Fixing Broken Health system
There is a need to create a system that serves with efficiency and also includes ethical, affordable and equitable aspects. No one will deny that India’s health system requires fixing. Increasing the budget to 3 per cent of GDP will be a welcome step but may not be the only one that is required. More money within the current patient centric health system will be akin to flushing it down the drain. Some feel with just an increase in outlay, many problems will sort themselves out. It is alleged that there is a 35 per cent shortfall of doctors. Why should we require a big army of doctors, when we know majority of the common ailments can be prevented with healthy life style? Why should public money be wasted on a large scale for treatment of ailments that can be prevented on the one hand and on those patients who are in ICU and are not likely to survive? We have to usher in a healthcare system that is health based and not disease based! This entails minimum medicines and minimum investigations. Thus hospital care can be curtailed for 70-80% people and only 20% may be left to avail the services of doctors/hospitals. Next is the question of affordability for those who must go to the hospitals. While it may not be a matter of concern if the well-off go to corporate hospitals, people with modest means should not be forced to go for expensive private treatment, resulting in impoverishment. Should financial protection be provided through more and better services in government hospitals, or by moving towards government-funded insurance programmes that empanel private hospitals?
Public and private healthcare centers
Health services in government hospitals are quasi-public goods, where a poor person will not get medicine if the budget is low or if large numbers of the well-heeled are given free medicine or diagnostic tests. Private hospitals facilitate profit-maximization with impunity. In government hospitals, failure takes place because of a lack of accountability, absenteeism, trade unionism and underfunding. The more politically clued in one is, the more one is likely to survive and prosper. While public goods have the chronic free rider-problem, private health service routinely excludes a large poor population, overcharges and reduces many to penury. Private healthcare is often without regulation. It is unregulated and non-transparent in a different manner from the public system. There is a different maze to be negotiated here. The poor or not-so-rich handle it by selling property. National Human Rights Commission observed, ‘there are complaints galore of private sector hospitals denying health rights, prescribing unnecessary tests and medicines and keeping patients in ICU longer to charge more.’
Yet the two services are two sides of the same coin and are complimentary to each other.
Non-communicable and communicable diseases
Vini Mahajan, the then health Secretary Punjab had observed ‘nation faces continuing burden of communicable diseases, mother and child health, and an increasing impact of non-communicable diseases.’ Communicable diseases such as malaria are no longer the scourge they used to be, but the spread of dengue and swine flu in recent years makes it clear that there is no room for complacency. Most of the preventive aspects do not fall in the domain of doctors. Vector control in terms of preventing stagnant water, spraying, fogging, etc, are primarily in the domain of the municipal government or panchayats. Hepatitis C has become a major health problem, and available evidence suggests that unsafe injection practices, common in villages and small towns, are a major contributory factor, highlighting the importance of regulation. Related areas of serious concern include the quality of food and medicines available in the market, and suggest the need to strengthen the food and drug administration.
Issues relating to non-communicable diseases (NCDs) are more complex. NCDs range from diabetes and hypertension, to cardiac, kidney and liver diseases, developmental delays and disabilities and mental health issues. Cancer and drugs/substance abuse have become top-of-the-mind issues. Many NCDs are exacerbated by lifestyle choices, such as lack of exercise, obesity and excessive use of tobacco or alcohol. The challenge then is to provide credible data and analysis to the population in order to influence their lifestyles. Many of the conditions can be controlled or prevented through early detection. Mental health issues face the additional challenges of stigma and lack of sensitivity not just in the general population but even among health workers. These need focused attention.
Collaboration between a predatory private sector and an inept government sector ends up with an asymmetrical alliance which works against the poor. Efficiency is a must for public health systems but co-existing with private players in the same premises is not the best solution. Private players will be tempted to shift the expenditure to the state, shooting from the shoulder of the poor. The inexorable march to profit-making will eclipse other systemic issues.
The Niti Aayog will do well to design a public health system around a new architecture with attendant rules and contracts for transforming the ecosystem rather than trying to pluck the low hanging fruits. Well trained health workers can be employed to cover the entire population who will impart healthy life education in each home and would not allow the citizens to fall sick due to lack of any ‘dos and don’ts, under its care. This will minimize the flow of patients to hospitals at all levels. This will be much less expensive for the nation, and would lead to great savings in eventual expensive medical treatment. With most of the population remaining healthy the man-hours lost would be much less and nation’s productivity would increase. This will also eliminate rampant unethical practices. Let us hope Ayushman Bharat Yojna proves a leap forward in the area of healthcare as well as medical treatment.