As run-up to the National Roundtable on Universal Healthcare to held on April 23, 2016, FDR had the opportunity to interview Dr.Keshav Desiraju, former Health Secretary, Government of India on Healthcare sector challenges and the reforms needed to invigorate it.
“Better governance of health systems and reduced corruption, additional expenditure for training of health personnel or ensuring availability of drugs and medications at all public facilities are essential for better health outcomes.”
1. To begin with, public expenditure on healthcare is quite low in India, a mere 1.3% of GDP. The Draft National Health Policy 2015 suggested that it should be increased to 2.5%. In our current healthcare framework, does higher expenditure ensure better health outcomes? Could we better the health outcomes at the current Public Health Expenditure?
Given the low levels of current public expenditure, both by the centre and by the states, additional expenditure will lead to better health outcomes, especially if this additional expenditure goes into training of health personnel or into ensuring availability of drugs and medications at all public facilities. However it is also true that even at present levels of government expenditure, much better outcomes would result from better governance of health systems and reduced corruption.
2. A complete overhaul of Medical Council of India is under consideration given its failures in regulation of medical education and profession. How should regulatory bodies especially in healthcare be made more transparent and accountable? Should there be separate regulatory bodies for medical education and medical practice?
The MCI presently has three functions. These are a) the oversight of medical education including curricula and syllabi, recognition of courses, etc., b) accreditation and recognition of medical colleges, number of seats, etc. and c) regulation of the practice of the profession and the establishment of medical ethics. There is a strong care for these functions to be separated, to be insulated from each other, under the overall supervision of an apex body. Further these bodies should not be run entirely by doctors but should include experienced professionals from other sectors including civil society. It is also necessary for these bodies to. Include both elected and nominated members, with great attention being given to the mode and conduct of the elections.
3. Primary healthcare is a largely neglected component despite the government’s thrust on specific high frequency issues such as Polio, TB etc. How could we get the focus back on holistic primary healthcare and services to bridge health equity gaps?
To start with, a much greater focus on family medicine, and a recognition that MBBS doctors working as medical officers play a very important role. It is not necessary for all doctors to be specialists. Also, more posts within government for public health doctors, nurses and health workers. Government hold also revisit the proposal to introduce a B.Sc. Rural Health Care degree, to be taught either in science colleges or in district hospitals. Persons with thus degree will then need to placed in sub-centres and PHCs, not to work as doctors but with public health responsibilities.
4. Health workforce in India be it nurses, lab technicians, assistants, etc. is very low compared to global average. How do address this challenge and make health industry a sector for gainful employment in tune with Skill India?
Substantially more posts within the public sector for persons with these qualifications. The private sector will absorb some people but more will need to be done by government.
5. Recently, ‘Health Protection Scheme’ was announced by the Government of India. Do you think that this scheme would address the issue of healthcare to the poor? Is providing insurance a viable route for providing universal health care?
We should learn from the experience of functioning health insurance schemes such as RSBY or Arogyasri. Insurance will not really provide satisfactory health care unless it addresses outpatient care. Further, a successful insurance model depends on the ready availability of a range of credible service delivery points, i.e., functioning, well equipped, well-staffed hospitals.
6. The Budget 2016-17 announced 3,000 Jan Aushadi stores to provide affordable generic medicines. Currently, India has a total of 137 such stores in 19 states. Is this move sufficient to reduce the Out-Of-Pocket Expenditure?
137 stores are not sufficient, but in principle it is an excellent idea to make generic medicines freely available. This was tried earlier, in 2009, and it is worth finding out why that programme collapsed, which were the interests that worked against it and what is different this time.
7. In India, unlike other developed countries, the private health care has overtime become the dominant player in healthcare services. Given this, how do you think could we now integrate both the public and private healthcare providers to ensure universal health coverage especially in the rural areas?
The private health care system has become a major player not because of any inherent strengths or because the public prefers a private service but because the government system has not been allowed to work. Poor administration, poor HR management, the stranglehold of doctors refusing to work in rural areas, low budgets, have all contributed to the relative failure of government facilities to deliver. Integration of public and private provides, whatever that means, will be possible only if we have a clear sense of what the private providers are standing to get and where their profits are coming from.
8. Also, over diagnosis and overtreatment have become rampant given the abysmal regulation of the private sector. How can we address this effectively?
For a start, through a proper implementation of the Clinical Establishments Act, 2010 and the provision of the resources to make this happen. Also a greater capacity within the MCI, the only agency at present other than the courts with the authority to take action, to rake deterrent action.
9. Though India is still a developing nation, it is saddled with the dual conundrum of communicable and non-communicable diseases. How do we develop the capacity to handle this?
Much greater public resources, both financial and human. It is not only primary care that needs attention; secondary and tertiary care also need investments as do medical, nursing and allied health education in the government sector.
10. To end on an optimistic note, what do you think are the strong points in our health system?
We have always believed that public health is a public responsibility. We have the foundations of a strong, robust health care delivery system and must build on it. We have shown great capacity in the past in the battle against communicable disease. We have had institutions that provided education of the highest quality. These are strengths we must not lose.