Wednesday, September 17, 2014

Present state of Healthcare in India !!!
  • Healthcare in India is a story of insufficient resources and poor outcomes. 
  • Investment is well below WHO guidelines in both qualitative and quantitative terms. 
  • Bed density is low (less than 1.5 beds per 1000 persons as compared to WHO guideline of 3.5), doctors few (less than 1.8 per 1000 as compared to WHO guideline of 2.5), and out of pocket spend high (86% as compared to an average of around 40% for low income countries). 
  • Rural India lags even further behind, with around 30% of the rural population having to travel over 30km for treatment.

Significant inequality in access is worsened as the existing healthcare workforce is inadequate and under-utilised. With low salaries, insufficient incentives, lack of career growth, inadequate training and inconsistent policies, the majority of the medical workforce chooses not to practice in the formal sector. India’s regulatory system hardly keeps up with the very diverse set of medical practitioners.

Meanwhile, infectious and chronic diseases continue to prevail. Health indicators continue to lag, healthcare spending is growing slower than GDP growth, out of pocket spending continues to be high, and infrastructure gaps remain substantial.

Universal Healthcare around the WORLD !!
  • Universal healthcare offers the one solution, by extending access to healthcare as widely as possible and providing quality care through minimum standards. 
  • Soviet Union implemented it in 1937, with the UK following nearly a decade later. 
  • Most nations have funded it through general taxation, supplementing it by specific levies and private payments.
  • Compulsory insurance utilising common risk compensation pools and a choice of insurance funds, such as in the US and Switzerland, have helped reduce inequality and increase access. 
  • Lives have been saved, with resultant growth.

What can India do in this regards ?
  • India’s government needs to play a stewardship role. By focusing on universal healthcare as a long term journey, with consensus on political backing and hard choices along with secured long term funding, universal coverage for good quality healthcare can be achieved. 
  • By building an effective regulatory framework and consistent policies across states and the Centre, workforce shortages can be overcome, along with integrating healthcare facilities across the village, town and district levels. 
  • Patient interest can be kept as a primary focus by reforming such bodies as the National Rural Health Mission and Rashtriya Swasthya Bima Yojana (RSBY).

Role of Private sector !!
Private sector can help improve India’s healthcare infrastructure. But without faster accreditation, few private players will gain credibility, or raise standards, resulting in low customer satisfaction, longer hospital stays and poor governance. The National Accreditation Board for Hospitals and Healthcare Providers needs to roll out incentives encouraging accreditation and make it a mandatory process.

Finding of a Kolkata Group led by AMARTYA SEN !!
  • The Kolkata Group led by Amartya Sen, in its 2011 Public Declaration, pointed to the many limitations of the private sector in health. “Influential policymakers in India seem to be attracted by the idea that private health care, properly subsidised, or private health insurance, subsidised by the State, can meet the challenge. However, there are good analytical reasons why this is unlikely to happen because of informational asymmetry (the patient can be easily fooled by profit-seeking providers on what exactly is being provided) and because of the ‘public goods' character of health care thanks to the interdependences involved. There are also major decisional problems that lead to the gross neglect of the interests of women and children in family decisions.” It is also well known that insurance schemes (whether funded by the Central and State governments) at best provide limited health care and at worst divert a large part of the health budget to expensive hospitalised tertiary and secondary care, to the great neglect of primary care.
  • Clearly, there is no alternative to a progressive strengthening of the public facilities and thereby reduce people's dependence on private providers. However, the public system may need to “contract-in” the services of willing private providers, to fill gaps in its capacity to deliver all the services assured under UHC. Such “contracted-in” private providers will have to deliver cashless services and would be compensated on the basis of pre-determined cost per package of health services rather than “fee for service” for each visit or procedure. In such an arrangement, the private sector acts as an extension of the public sector where needed and will not compete for the same set of services for the same people.

PPP projects !!
  • Public-private partnerships or build-operate-transfer or operations and maintenance contracting schemes can utilise private capital for provisioning healthcare services. 
  • With our growing population, the need for treatment of non-communicable and lifestyle diseases will increase, particularly in Tier 2 and 3 cities. 
  • Affordable healthcare programmes (rolled out as public-private partnerships) will offer significant margins (in volume) for private players, while helping to address talent resourcing and under-utilisation issues. 
  • Initiatives like Ayush Graham Bahawali Project, in Nainital, running on a build-operate-transfer mode, provide alternative medicine and low cost affordable healthcare, partly based on land grants by the government.

Insurance Coverage !!
  • Insurance coverage is also abysmal in India, with just around 25% of the population covered. 
  • To achieve universal access, a coverage ratio of around 75% needs to be targeted, with the remainder offered access through government payments via RSBY. 
  • Access with low out of pocket spending can be achieved through an expansion of healthcare insurance, with the government playing a payor or guarantor role instead of providing services.
Social insurance schemes really need to be rolled out at scale, with the government deploying a greater share of healthcare funds for RSBY. Pilot programmes launched at a state level can help us determine the best model for the Indian market. 
Community health insurance schemes like those launched by the Karuna Trust in Karnataka help improve access and utilisation of health services by the rural poor. Those left behind in India’s growth should be offered a helping hand.

Drug Pricing !!
  • Universal healthcare requires cheaper drugs. Capping drug prices has become controversial. But pharma firms are coming under pressure to lower drug prices across the world.
  • Our inconsistent drug pricing regime offers high volatility. The last drug pricing control order fixed the prices of 348 drugs based on the simple average market price of the product, with no relationship to manufacturing cost. The latest order adds a further 100 drugs to this scheme, with little consultation. Such ad hoc policies create uncertainty, reducing incentives to foster innovation or bring new drugs to the Indian market.
While drug providers could crib about purported losses, the domestic pharma market is 75% of the volume exported. Drug providers should take a price cut and benefit from India’s healthcare expansion. Public interest can also be private interest, in greater volumes.

  • Regulatory systems need strengthening — from hospital accreditation to health professional education and from drug licensing to mandatory adoption of standard management guidelines for diagnosis and treatment of different disease conditions at each level of health care. 
  • national inter-operable Health Information Network  is needed to improve governance, accountability, portability, storage of health records and management. 
  • Community participation must be supported to actively engage people in the design, delivery, monitoring and evaluation of health programmes.
  • And finally, larger investments should be made in health promoting programmes in other sectors such as water, sanitation, nutrition, environment, urban design and livelihood generation.


High Level Expert Group (HLEG) by Planning Commission on UHC !!

  • The High Level Expert Group (HLEG) established by the Planning Commission has submitted a comprehensive framework for providing UHC in India.
  • A health entitlement card should assure every citizen access to a national health package of essential primary, secondary and tertiary care, both inpatient and outpatient. 
  • The HLEG is very clear that services included under UHC must be tax funded and cashless at delivery. 
  • User fees are to be abolished because they are inefficient, inadequate and iniquitous. 
  • Contributory social insurance is not appropriate for countries like India where a large segment of the workforce — close to 93 per cent — is in the unorganised sector and vast numbers are below or near the poverty line.

Moral of the STORY !!!

It is time to recognise that everyone, not just the poor, needs to be protected against rising health costs that can impoverish any family. We are on the threshold of a historic transition to guarantee health security for all Indians. UHC will greatly reduce out-of-pocket expenditures and provide much needed relief to people. Apart from improving people's health, adopting UHC is likely to generate millions of new jobs, enhance productivity, and promote equity. Statesmanship must assert itself to create a national framework of UHC that is capable of State-specific adaptations. It is time to give the people of India the efficient, affordable and equitable health system they desire, deserve and demand.

Miscellaneous fact  !!
  • India's public spending on health — just around 1.2 per cent of GDP — is among the lowest in the world.

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