India’s path to universal health care

After looking at the obvious and large swelling in her neck, her family doctor recommends she go to a hospital to see a specialist.

Jayama is perplexed by the advice. The last time she sought treatment she needed a 10,000-rupee loan. Two years later, she still hasn’t managed to pay it back. When asked about using Ayushman Bharat (ModiCare), Jayama says she’s never heard of it, or for that matter, of Modi himself; she’s illiterate. After the basics of how a visit to a thyroid specialist could be covered are explained to her, she pauses for a few moments, then responds with an expression in the local language, Kannada: “Aadare olleyadu.” Roughly, it translates as “If it happens, it’s good.”

I recently read about this incident somewhere and could immediately relate to it, as I frequently encountered such patients during my rural postings. The above scenario is a fitting illustration of where do we as a nation stand in terms of universal health coverage, the prevalent challenges in implementing the same, the lacunae in our system which has quite inspiring policies but fails to impress in terms of implementation, and at the same time also shows a ray of hope for patients as well as us, health providers.

Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

It goes without saying that UHC is a necessity, and should have been realised long back, but why does our nation, the 6th largest economy still struggle to actualize this dream and what are the possible solutions to enable the same?

Challenges to UHC such as affordability, low per capita income, lack of doctors, illiteracy, wide socioeconomic disparity, lack of government will, etc etc are discussed in health forums and news media quite frequently. Though it’s essential to understand the problems, finding feasible solutions to the same will bear more fruits and thus we will focus on the existing but not yet well utilised solutions as well as some yet to be tried but promising ones.

Healthcare is expensive, so regulate it further! Put a cap on fees of doctors, healthcare equipments, hospitals, bring them in an affordable range and viola! Problem solved! Is it? Providing a ceiling cost for necessary and expensive procedures which does not hamper the sustainability is okay. But over regulation will demotivate the most meritorious students to take up medicine as a career and will make the healthcare businesses shift to more sustainable and profitable ventures. It has been historically seen that such measures force the indigenous businesses to shut down and thus, importing, at a much higher rate will be the only option left. Thus, regulations would not be the ideal way to move ahead.

Increasing the GDP allotment to healthcare is a no brainer. But where should this money be spent? Should government become a healthcare provider or settle with being an enabler? NHS or public healthcare adopted by UK seems idealistic for India (who for a fair term of time romanticized to be a pure socialist!). But what is the problem with idealistic measures? They don’t work. UK has 1/20th the population of our country yet a slightly higher GDP! This amongst the many other advantages it has (such as the narrower urban rural gap, smaller area to govern, etc) makes them the perfect candidate for public health care, but for a country like India, the model adopted by larger countries like USA of insurance based health care makes more sense! Of course, with a fiscally prudent Indian touch!

Primary health care to a good extent is affordable and can be managed by government. But when it comes to higher health care and expensive operations such as heart operations, people generally have one to few instances in life where they have to bear the financial burden of such procedures and many are lucky enough to escape from its claws but the wrath of expensive procedures troubles everybody and throughout their life. Thus, there is a need to spread out such costs vertically as well as horizontally (throughout life and across people). And this is exactly what insurance does. And so, Ayushman Bharat providing health insurance of 5 lacs per annum to the lower 40% of the population only brings us closer to UHC.

The one thing where we Indians can claim leadership is frugal innovations! Whether it is having a handheld tablet (a mini diagnostic lab) having more than 200 tests in a meagre thousand dollars or ultra cheap private healthcare models, India has been a brewing pot for a number of such innovations! Necessity is the mother of inventions, correct? Technology has a huge role to play in healthcare especially in a resource scarce country like India! Tele healthcare can compensate for lack of general and health infrastructure in rural parts of the country. The need is to identify such technologies, implement, improvise and if it’s worthy, scale and integrate! 

When it comes to serving 1.3 billion population, help from the private sector is prudent if not desirable (considering our socialist hangover). Public private partnership has been experimented with decent success. Government has huge numbers of patients, and private sector has infrastructure, financial resources and operational acumen. Hence, it seems a perfect marriage between both. But like every other marriage, both have to accommodate and understand each other. While private sector has to shift from a high margin low volume model to low margin high volume business model, government has to dig deeper into their pockets and also enable measures to have transparency and disable deceit by their private partners. Encouraging CSR (corporate social responsibility) in health sector is also essential. Like every marriage, it will take time but if worked on with sincere efforts, it will blossom! 🙂

All this is great! But the core of healthcare, doctors, are still less right? Measures taken by the government such as converting diploma PG seats to degree PG seats, hike in number of medical seats, relaxation of rules and regulations enabling increased medical colleges and seats have been a welcome step. At the same time upskilling is of utmost value. On one hand, we have an unacceptably low doctor patient ratio and on the other hand, doctors are entangled in a lot of paperwork, managerial/clerical work and also simple medical procedures that don’t necessarily need heavy medical training. Utilisation of Para medicos in such cases has brought revolutionary results and digitisation (it can bring much better results with much lesser efforts and time) will only add to it.

While talking about all the new things we can do, we need to fix the existent public health system which is leaky to say the least. They provide great service to masses who otherwise have not been able to avail healthcare, but they are clearly over burdened, has lethargy at some levels which is considered a norm in government jobs and is leaky due to lack of optimal systems. Fixing these loopholes is the need of the hour.

Healthcare is not an isolated island, it’s part of a bigger machine. Before hospitals reach villages, it’s necessary for water, electricity, roads to reach there. So overall economic growth will aid the process, provided it’s benefit is honestly shared with the rural population.

With right intention and focused effort, universal health care will soon be a reality and smile will return on the face of patients like Jayama. 🙂

-Vishal Jha

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