New Delhi: The Union budget has announced a free healthcare insurance plan to cover half a billion people in India. Dr Mark Britnell, head of global health practice at consulting major KPMG, says the budget has sent a strong message that health is now in the spotlight. However, he says if the ambitious scheme is not delivered, the government will come under scrutiny globally and the government would be voted out. In an interview, Britnell spoke on the challenges of the healthcare system in India.
What are your views on the National Health Protection Scheme?
It’s big news globally. I also know from speaking to colleagues in other countries that people do believe that PM (Narendra) Modi will take this seriously. Universal healthcare is the greatest gift a nation can give to its people, along with education. It was the last budget and it spelled like a gripping thriller like the PM was saving the best chapter for last.
A similar policy announced in 2016 which never saw the light of the day. What makes you confident this time?
There are two principal issues; first of all, India has got a good economic forecast, secondly, you have got elections. It seems that there has been some financing now of this announcement. The first phase of financing is enough to launch the scheme. I know there was money put aside in 2016, but I don’t think there was sufficient political will. There are three things that any country needs, to develop universal healthcare. The most important is political will, we have that now in PM Modi. If it’s not implemented this time, it will look foolish on the global stage and he will be punished nationally in the general elections if he does not deliver. The real difference is that this was a major announcement with money at a time when the world is wanting and expecting India to develop (universal health care) because of its economic growth. I think I am more optimistic now than I have been.
What are the ingredients of making this scheme successful?
Three things are needed to develop universal healthcare: money, managerial and clinical skills. So you need will, skill and money.
So you think there is enough political will and money to implement this scheme?
I do believe that the political will and the money and the timing of next elections and the size of the promise make this different. However, if this is all the money on the table, the scheme will fail, but I believe this is not all the money. Because you have redirected so little of your national wealth 1.5% of GDP to date, so it’s about time that more national wealth is pumped in. There is also issue of local GST; that’s a very bold move. So you have grand economy, GST and the health cess. The government is putting in place the financial building blocks for a sustainable universal healthcare.
What are the major problems that ail India’s healthcare sector?
There are three large problems, India needs better managerial skills. So, if all of the money is generated and directed to states, there needs to be much greater management, accountability and responsibility between the federal government and the state government. Second issue is, even when the states have got the money, we know some poorest states in other countries divert that money away from health to more pressing issues; in India’s case, it would be sanitation and education. And the third issue is the dark side of India—which is corruption. Not all the money ends up where it should be.
I have doubts and questions also because the model of care in India is far too hospital-dominated; people in India particularly, which is unusual, don’t seem to trust many doctors if they are not in hospitals. Basically, the most expensive part of healthcare is when you go to a hospital. In other countries, 90% of the healthcare can take place in primary care and that costs only 10% of the cost usually of what we spend in hospitals. The model of care, if you don’t care, you will end up spending all your money in hospitals and most of that money will go to private hospitals. Because they will not reduce the prices, so you have to change the model of care.
You have to make sure that the private sector comes together with the public sector, create joint ventures and develop primary health care which is facilitated by e-health and tele health care and tele medicine.
What are your views on India’s healthcare spending?
India spends 1.5% of GDP on healthcare publicly and 4.5% overall. When you look at other BRIC countries—forget about the G7 and G8—they are spending between 3 and 7% of the GDP. Brazil spends 4%, South Africa 4%, China is 4%.
You are spending at least a half, two thirds less than the BRIC countries. The global health community is increasingly becoming frustrated with India for being such a laggard in health investment because of the income disparities. It’s not easy to take India seriously as an economic powerhouse when you know that people are dying at 68 years of age, it doesn’t feel right and it undermines your credibilities as a fantastic nation.
In your book ‘In search of the perfect health system’, you have a chapter on India titled ‘one country two worlds’. Why do you say that?
Because of stark polarization of wealth and health in India, which is something that no developed society can tolerate because your income disparities are so large. In such a large and populous country, if you want to be considered as global powerhouse, then clearly, you have to make sure that more money is invested on healthcare.
What is your idea of perfect healthcare system? Does it exit?
It doesn’t exist and I say three things about this, but in my book, I look at 12 best possible health care from different parts of the world and I say every country has something to teach and every country has got something to learn. I do believe that like in other industries like in finance and telecommunication, there is a lot more global connectivity and health care still seems to be like a corner shop where every country just tries its hardest and does not spend enough time looking at other countries. This book is a welcome contribution to that knowledge transfer and share.
What about other countries? How has been their experience in implementing universal healthcare?
The quickest country that has implemented universal healthcare is South Korea and that took 12 years. Most countries will take 20 years. universal healthcare is a marathon and not a sprint.
I think one of the issues you face is how capable your administration and management is to manage the money transparently to make sure that it arrives in the intended destination which is the 100 million families that are below the poverty line.