New Delhi: We are already 60 years late in setting the country’s healthcare agenda and need to act now, Naresh Trehan, chairman and managing director, Medanta-The Medicity, said at Mint’s India Agenda event on “Universal Healthcare: Critical Areas and Opportunities”.
The event, which had on the panel Trehan; Shivinder Mohan Singh, managing director of Fortis Healthcare Ltd; Amarjeet Sinha, joint secretary, National Rural Health Mission, ministry of health and family welfare; D. Ragavan, sector chief executive officer, healthcare, South Asia cluster, Siemens Ltd; and Sumita Chopra, consultant, processes and projects at the World Bank; debated on issues of access to healthcare and the need for greater involvement of the private sector. Mint presents edited excerpts from the discussion, held in New Delhi on Wednesday and moderated by editor R. Sukumar:
What is the one word that you think is the most critical issue in universalization of healthcare?
Trehan: Inclusive. Very large population which is left out on the fringe.
Singh: Preventive. For the kind of population and expanse we have and for all the statistics that are telling us about cancer, cardiac, diabetes and other ailments that are going to fall on the country. There is no way that we can create an infrastructure and fix them. Fixing is only half the solution. If we can prevent them, we can get to a far better situation than being No. 1 in all the ailments.
Sinha: Inclusiveness. We are one of the few countries where universal healthcare is in the realm of the possible because, unlike many of the developing countries, we are not really as short on good human resource trained in modern medicine. We need to think about how we can go about doing it. From that point of view, I think matching our performance on the social agenda with our economic performance over the last two decades is what inclusiveness is all about.
Ragavan: Government spending on healthcare. We are one of the countries with the lowest government spending on healthcare. India spends 0.9% of GDP (gross domestic product) on healthcare, which is just 20% of the total healthcare pie. And if you expect 80% of people to pay out of their pockets for healthcare, you know where they are headed. Government spending is one of the first things we need to address.
Chopra: Information. All this is valid and we have an excellent healthcare system with National Rural Health Mission (NRHM) running it. But the main bottleneck we have seen is the lack of information flowing to the people to whom the health benefits have to go and coming back to the healthcare providers and government in time to be able to take corrective actions, to be able to deliver benefits where and when they are needed.
What aspect of healthcare are we focusing on? What really prevents inclusion?
Trehan: First of all, you start with the national priority. The government, for 60 years, has shown clearly that it is the least important sector in India’s life. So you have 60 years of catching up. It’s not rocket science, it’s building a pyramid from base-up that we have grossly divided into three segments of primary, secondary and tertiary care. The dual situation here is that health is a state subject. So actually the delivery on the ground at the state level is the state government’s responsibility. So as the unevenness in the development of states takes place, same way depending on the efficiency or integrity of that state, the healthcare at the bottom of the pyramid is delivered at that level. In other words it’s an implementation problem. The government started the NRHM scheme and in that the bottom pillar is the Accredited Social Health Activist (ASHA) scheme, which says that there is an accredited health worker in every village. If that is accomplished, you have a great starting point.
We have to do some creative thinking on how to stop copying the West for everything and innovate for our own systems, which will not only be valid for India, but (also for) the rest of the countries which are in our category or aspire to be like us.
Then comes the secondary care—hospitals or the civil hospitals and again very uneven standards. It’s a national asset. If they are not functioning well, we have a large network of private providers who are willing to do a public-private partnership (PPP). We all across the table are struggling with the government, where you can have a fair PPP model to make these things work better. If we can provide the human capital or the capital to provide the equipment or service it properly, we can make this system robust where it is already existing and then add where it is not existing.
Then comes the tertiary and that has two big disadvantages for the government. One, it takes a large investment to create good tertiary care hospital. Second, the super-specialists’ salaries, which do not come under the realm of the government’s salary systems. One thing that other countries have done very well, who signed the Alma-Ata Declaration of 1978 with India, in which they declared that we shall provide minimum standards of healthcare to all our citizens by the year 2000, is that the governments have turned from providers of healthcare to buyers of healthcare. Because private providers, if done properly, can do it much more efficiently. The cost comes down.
We need a new model. Trehan seems to be suggesting that we need something different in terms of the model itself that we use to reach out.
Chopra: The government’s standing from providers to buyers, which is what in a small way Rashtriya Swasthya Bima Yojana is trying to demonstrate and we haven’t seen a similar model all over the world. Using the existing infrastructure and resources available, diverting them in a manner where we can provide some benefits and using a technology platform to get back information on almost a real-time basis and then using that info to provide the right kind of benefits to those people. Making them aware of where healthcare is available, using the ASHAs in the field to take this awareness to the people. And then coming back to the government to understand what kind of problems need to be addressed in the health arena for these people.
Is the right kind of thinking going on in the government? What are the big things that we can expect to see from the government in primary healthcare?
Sinha: Yes, partnerships are required specially in a country where a large part of the health human workforce is not in the public system. I will emphasize far strongly on the need for crafting credible public systems. If the question is that should we give up crafting credible public systems, the answer is an emphatic no... because health is a sector which has huge information asymmetry, it cannot be managed by market principles alone. It is a sector which needs the counterveiling presence of a functional, effective public system which also needs partnerships.
What is it that China did and we didn’t? They did very basic things—get a provider in every village, food security, clean water as guarantee, basic immunisation and simple public health measures. They made sure that communities participated in meeting the public health challenges. We need to take the debate of health a little further. One thing that NRHM has tried to encourage is not to go with the solution, but to begin with the problem.
We spend, as per the economic survey, 1.45%, and as per the national health accounts, 1.19%, of the GDP on public health systems. Can we ever assume a trajectory of moving towards 8%? As a country if the public finances are going to change, alter, the priorities are going to change, you will probably move up to 2-3%. If that is the case, more efficient public systems will also have to be designed to provide the services and on the scale that would be needed. Partnerships are welcome, but they work very well in provinces where there is huge capacity creation. The possibilities are there, but a lot of this would happen if we are able to create functional platforms with communities in the lead.
What are all the areas where you think you can partner, you would like to partner, but there is no clarity on how you can partner with the government?
Singh: Today in terms of infrastructure, government has a very large access and infra present across the country. What it doesn’t have is probably a process where it can ensure that the delivery happens at that end point. On the flip side, the private health system is probably much smaller in terms of hospitals and beds, but has 80%-plus population going to it in terms of spend basis. That skew in itself is a little bit of a concern because it doesn’t reflect the infrastructure mapping.
There are three things in healthcare that need to be put together in a triangular fashion—reliability, affordability and accessibility.
What the government brings to the table for sure is accessibility. They already have a very large infrastructure. Private operators have been able to reach consumer from perception of reliability and on an affordable level to the extent that the consumer is coming to them as against going to free or subsidized government centres.
So it’s leveraging the access that is available with the government and topping that with systems, processes, capabilities and talent from a private healthcare set-up.
I am not convinced that the solution lies in spending more. I think we have to find ways to spend better. The biggest concern here is the mindset that both private and government look at each other with suspicion. I think that bridge needs to happen first and if that happens then enough schemes and opportunities are there in the government space to make this transition in a short period of time.
When you look at India, do you see innovations coming out of here or a huge amount of problems?
Ragavan: I appreciate that there has to be a counterveiling presence from the government. Government cannot merely become a buyer of healthcare. It has an obligation to get some amount of healthcare accessible to the largest population of the country. But unfortunately, this agenda is nobody’s agenda. Although it is the government’s subject, they are definitely not doing their job.
Healthcare has to be local. You cannot expect people to travel long distances because they will incur cost. So whose agenda is it to say that it is my responsibility to make sure that healthcare infrastructure is equally distributed in the country? The speed and sense of urgency that we have is a big issue in terms of lack of focus on health that we need to get it done. Curative and preventive...most chronic diseases can be detected early and cured also, but if you don’t do it, it becomes more expensive and cripples the economy. My only worry is that it seems like it is nobody’s agenda and nobody has a mental map that this is where we are and this is where we want to go.