A rare silver lining of the ongoing Covid-19 pandemic is the attention it has forced to addressing the public health issues. Besides, plugging the immediate perceived gaps to check the spread of the virus and provide medical-succour to those affected, the health-emergency at hand has caused policymakers to sit up and internalize how vulnerable a quarter of India’s population living on the margin is. For the first time, universal health care is being rightly described as what Prof Vikram Patel of Harvard Medical School calls “a system which all people, rich and poor, those in power and those who are powerless, can rely on to be given care with the same quality regardless of their station in society”.
Equally important, there is now widespread acknowledgment that public-funding of health care is grossly inadequate with, in 2019-20, just 0.32% of GDP by the Centre and 0.9% by the states going towards health. Since health is Constitutionally a state subject, the Fifteenth Finance Commission, which was ready with its final report, has withheld it to revisit its recommendations. While the Union Government has recently cut spending by all ministries other than health and defence, there is increasing pressure for more meaningful intervention. States, municipal and local bodies that have had to bear the brunt of this health crisis appear unanimous in their realisation that proactively looking after the physical well-being of their constituents is no longer optional.
The Prime Minister Jan Arogya Yojana (PMJAY), announced by Prime Minister Narendra Modi on Independence Day, 2018, and the Ayushman Bharat insurance scheme formulated alongside , are two new structures created to help universalise health care. A staggering 100 mn families, or 500 mn beneficiaries—mainly the poor—are to be insured by the National Health Authority for annual hospitalisation expenses up to Rs 5 lakhs with a “family floater” concept that has no cap on the number or age of family members within a group. Reportedly, 107 mn eligible people have been provided assistance at affiliated hospitals, mostly private.
The Ayushman Bharat scheme may soon be extended to include 450 mn middle class citizens, at present not eligible under PMJAY, on a “self-pay” basis. The Union Government would subsidise the insurance premium by a third, in order to make it affordable to those just above the poverty line and who are neither covered by the existing government schemes nor through their employers. The “family floater” idea would be retained but also feature a “cross-risk pool” to make this viable for insurance providers. The move would significantly expand coverage from the 125 mn people currently with a health insurance—70 to 80 million by employer supported health insurance and the rest through retail market bought private schemes.
The demand-side measures initiated under PMJAY, however, take care of only the affordability aspect and have done precious little to augment the thin and creaking health and medical infrastructure. At just 5 hospital beds per 1,000 people and 7 physicians and 17 nurses per 10,000 people—compared to a global average of 13.9 and 28.6, respectively—the need to significantly grow these numbers is stark. Even these few are highly skewed towards metro areas, leaving the villagers who need the services more vulnerable. As Paul Farmer, a well known medical anthropologist reminds us, “Excellence without equity looms as the chief human rights dilemma of healthcare in the 21st century.”
Currently, there are about 30,000 primary health centres (including community health centres) but most are poorly equipped, run without a qualified doctor and do not regularly keep even the standard drugs to dispense. Just last week, PM Narendra Modi, realising this inadequacy on the “supply side”, spoke in his Independence Day speech about setting up 150,000 village-level health and wellness centres (13,000 of which were operationalised between January and July 2020) and highlighted that the country’s medical colleges had enrolled an additional 45,000 students for MBBS and post graduate courses.
No doubt these are right steps but governments must commit to appreciably increase spending on the expansion of healthcare infrastructure. Once facilitated by the Finance Commission to get a greater share of the devolved tax–revenue, all states must commit to spend successively for the next 3 years, 50% more on health than in the preceding year, while the Central government abets this amount by matching the aggregate level of state-spend. With such an approach, the total public health expenditure, within say three years or 2023-24, could be grown to a somewhat respectable 3% of GDP. In addition, we must revisit the entire framework of how healthcare in India is funded and managed; this will require innovative solutions that undoubtedly put public funding and the governments at the centre, but usher in greater roles for the community and private sector.
The local communities, who are the most important stakeholders, should be given a formal role in management of PHCS and rural hospitals. Prevalent local conditions—economic, social and cultural—would necessitate not having a one size fits all approach for different geographical pockets. There are numerous examples of effective implementation that could be emulated. Thailand, for example, has effectively run community financed and managed drug banks in rural areas, while in poor countries of Central America, villagers regularly “donate” their labour to build local health, water and sanitation infrastructure. Each public health facility must have an executive committee with an elected local pubic representative as chairperson and the sarpanchs of the serving villages/councillors of city wards as members. Besides bringing local knowledge to the diagnosis of ailments, this would help incorporate in the treatment the proven medical practices.
The change in approach of health care can be institutionalised with each medical college in the country being formally assigned to take care of an identified rural or urban district by specialising in their health issues and regularly training the manpower serving them. In addition, all the medical students must be required to work in rural PHCs for a full semester as part of their academic curriculum. Compulsory working in rural dispensaries and hospitals for two years, after graduating from any Indian medical school also be made mandatory and enforced across all states. In fact, the first degree, viz MBBS, should be conferred only at the end of rural service including to students intending to join post graduate courses at home or abroad.
Though health outcomes are the result of an interaction of several variables, augmenting the physical health infrastructure is a good starting point. Within 3 years, the national goal should be to create one PHC or wellness centre with 5 to 10 emergency beds in every gram panchayat, one 50-bed rural hospital in every taluka/tehsil headquarter and all the existing 1,003 district level hospitals being turned into 200 bedded tertiary hospitals operating on referral basis. These changes would quadruple the number of public facilities from the present 30,000 and double the beds in them from the existing 8 lakh. The emphasis, however, has to be on provision of adequate staff and medical equipment rather than building of structures per se.
Simultaneously, the Centre and States must evolve Public Private Partnership models of managing dispensaries, wellness centres and rural hospitals set up with government funding. Options include combining the best of private initiatives and managerial abilities with the government support of land, finance and regulatory clearances. In fact, to attract private resources in the creation of rural health infrastructure, particularly curative, a Viability Gap Funding mechanism can be introduced. Having seen success in creating physical infrastructure for transportation and highway building, there is little reason such collaborative arrangements would not be as helpful in basic healthcare.
The proposed Central scheme of a national digital health card that would digitise every citizen’s personal medical records, and connect diagnostic centres, medical institutions, is a desirable step. Portability of medical records would initially pose challenges, but this is a needed development to cut costs, save time of medical practitioners and keep records of treatment besides ushering in greater responsibility in use of drugs and medical procedures—a critical step in our move forward towards health for all.
Dr Ajay Dua, a former Union Secretary and DG, ESIC, had specialised in Health Care & Management at London School of Politics &Economics.
This is the second of a two-part article. The first part was published on 16 August 2020.