Universal access to healthcare implies that everyone gets equitable access to healthcare and there is no discrimination whatsoever, especially discrimination based on the capacity to pay. Worldwide countries which have established universal or near universal access have clearly demonstrated that public financing of healthcare is critical to realize this. However delivery of health services need not be only in public domain.
For instance Canada, which has the best and most equitable healthcare system in the world assures full access to everyone without the need to make any payment at the point of care. Health Canada, a public Corporation pools all resources and is a single payer for all healthcare services. While most hospitals are run by governments in Canada, private hospitals are also given access to these resources when citizens access them. And for out-patient care most providers in Canada are private providers who are contracted in by Health Canada on pre-agreed fee for services. The NHS in UK is very similar and Brazil, Venezuela, Mexico close to emulating these models. On the other hand there are examples like Sweden, Sri Lanka, Cuba which are completely state run systems which provide universal access to healthcare. Thailand is the most recent entrant into this club and I think we have a lot to learn from the Thai experience because the structure of the healthcare system in India and Thailand historically has been very similar.
In India the NRHM affords us a great opportunity to change the way the healthcare system works in India. NRHM talks about architectural corrections, public-private partnerships and the UPA backs this with a political commitment of providing upto 3% of GDP to realize universal access to healthcare. But so far the UPA and NRHM have failed because the required political backing to make radical changes and shake up the healthcare system has not been forthcoming. So what needs to be done to realize universal access to healthcare? To begin with:
• equating directive principles with fundamental rights through a constitutional amendment
• incorporating a National Health Act (similar to Canada Health Act) which will organize the present healthcare system under a common umbrella organization as a public-private mix governed by an autonomous national health authority which will also be responsible for bringing together all resources under a single-payer mechanism
• generating a political commitment through consensus building on right to healthcare in civil society
• development of a strategy for pooling all financial resources deployed in the health sector
• redistribution of existing health resources, public and private, on the basis of standard norms (these would have to be specified) to assure physical (location) equity
As an immediate step, within its own domain, the State should undertake to accomplish the following:
• Allocation of health budgets as block funding, that is on a per capita basis for each population unit of entitlement as per existing norms. This will create redistribution of current expenditures and reduce substantially inequities based on residence. Local governments should be given the autonomy to use these resources as per local needs but within a broadly defined policy framework of public health goals
• Strictly implementing the policy of compulsory public service by medical graduates from public medical schools, as also make public service of a limited duration mandatory before seeking admission for post-graduate education. This will increase human resources with the public health system substantially and will have a dramatic impact on the improvement of the credibility of public health services
• Essential drugs as per the WHO list should be brought back under price control (90% of them are off-patent) and/or volumes needed for domestic consumption must be compulsorily produced so that availability of such drugs is assured at affordable prices and within the public health system
• Local governments must adopt location policies for setting up of hospitals and clinics as per standard acceptable ratios, for instance one hospital bed per 500 population and one general practitioner per 1000 persons. To restrict unnecessary concentration of such resources in areas fiscal measures to discourage such concentration should be instituted.
• The medical councils must be made accountable to assure that only licensed doctors are practicing what they are trained for. Such monitoring is the core responsibility of the council by law which they are not fulfilling, and as a consequence failing to protect the patients who seek care from unqualified and untrained doctors. Further continuing medical education must be implemented strictly by the various medical councils and licenses should not be renewed (as per existing law) if the required hours and certification is not accomplished
• Integrate ESIS, CGHS and other such employee based health schemes with the general public health system so that discrimination based on employment status is removed and such integration will help more efficient use of resources. For instance, ESIS is a cash rich organization sitting on funds collected from employees (which are parked in debentures and shares of companies!), and their hospitals and dispensaries are grossly under-utilised. The latter could be made open to the general public
• Strictly regulate the private health sector as per existing laws, but also an effort to make changes in these laws to make them more effective. This will contribute towards improvement of quality of care in the private sector as well as create some accountability
• Strengthen the health information system and database to facilitate better planning as well as audit and accountability.
Infact the NRHM clearly articulates the need for architectural correction. Such restructuring will be possible only if:
The healthcare system, both public and private, is organized under a common umbrella/framework as discussed above
The financing mechanism of healthcare is pooled and coordinated by a single-payer system
Access to healthcare is organized under a common system which all persons are able to access without any barriers
Public finance of healthcare is the predominant source of financing
The providers of healthcare services have reasonable autonomy in managing the provision of services
The decision-making and planning of health services is decentralized within a local governance framework
The healthcare system is subject to continuous public/community monitoring and social audit under a regulated mechanism which leads to accountability across all stakeholders involved
The NRHM Framework one way or another tries to address the above issues but has failed to come up with a strategy which could accomplish such an architectural correction. The framework only facilitates a smoother flow of resources to the lower levels and calls for involvement of local governance structures like panchayat raj institutions in planning and decision making. But the modalities of this interface have not been worked out and hence the local government involvement is only peripheral. The 12th Plan will need to focus on developing such modalities to bring in the structural changes.
In order to accomplish the restructuring that we are talking about the following modalities among others would need to be in place:
All resources, financial and human, should be transferred to the local authority of the Health District (Block panchayats)
The health district will work out a detailed plan which is based on local needs and aspirations and is evidence based within the framework already worked out under NRHM with appropriate modifications
The private health sector of the district will have to be brought on board as they will form an integral part of restructuring of the healthcare system
An appropriate regulatory and accreditation mechanism which will facilitate the inclusion of the private health sector under the universal access healthcare mechanism will have to be worked out
Private health services, wherever needed, both ambulatory (FMP) and hospital, will have to be contracted in and appropriate norms and modalities, including payment mechanisms and protocols for practice, will have to be worked out
Undertaking detailed bottom-up planning and budgeting and allocating resources appropriately to different institutions/providers (current budget levels being inadequate new resources as suggested in the paper will also have to be raised)
Training of all stakeholders to understand and become part of the restructuring process
Developing a monitoring and audit mechanism and training key players to do it
The above is not an exhaustive list but certainly critical issues to be addressed under the 12th Plan strategy. Further the most important challenge would be reining in the completely as yet unregulated private health sector. Where the private health sector is concerned it functions completely on supply-induced demand which fuels unnecessary procedures, prescriptions, surgeries, referrals etc.. leading to its characterization as an unethical and mal-practice oriented provisioning of healthcare. This has huge financial implications on households, inflating costs of healthcare, spiraling indebtedness and pauperization and being responsible for the largest OOPs anywhere in the world.
The challenges across the country differ due to different levels of development of the public and private health sectors in the states. For instance a state like Mizoram, a small and hilly state, already has an excellent primary healthcare system functioning with one PHC per 7000 population and one CHC per 50000 population and since it has virtually no private health sector the demand side pressures are huge and hence the public health system delivers. Each PHC has 2 to 3 doctors on campus available round the clock with 15 – 20 beds which are more or less fully occupied and 95% of deliveries happen in public institutions. So Mizoram has indeed realized the Bhore dream. The problem in Mizoram is that there are very few specialists available and hence higher levels of care become problematic – the CHCs are however run by MBBS doctors who have received some additional trainings. Mizoram does not have a medical college but it does have reservations in other state medical colleges. While the state cannot provide tertiary care it has a budget to send people elsewhere to seek such care. And Mizoram does this with 2.7% of its NSDP and has the best health outcomes in India. In some sense Mizoram is like Sri Lanka – a statist model. There are few other states in India which can do a Mizoram because they too do not have a significant private health sector but to do that they have to demonstrate the political will of Mizoram.
Even though extremely successful Mizoram cannot be the national model because the reality across most other states is very different, the reality of an entrenched private health sector which is unethical and unregulated. The private health sector has to be reined in and this can only happen with a strong political will which declares healthcare to be a public good and which takes on the private sector to get organized under public mandate. Under NRHM sporadic efforts towards this end are being undertaken in the name of public-private-partnerships like Chiranjeevi in Gujarat, Yeshasvani in Karnataka, Arogya Rakshak in AP, Rajiv Gandhi Hospital in Raichur (Karnataka Govt and Apollo Hospitals) etc. They may have achieved limited success but then healthcare systems cannot be built by segmenting it into programs and one-off initiatives like PPPs. There have to be serious efforts at building a comprehensive healthcare system and it goes without saying that given India’s political economy of healthcare the private sector will have to be a significant partner in this process. So states have to think beyond the Chiranjeevis and Yeshasvanis and learn from the recent experiences of Thailand, Mexico and Brazil to invest in an organized healthcare system, and with a booming economy resources will not be a constraint.
So the challenge for the 12th Plan is enormous demanding huge restructuring of the healthcare system in the country through strong regulatory mechanisms both for the public and private sectors, education of professionals in ethics of practice, pushing the politicians for creating a strong political will to make healthcare a public good as well as generate and commit adequate resources to realize universal access. The restructuring of the healthcare system and its financing strategy, given the price advantage of India and economies of scale it offers, will actually reduce nearly by half the healthcare spending in the country and reduce substantially the household burden to access healthcare. Calculations I have done show that for universal access to healthcare across India we need less than 3% of GDP provided we show the political will to shift healthcare from the domain of the market to the category of a public good. This will indeed do a lot of public good!
Ravi Duggal / firstname.lastname@example.org