It is high noon for healthcare in India

Soumya Swaminathan

Swami Subramaniam

India faces a huge number of health challenges and while progress has been made in some areas, it performs poorly in others.

Our response has been to increase capacity in the system (more doctors, more hospitals) and financially underwriting utilisation of this capacity through schemes like Ayushman Bharat.

There are two elements of this scheme: the PMJAY or health insurance coverage for the 10 crore poorest families for inpatient care, and secondly, strengthening of primary healthcare services.

However, whenever suppliers (for-profit hospitals) control the levers of consumption, demand is artificially inflated to match supply.

The question of adequate and appropriate supply of healthcare services to all citizens is important at a time when the country is aiming to achieve the Sustainable Development Goal 3 of Universal Health Coverage (UHC) by 2030. UHC is a complex issue requiring a varied range of solutions (detailed in the book Mission Possible: Paving the road to Universal Health Coverage by Swami Subramaniam and Aparajithan Srivathsan). Here we cover some design principles if UHC is to become a reality:

Primary Healthcare

Primary healthcare should be the hub for comprehensive healthcare. It should deliver and coordinate all healthcare needs, including functioning as a gatekeeper for speciality care. For primary care to effectively promote good health it must be made as friction-less as possible, by making it free and having the healthcare team deliver care in or near the homes of citizens. The care should be person and family centered, not siloed by disease type. The goal should be to improve access to quality healthcare, while reducing out-of- pocket expenditures, and a flexible approach is needed given the heterogeneity of India.

Speciality Healthcare facilities

The multi-speciality general hospital that co-locates disparate specialities under one roof is too complex to scale up to meet the increased volumes in a UHC regime. For most elective tertiary care, e.g., joint replacement surgery, a “focused factory” model works optimally both cost and quality wise.

This has been exemplified by the success of eye hospitals in India. Such focused care institutions could be an alternate design option to provide high volume procedures. By using standardised protocols and shifting routine tasks to lower cost workers, costs are controlled without compromising quality or efficiency.

Eliminate waste

The complexity and fragmentation (and commercialisation) of healthcare leads to waste. This needs to be substantially controlled if UHC is not to become a drain on resources.

Methods to reduce waste include use of generics in the place of branded products, optimising supply chains, full transparency in medical records through digitalisation so that they can be subject to scrutiny and a 360-degree evaluation system.

Extensive use of tech

Health information technology must be deployed extensively so that information-based healthcare becomes a reality. The government must set standards and provide safe places (Health Innovation Parks) where innovations can be developed and tested in real-world conditions.

Remote care technologies and policies that allow frontline health workers to deliver some of the care currently in the sole purview of physicians must be strengthened. The new cadre of CHOs in the Health and Wellness centres, if technologically enabled, could play a key role in delivery of comprehensive primary healthcare.

Managed competition

For-profit providers should be charged with delivering elective care, such as the conduct of high-volume procedures in focused facilities, where care costs can be pre-negotiated within a rules based managed competition setting.

They can also participate in delivering primary healthcare services, under a capitation model, where for a fixed payment per head they commit to achieving targeted clinical outcomes in aggregate in the population they serve.

Govt, ecosystem manager

The government must play the role of change driver and ecosystem manager. As the steward of all healthcare services, the government has to provide progressive and fair governance that elicits the best clinical outcomes at the lowest possible cost. The government’s role should include setting standards and nurturing innovation.

Health technology assessment capacity at State and Central levels must be strengthened, so that it can arbitrate on matters related to the use of medicines and diagnostics as well as broader data gathering and analysis to inform policy decisions.

Some of these recommendations may seem radical. But unless we bring about wholesale transformation, UHC will remain an aspiration and not a reality.

The recent pandemic and the ongoing epidemic of non-communicable diseases should serve as a warning that health system strengthening cannot be delayed.

Timely measures to implement UHC can save costs in the long run, in addition to creating a healthier and more productive population. It may be time to consider a Right to Healthcare Act.

The imminent Budget exercise may be an opportune time to initiate action on these issues.

Swaminathan is Chairperson, MSSRF; Subramaniam is CEO of Ignite Life Science Foundation