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Tackling hurdles to healthcare for all

(L to R) Dr A. Velumani, chairman and managing director, Thyrocare Technologies; Meeta Rajivlochan, principal secretary (reforms), finance department, government of Maharashtra; Anil Padmanabhan, executive editor, Mint; Shubhra Mittal, policy and training manager, J-PAL South Asia, Institute for Financial Management and Research, and Dr Dileep Mavalankar, director, Indian Institute of Public Health-Gandhinagar. Photo: Abhijit Bhatlekar/MintPremium
(L to R) Dr A. Velumani, chairman and managing director, Thyrocare Technologies; Meeta Rajivlochan, principal secretary (reforms), finance department, government of Maharashtra;
Anil Padmanabhan, executive editor, Mint; Shubhra Mittal, policy and training manager, J-PAL South Asia, Institute for Financial Management and Research, and Dr Dileep Mavalankar, director, Indian Institute of Public Health-Gandhinagar. Photo: Abhijit Bhatlekar/Mint

India has a long way to go before it can achieve universal healthcare. At Mint's Healthcare event, a panel discusses the challenges that range from lack of doctors, poor government policies to inadequate financial resources

India has a long way to go before it can achieve universal healthcare. Challenges range from lack of doctors, poor government policies to inadequate financial resources. At Mint’s Healthcare event held on 17 June in Mumbai, Dr A. Velumani, chairman and managing director, Thyrocare Technologies; Dr Dileep Mavalankar, director, Indian Institute of Public Health Gandhinagar; Meeta Rajivlochan, principal secretary (reforms), finance department, government of Maharashtra; and Shubhra Mittal, policy and training manager, J-PAL South Asia, Institute for Financial Management and Research, participated in a panel discussion on Healthcare for All: Bridging the gaps. Edited excerpts:

Challenges in achieving healthcare for all

Dr Mavalankar: We are not ready as a nation to commit ourselves to spending the money required to reach healthcare to everyone. That is the challenge India has struggled with and somehow as a nation we haven’t been able to either allocate the money, muster the political will or gather the confidence to increase it. It increased in the last few years from 0.9% of the GDP may be to 1.1-1.2% but what we require is 2-3%. First we have to ask ourselves why are we failing to deliver. Do we not have the money or are we unwilling to devote that money? Second issue is it’s not just the money, it is also the management of healthcare. Health services requires discipline, quality, and good policy.

The third point is: it is a national agenda but finally it has to be delivered by the state governments because as per our Constitution it is the state’s responsibility to deliver healthcare. Finally, where we are very weak is the lack of data required to see whether we have reached everybody or not. We can’t even count the number of infant deaths. Health statistics are supposed to drive what investments we need to make to reach universal care. It is the social and political priority which many in western Europe did 50 years ago—the social consensus that nobody in the country should be left untreated because they don’t have money. I think we are waiting for that kind of social and political consensus.

There are two problems when one thinks about healthcare for all: access and quality- Shubhra Mittal, policy and training manager, J-PAL South Asia, IFMR

Mittal: When we talk about challenges in healthcare for all, I think in two ways. One problem is about access, and related to access is this issue of quality. A lot of your primary care is free of cost in a government healthcare system but what you often find in parts of the country particularly in rural areas is a lot of people still go to private providers for healthcare. They still account for majority of healthcare services. We are talking about basic healthcare services. We are not even talking about secondary and tertiary at this point in time.

There is also health-related financial shocks pushing people into poverty.

So what we have seen increasingly as part of the whole conversation about healthcare for all is about providing universal healthcare insurance. The idea is to reduce the out-of-pocket expenses that people have and to shield them from the financial shocks with the hope that they can even have access to even better quality care. This is great when we think about it but the challenge really is what is the ground reality. Does providing people health insurance solve some of the issues and do people use it? Do people enrol? Does it really reduce the cost of healthcare? Do people actually spend on healthcare? You would expect it to but there are lot of studies that has been done particularly in developed countries such as the US and other developing countries like Mexico that show that it’s not simple and goes back to insurance being a complicated product. We really need some good studies that can help us get to those ideas.

Integrate private healthcare to public

Rajivlochan: If we wish to achieve healthcare for all, perhaps the first thing that we need to do is to increase the number of healthcare providers specifically doctors and nurses available in the country. If you look at the figures today, there are over 950,000 allopathic doctors who are available in India and that comes to a ratio of about one doctor for 1,300 people. If you were to look at the government health care services, there is one allopathic doctor for 11,000 people. Figures for rural areas would be much worse. So what do we do?. There are two strategies which I would like to suggest on the basis of my experience. We should integrate private practitioners to a healthy system of primary care at ground level. If we do so I genuinely believe we can immediately at least double the number of doctors who would be available. At the same time, what we need to do is to build up knowledge management system. We have so little information about what is happening on the ground. Some very basic statistics are needed.

There is a shortage of doctors... also mal-distribution... rural India has one doctor for 30,000.- Dr Dileep Mavalankar, Indian Institute of Public Health Gandhinagar

Dr Mavalankar: Many countries run their healthcare system with nurses and para medics. In some sense, we need to have a nurse base. Even in Sri Lanka, apothecary doctors which in simple terms mean a pharmacist trained to be a simple doctor. Pharmacists are in overproduction in India and nurses are also being over produced. Yes, there is shortage of doctors, but there is also mal-distribution. How many general practitioners are there in my own city Ahmedabad—around 8,000 are the members of the General Practitoners (GP) association and 500 are the member of the obstetrics association. Rural India has one doctor for 30,000. So I think it’s a government policy issue. We should try getting away from depending only on doctors and increase the capacity of para medics. Once you have a pathway and a standard algorithm my sense is even a cell phone can help diagnose now.

Alternative to health insurance

Rajivlochan: What we also need is a good referral system at the level of primary care because in the end, the one person who has a stake in the healthcare system is the local practitioners who interact with people on a daily basis. In order to build a primary care network the government should contract private practitioners to fill up the gap and the government should cover the cost of consultation and medicines. If we can do something like that, then that would a huge relief for poor people. Consultations and generic medicines should be possible for government to cover. Once you have that you have a base system from which a referral system or insurance and other systems are possible. The problem is we don’t have anything at the base. That base the government should pay for it but that will come when there is a consistent demand for that kind of a system. There is no demand. There is a lot of demand from corporate hospitals for secondary care and tertiary care.

Mittal: What we really want to do is to understand how the insurance works in the Indian context. There has been studies that has documented the implementation-related challenges. Beneficiaries have cards but they don’t know what to do. There are challenges in processing and all of these are implementation related.

Primary care is not something we are even really focussing on. So even in health insurance we need to have more research and the way these policies are designed. How is it having an impact and what are the kind of challenges they are experiencing? Is it leading to improvement which is what we are really concerned about? And if that’s not the case maybe we want to think about innovative ways of either informing people about how this works and figuring what are the bottlenecks and thinking about innovative ways. So that means doing more research and having good data. There is also a challenge in making people invest in preventive care. As an individual, you are more likely to invest in curative care because you see the direct benefit of it. With preventive care, you are telling the person you need to make the investment today but he or she may not see the benefit. So sometimes it’s very hard for people to even kind of make them understand or realise it.

How do we address the issues in providing healthcare for all?

Dr Mavalankar: Systems are required but look at Germany did years ago. No system was there but they politically decided that we must get at least some healthcare and everybody is equal. We say it’s so complicated that we cannot do. We have sent rockets to Mars but we cannot build our own healthcare system that also at the primary level.

Rajivlochan: Government policy comes largely from whatever social consensus exists in society. Sure, we can use nurses and many of the societies do use that but in our government whenever we have tried to use that there has been very serious opposition from the allopathic doctor community. We are running an emergency medical service and because we didn’t have enough allopaths to provide ambulatory care. We said we will do with an ayurvedic doctor. That was challenged. There is so much litigation on this particular issue. So if you are not able to generate enough resources, please use whatever other resources are available.

At least let us train them because in any case they are de facto providing care to people. Why not do that? So that’s the social issue which the community needs to sort out and regarding medicines, here we need to look at economies of scale. If we are able to achieve significant economies of scale we were able to bring down the prices. So I think what we can do is to look at economies of scale which is possible if the government can introduce greater efficiencies into their procurement systems.

Dr Velumani: The worst disease the society is facing is lack of stamina. So this needs to be seriously addressed. All said and done, I have observed that in 1995 only 1% of the total diagnostics was preventive care, remaining 99% was sick care. Today around 7-8% is preventive care and that’s a good growth though it took 20 long years. Any country is said to be developed only when it does preventive care. India cannot claim itself to be developed until adequate funds are spent and it’s not costly. Scale is needed. Don’t sit and cry in India that scale is not there. There’s 1.25 billion population. So people need to get into action. Put a few things in place, see the results, people will observe it. People will follow it.

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