Health is a non-negotiable goal. It is vital for the progress and wellbeing of any country. For India to sustain and enhance its current growth and development it must have a robust universal healthcare system in place. The current system is glaringly deficit in many areas.
To begin with, public expenditure on health is a meagre 1.3% of our GDP. The draft National Health Policy rightly points out the need for increase in public health expenditure to about 2.5% of GDP. Other emerging economies such as China, Brazil, South Africa, etc. spend around 3 to 5% on public healthcare. As a result, they have been able to achieve better health outcomes. This dearth of expenditure has resulted in inadequate infrastructure and uneven distribution of health workforce. This in turn ensued poor access to public health services and subpar treatment facilities.
As a direct consequence, the private healthcare industry has grown by leaps and bounds over the decades. To put it inperspective, more than 70% of outpatient care in 2014 was in the private sector. The lack of proper regulation of the private sector is hurting the common man. Overdiagnosis and overtreatment have been rampant given the prevalence of information asymmetry between the provider and the patient. While our super-specialty hospitals are getting known for their excellence and promoting medical tourism, the fact remains that nursing homes which are the first point of contact have under-qualified and sometimes even unqualified healthcare providers.
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In addition, the private sector sees no incentive in promoting preventive healthcare, which can greatly reduce the need for secondary and tertiary health services. This puts the onus on the government to come up with effective preventive healthcare programmes which are integrated at the primary level. Although there has been some thrust (for example, Mission Indradhanush) in this area, efforts need to be doubled and sustained.
The recent drive towards insurance as a model for universal health coverage needs to be analyzed thoroughly. Programmes such as the Rashtriya Swasthya Bima Yojna(RSBY) have only been marginally successfulin ensuring health services. They are riddled with penetration and implementation issues. The tendency for overtreatment has also been reported. Global experience especially the United States has shown that insurance model of health care has failed to truly provide inclusive health coverage. While risk-pooling and other innovative methods can be adopted, care must be taken to ensure that insurance doesn’t end up subsidizing the private sector at the cost of the taxpayer.
Moreover, health information systems are fragmented leading to severe gaps, at times, duplication and most times inadequate data. Issues of data gathering, coordination, integration and related issues plague the process. Although, National Rural Health Mission has setup a national portal for health information, continuous updation is lacking given the large and infrequent intervals in data collection. The corresponding issue of lack of proper utilization of data for formulating better policies and schemes must be addressed. More targeted surveys which are regular must be adopted and successfully integrated. Accurate demographic profile thus obtained is highly crucial for rolling out targeted schemes.
The deficit in skilled workforce is another challenge area. Though the general demand for more number of doctors is common and legitimate, greater demand is for trained nurses, lab technicians, midwives and other support staff. India has around 2 health workers per 1000 population while the UK, which is globally hailed for its universal healthcare has 25 to 1000 ratio. We need to augment our health workforce proportional to its demand.
Equally important if not more is the skewness in the distribution of health workforce with the maximum density being in urban areas and to the other extreme, dismal paucity in rural areas. Contributing to this is the reluctance of many doctors to practice in rural areas for want of income and resources. Such issues must be addressed through innovative means using Public Private Partnership models wherever feasible.
Further, a major challenge is drug pricing and the access to generic drugs. About 67% of the entire ‘out of pocket’ expenditure is incurred on drugs. Presently, the Jan Aushadhi scheme (as of October 2015) covers 449 generic drugsin about 114 stores. The plans to scale up the number of these generic drug stores (The 12th Five Year Plan envisages the number of stores to reach 3000) must be fast-tracked and implemented on mission mode. The recent article published in Lancet ‘Assuring health coverage for all in India’, (Dec 12, 2015; pgs 2422 – 35) also corroborate these challenges.
Ultimately, vigorous governance and accountability mechanisms are necessary for the fruition of healthcare. Health being a state subject is under the individual state’s purview. There is a decent level of chaos between the center and the states and across various ministries covering similar issues be it health, water, sanitation or welfare and others. Such convergence must be taken into account while formulating and implementing policies. Effective decentralization and active involvement of civil society in accountability measures must be promoted.
Challenges inherently are disguised opportunities. India has the public demand necessary for qualitative, accessible and affordable healthcare, the capacity to expand its workforce, a solid pharmaceutical industry and the environment conducive to innovation. These must be exhaustively tapped into for they not only can make universal health coverage a reality but also present great potential for employment generation. •