- April 23, 2019
- Posted by: Shivani Agarwal
- Category: Featured, HEALTH CARE, HEALTH POLICY & MANAGEMENT, Latest Work
Sustainable Development Goal number 3 aims to achieve universal wellbeing and health.
India is a proud home to 1.2 billion people and sadly too many communicable and non-communicable diseases. With 17.74% population of the world, no one will deny that, if India moves, the world moves. It is the cornerstone of a healthy and disease free world. However, unfortunately, it ranks 154 in 195 countries and territories on the health indicators scale, according to the latest Global Burden of Diseases Study. According to the same study, India ranked poorly in tackling diseases like tuberculosis, diabetes, chronic kidney diseases and rheumatic heart diseases, and provinding access to health care amongst other parameters. The country is struggling with a host of issues like rural-urban divide, inter and intrastate differences, affordability, quality, a lack of investment, poor data quality among many others which are not allowing to grow as a healthy nation.
Other countries, comparable or even smaller to India, like Cuba, Thailand, Mexico, and Malaysia are outperforming us. We can fare better if all the stakeholders, citizens, state (public health institutions and medical institutes) and private players (hospitals and colleges) play their role justifiably. Public Health is a State subject in the Seventh Schedule of the country’s constitution. Thus it involves crucial involvement of the state governments too.
However, the picture is not all gloomy and bleak. Recently the efforts have fared quite well in controlling the infant mortality rate (IMR) and maternal mortality rate (MMR) majorly through the constant endeavours of the institutionalized delivery and maternity benefit programs etc., initiatives taken under National Health Mission. According to the recent official data of the government, IMR has declined to 34 (per 1000 live births), and MMR has declined to 130 (per 100000 live births). Ayushman Bharat launched recently is a step in the right direction. It seems to have a defined benefit cover of Rs. 5 lakh per family per year, encourage co-operative federalism and flexibility to states and promote cashless benefits from any public/private empanelled hospitals across the country to any of the beneficiaries. But as we pat our backs for the right results, there still lies a lot of room for improvement.
Rural-urban Divide
80% of all the doctors and 75% of dispensaries serve 28% of the 1.2 billion population (KPMG-OPPI). We face the double whammy of lack of care providers at the grass root level and over the burdening of the medical facilities in the cities. There is a huge divide between urban and rural set-up, rich and poor strata, primary, secondary and tertiary care. The top-notch institutions like All India Institute of Medical Sciences (AIIMS) are limited only to the urbanized cities when 70% of our population lives in the rural area.
It has been proved that adequate primary health care services in the initial stages can save patients from undergoing prolonged trauma and financial burden. But primary health centres are either ill-equipped and unhygienic or missing altogether. It is quite ironical to find India to be growing as a preferred destination for medical tourism when our primary health care is still struggling. One reason is the reluctance of the doctors to serve in the rural setting due to limited opportunities, unexpected lifestyle and incommensurable returns on their “investment” in medical education.
Financial investment
We host 17% of the world population and spend less than 1% of the world’s total health expenditure. We seriously need more investment in the health sector to expand the available spaces, equipment, upgrade technology and reach the poorest of the poor. The National Health Policy 2017 has proposed to increase the expenditure to 2.5% of our GDP. It, however, is not enough as compared to around 4% expenditure in the developed countries. Also, it is to be understood that our public health institutions cannot grow at the mercy of government funds alone. Some other options to explore could be leasing out spaces for advertisements for non-medical purposes to avoid any favours or collusions; moulding the best practices from around the world like the 30 Baht system from Thailand or the Cuban model according to our needs, encouraging patients who can afford to avail facilities and pay, introducing public-private procurement in such facilities and encouraging philanthropy and corporate social responsibility.The Niti Aayog and Union Ministry of Health and Family Welfare recently proposed leasing a portion of the public hospital land to the private players for operating a unit for non-communicable diseases is rightly intended. This Public Private Partnership model has however come into debates because of the ‘conflict of interest’ as the private player would come into the decision making process. A public healthcare facility cannot deny service to anyone while a private player can.
The costly medical procedures, medicines and post-hospital visit expenses discourage patients from undergoing formal medical procedures. The out of pocket expenses in India are as high as 60% (WHO). Free check-ups and medicines along with the National List of Essential Medicines are some of the initiatives to reach the poor however they are too plagued with the problems of inadequate coverage, imbalanced demand, and supply, compromised quality and hygiene. In the case of medical insurance; also, we are still far behind as only less than 20% of the population has some health insurance (CBHI). Even within this, the risk pool is reduced, as only those who would need care are more likely avail insurance. This forces the insurers to screen the beneficiaries to protect their returns. Thus, intervention is required to nudge both sides to expand the utility and availability of insurance facilities.
From the perspective of a public health institution, this problem canbe solved through a systematized channel of a seamless transaction between citizen, hospital and the government. Through prepaid subsidized vouchers or direct benefit transfer system, one can ensure inexpensive services to people belonging to the specific economic background. One possible direction to move on can be to opt for “progressive universalization” where we have a small set of essential medication that is fully subsidized for all and other ones be partially paid for by poor and entirely by the rich. Given the huge diversity in India, these sets would vary for different demographical and geographical variations.
The Tamil Nadu scheme of Chief Minister’s Comprehensive Health Insurance Scheme to provide Rupees one lakh to families below a certain level of income for specified procedures. A model like this can be replicated for other states modified according to their disease incidence and medical system. There is also the need for systematized guidelines for health insurances which allows flexibility to withdraw products, ease up renewal norms, etc. We need to move towards universal health coverage to enable our population to grow healthy and live healthily.
Quality checks
Lack of quality of services mars the entire system. It fades away the confidence in the state-owned services and creates a huge gap between the citizens and the public services. Incidences like consecutive deaths of more than fifty infants in Gorakhpur in government-owned hospitals and deaths of women upon sterilization in Chhattisgarh in a state-owned camp refresh the wrong image of these institutions. It is then a Herculean task to come into good books. This is not a problem only in rural areas but also in urban areas. The flourishing private sector provides lucrative opportunities for qualified doctors. However, the pricing of the services makes it unaffordable to the masses. The government doctors are well qualified and experienced, but the ecosystem does not allow them to provide the services in the best of the possible ways.
The problem also lays in the job holders not being accountable for their laxity at work. The common perception views government jobs as those with an immense sense of security and unfortunately, many government officials are seen with a lackadaisical attitude. We need a robust system of keeping account of the work hours, effectiveness and efficiency of the doctors and staff through an online platform at the level of each care provider. An interactive interface between the clients and service providers and a proper grievance redress mechanism would keep both of them at their toes, without any bias. Mera Aspataal (My Hospital) is a mobile app introduced by Ministry of Health and Family Welfare to collect, consolidate, analyze and disseminate the feedbacks on healthcare facilities. Internet penetration and mobile phone usage have expanded manifold in recent times. Such initiatives of app based interactive platforms are steps in the right direction to have better inputs on improving the services. These, however, need to be publicized especially amongst the youth to maximize their utility potential.
There are gaps in data collection in term of quality, its periodicity and coverage both in public and private sectors. This creates hindrances in policy targeting, mid-course policy correction and policy analysis. Each institution can be made accountable through the online publication of data periodically to allow efficient allocation of our limited resources and keep the health sector healthy. The big data analytics needs to be used tactfully to have reliable and concrete data on health issues and requirements, following the ethical issues of data usage in consideration.
It is important to realize that we are undergoing an epidemiologic transition, seeing changes in the patterns of mortality and diseases. We are grappling with high infant and child mortality as well as the degenerative diseases, communicable illnesses on the one hand and the growing non-communicable diseases on the other, and under-nutrition as well as obesity and overweight. As challenges are evolving, our policies, institutions, technologies, and attitudes need to adapt to cope up with the changing times. Equitable distribution of quality and affordable services is the primary target of our public healthcare system which can be brought through structural policy changes backed by financial investment with a continuous revaluation and vetting of the existing practices. It is imperative to have a robust health sector in our country to save the demographic dividend from becoming a demographic disaster.
