourists travel to India also seeking alternative medicine treatment such as ayurveda. For example, the number of medical tourists visiting Kerala in southwestern India was approximately 15,000 in 2006, but it was predicted that this number would reach 100,000 by 2010 (Blonnet, 2007). There is a new initiative underway to establish a public/private partnership for the purpose of building a 900 bed, “Medi City” on 43 acres of land near the outskirts of Delhi. It is suspected that this facility will have the capacity to offer 17 super specialties, and a medical college and para-medical college, with an integration of allopathic and alternative medicine and care including unani, ayurvedic, homeopathic, and telemedicine. Telemedicine is an approach to practicing medicine that allows for the diagnosis and treatment of diseases remotely over long distances by use of videoconferencing, cabled networks, and the internet. There are already approximately 100 telemedicine centers in India. Telemedicine is popular in many industrialized countries (Blonnet, 2007). In general, Indians lack dental coverage (Parkash et al., 2006). Dental care is almost unheard of in India. As people age in any system the quality of their lives is often determined by their health status, this includes dental health. If they are healthy and active they are likely to enjoy quality during their advancing age. Dey (2006) suggests that, “of the many determinants of the quality of life: financial security, emotional security and health and well being, the last one occupies the prime position, as all other issues become irrelevant in poor health” (p.134). Further, India lacks a clear policy or strategy for the development of health care for older people. A comprehensive care package that includes, “promotive, preventive, curative and rehabilitative services is essential for this population group” (Dey, 2006, p. 134). PREVENTIVE Prevention is perhaps the most serious challenge in Indian health care partly because of inadequate funding and a disparity in regard to access especially for the poor. Because health insurance is inaccessible to large numbers of Indians, prevention is a major problem. All over India a vast number of its poorest residents are packed together in what is being referred to as the new slums. These make-shift, cardboard-constructed, shanty town appearing shelters that can be seen for miles in many areas of India. These communities lack clean water, electricity, sanitation (UN-HABITAT, 2007; Joshi, n.d.). These conditions are perfect breeding grounds for diseases, especially infections. To further complicate the situation, people living in the more permanent building structures exhibit similar health problems. Prevention under these circumstances is difficult. As one visitor to India puts it, “from the comfort of my four star hotel room, I looked across the roadway and sprawled out for miles and miles, all I could see were flickers of light breaking through the otherwise total darkness, that I knew emanated from small make shift fires surrounding the cardboard shanties that seemed to consume the entire city. My heart was heavy with pain and a sense of shame for the conditions under which these people were striving to just survive. How blessed I felt to have more than just what I needed to not just survive but to thrive.” As lifestyles began changing in India due to improved economic growth, much of which is related to jobs being outsourced to India from the industrialized world, there has been a growth in India’s middle class. There has also been an increase in some of the same top diseases such as cardiovascular diseases and diabetes that are seen in the developed world. RESOURCES Family is a major human resource in India. Although every region has its own unique characteristics and traditions, especially in relation to housing preferences and lifestyles, there are many similarities. Despite the customs, language, religion, or caste affiliations, Indians live together, relatively harmoniously. Family, defined as extended, is a source of support throughout life in India. Roles and responsibilities are influenced by age and gender. Children are cherished and considered as gifts from God and they have full support from their families for their entire lives because family progress, unity, and support is held in the highest regard for life. There are genuine displays of respect for family, especially parental and elder respect. Parents and grandparents are looked to for guidance and support through many of life’s challenges. For example, arranged marriages are still the norm although younger Indians however, through their intrigue by the western world’s love-based marriages, are beginning to pressure their parents to respect their individual choices of a spouse. They are also beginning to reject the tradition of marriage signifying the joining of two families as one. Public display of affection, even between married couples is taboo and often misinterpreted by outsiders. This is especially misunderstood by health professionals in the western world. In regard to roles, responsibilities, and financial support, although men have traditionally assumed primary responsibility for financially supporting their families, women are beginning to work more. But, especially in the urban areas, women have for many years often worked and contributed to the family’s income. Despite working, women remain primarily responsible for maintaining the household and caring for the children and aged relatives (Rampur, 2009). This is especially difficult if the parent or grandparent happens to be chronically ill. However, even though the woman has a career, she must still care for sick family members. There are a variety of living conditions in India. Rich urban families enjoy modern homes, servants, and cars; the middle classes usually live in apartments or smaller homes. Poor families live in simple huts or scantly roofed houses. Many of India’s poorest residents live in what is referred to as the 21st century slums which presents some of India’s greatest challenges. Religion is also a strong support for families who are ill and particularly those at or near the end of their lives. Approximately 82% of Indians practice Hinduism. Reincarnation is central to the Hindu religion. Other religions include Buddhism, Christianity, Sikhism, Islam, and most recently, Methodist. Although only 3% of the Indian population is Christian, 50% of Dalits (the untouchables, oppressed) are Christians (www.hrw.org 2000). The cultural and religious backgrounds of patients and their families should be included in the assessment made by health professionals attempting to identify the best treatment options for the patient. MAJOR HEALTH ISSUES India is a disease-ridden country. Its people suffer from such diseases as malaria and tuberculosis. In fact, one-third of the world’s tuberculosis cases are in India. Also, polio, although eradicated in most of the world is still prevalent in India. Although there has been a decrease in the incidence of diseases such as polio, leprosy, and neonatal tetanus in India, there has been a rise in drug resistant dengue fever, viral hepatitis, tuberculosis, malaria, and pneumonia (Gubler, 1999). There is also an unusually high incidence of Type 2 diabetes (Abate & Chandalia, 2001) known also as non-insulin dependent diabetes. The lack of clean water, poor sanitation, growth of new 21st century slums, and malnutrition are but a few of the challenges overshadowing efforts by the country to promote health and prevent illness. India’s malnutrition rates are among the highest in the world, contributing to almost 6 million deaths of children every year, more than half the world’s total (Pandey, 2006). According to the WHO, 900,000 Indians die each year because they consume contaminated drinking water and are breathing polluted air (Robinson, 2008). The majority of these deaths, approximately 700,000, result from diarrheal illnesses contracted from contaminants in the water supply. The number of persons living with AIDS in India is estimated to between 2 and 3 million. The top ten diseases causing death and years of life lost due to these diseases in India are listed on Table 12-1. Disparities One-fifth of maternal deaths and one quarter of child deaths in the world occur in India (UNICEF, 2009). Also India has one of the lowest life expectancies and highest infant and child mortality rates in the world (WHO, 2010). There is also a rural/urban divide in India reflected by major access problems especially in the rural areas of India. This is reflected by substantial rural/urban differentials in the allocation of resources, and the lack of available doctors and hospitals. However, there is a noticeable access problem in the urban cities of India partly as a result of urban slums that become the foundation of communicable diseases that widely spread under these conditions. Also data from urban slums show infant and under-five mortality rates for the poorest 40% of the urban population are as high as the rural areas (Deogaonkar, 2004). Table 12-1 Top 10 causes of death (all ages) in India, 2002, with the number and percent of years of life lost by disease. Data From: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls Health outcomes, though improved over the years, are still strongly determined by factors such as gender, caste, wealth, education, and geography (Subramanian, Ackerson, Subramanyam, & Sivaramakrishnan, 2008; Subramanian, Nandy, Irving, Gordon, Lambert, & Davey Smith, 2006; Subramanian, Davey Smith, & Subramanyam, 2006). India’s 3500 year old caste system, although illegal today, is still practiced. It is the longest surviving social hierarchy existing in the world. The system is typically characterized by four distinct levels, and once you are born into a caste you remain in that caste for life. The highest caste is Brahmins, the thinkers, philosophers, priests, and teachers. The next highest caste is Ksyatriyas, the rulers and warriors who are concerned with defending and governing the state. The third level, the Vaisyas, are merchants and traders, and the fourth level, the Shundras, are laborers, artisans, and menial workers. The Shundras became known as the Harijans (God’s children), previously referred to as the untouchables, and most recently this group has been called Dalit, or oppressed (Murthy & Daniels, 2005). A major concern when a patient enters the healthcare system is that they receive quality care irrespective of who they are or their financial status. SUMMARY Similar to other countries, the hallmark difference in India’s healthcare system is primary care. Despite a lack of resources, there has been substantial improvement in the addressing of many health problems plaguing this society. Initiatives such as primary care centers of excellence, major pharmaceutical business, and medical health tourism have been successful. However, there is a need to expand insurance coverage and services to rural areas. Overcrowding, regional funding differences, disparities in access to healthcare services, and the lack of dental care are among some of India’s greatest challenges.