Sustained Efforts Needed for Healthcare Reforms in IndiaNovember 29, 2018 0 comments
The Ayushman Bharat scheme promises large-scale healthcare reforms in India, but sustained efforts are necessary to pursue it till the end.
Since the submission of the Bhore committee report in 1946, the Indian Government has made concerted efforts to provide healthcare through a country-wide network of three-tier healthcare institutions, supplemented by various programmes. Success stories around eradication of smallpox and dracunculiasis, elimination of leprosy, neonatal tetanus, controlling vector-borne diseases, and reduction in maternal/infant mortality, have all rode on this model. At the same time, the Government failed to establish comprehensive quality and provide curative and rehabilitative care to the people, especially in remote areas. This bred inequality and inequity in access to healthcare. This unfortunate reality manifests until today. As the world changes, we are faced with a double burden of disease even as new health threats keep emerging. Disaggregating prevailing morbidity and mortality patterns exhibit our social gradients for health outcomes and the use of health systems. Ayushman Bharat seeks to address all of these.
Imagine the prospect of a peasant walking in for a coronary stent without having to pay a rupee to the hospital. If at first an idea is not absurd, there is no hope in it. A grand idea should seem impossible. The world’s largest ever public health scheme for a country with widely skewed social determinants of health is one such grand idea. Its sheer scale and scope is staggering: A hundred billion rupees and half a billion people — neonates to young and old, cashless and nationally portable access to seamless healthcare. This means two-third of India’s population is secured against catastrophic medical expenses. Like all grand ideas pursued with imagination, vigour and application, Ayushman Bharat is on the cusp of creating a paradigm shift in universal healthcare. It rests on two essential vectors: Recognition of the fact that universal health insurance is essential for universal healthcare delivery. And that this can be fulfilled by subsuming ongoing Government initiatives while making the Ayushman Bharat proposition portable across the country.
Initiatives launched under the scheme will play a critical role in helping the country meet its social development goals. Much of this will rest on active collaboration with State Governments and private healthcare. For better results, the scheme will need robust focus on operational and implementation aspects. We will have to invest in capacity-building of resources at hand. The Government as well as the industry will have to forge partnerships with a focus on improving coverage and providing access to quality healthcare services. All this while ensuring that money allocated is utilised as intended. I see four critical success factors to Ayushman Bharat:
- i) Infrastructure access: With the exception of community and primary health centres, the country has about 55,000 hospitals, that trots up to 1.6 million beds. This is an inadequate number compounded by wide swing across States. We have to build capacity as utilisation increases. At the same time, we must also increase capacity utilisation of existing primary and community health centres. Meticulous implementation and robust healthcare delivery in these centres can reduce the need for secondary and tertiary care. Addressing problems associated with supply, logistics and spurious medication is a challenge. Another issue is participation from the private sector. The Government must assure enough incentives to the private sector which is already faced with the problems of receivables and collection from Government insurance schemes. We must have a strategy for negotiating/containing process for healthcare services. All our States typically follow a package rate model. Package rates are not a substitute for arriving at actuarial rating. Without market intelligence, arbitrary pricing and unethical methods remain a risk.
- ii) Skilled professionals: We have more than a million doctors but their density is skewed. Manpower optimisation practices and creation of skilled manpower, including nurses, technicians and other support staff through short-term training courses, can increase resource efficiency for doctors. The Healthcare Sector Skill Council had initiated this. There are success stories from other developing countries. Costa Rica, for instance, established multiple integrated primary healthcare teams each looking after 5,000 people. These teams typically comprise paramedics who visit patients; an executive who maintains records; a nurse; a pharmacist; and a doctor. Similarly, Ethiopia has a concept of health extension workers — rural high school graduates, with a year-long training. These health extension workers have played a key role in reducing child and maternal mortality by 32 per cent and 38 percent respectively. Our system of Anganwadi and village healthcare workers like ASHA Didi can act as catalysts.
iii) Quality: In our country, the average duration of medical consultation is little more than two minutes. Research conducted by the World Bank showed that only 30 percent of consultations result in correct diagnosis. Half a million of our children die of diarrhoeal diseases every year. It also revealed that in Delhi, only 25 per cent of medical practitioners ask parents whether there was blood or mucous in the child’s stool (a defining symptom). While we have quality standards drafted by bodies such as the National Accreditation Board for Hospitals (NABH), compliance is a different kettle of fish. And less than one percent of our hospitals have NABH accreditation. Large-scale quality and patient experience audit backed by implementation and interventions is required to drive the overall quality on multiple parameters. Infection control is especially important.
- iv) Patients: We must proactively evangelise patient education around health insurance. This includes educating them on seeking healthcare from the right set of institutions. The Government should take the lead in facilitating public health, focusing on awareness and education. Pulse polio campaign was a great success. We need a similar initiative for non-communicable diseases too. Increased penetration of smartphones is an opportunity. In Kenya, for example, M-TIBA is a dedicated health account on cell phones. It allows anyone to send, save and spend funds for medical treatments. It uses internationally recognised ‘safe care’ standards to monitor quality of care at approved facilities.
Healthcare is a dynamic space subject to change due to a variety of factors. One of the key drivers is the use of technology. Relevance of technology and digitisation are imperatives as we look at newer ways of healthcare delivery services. The Government must invest strong emphasis on adoption of technology by the entire healthcare ecosystem. This must provide accessible and affordable patient care to the last mile. As Ayushman Bharat unfolds, an evidence-based strategy will have to address and resolve a slew of issues; many chronic.
Our primary healthcare has focused on reproductive and maternal health, neonatal and paediatric health besides communicable diseases. Our needs are greater than this. We need preventive and/or promotive health: Prevention, early detection and treatment. A strong primary healthcare system will lead to a healthier India. For instance, detection and treatment of diabetes at 35 will avert kidney failure at 50 if the condition remains undetected and untreated. In my estimation, we must be careful of the following:
- i) It must be mandatory for every NHPS beneficiary to register with a wellness and health centre. Medicines and diagnostics can be provided at subsidised prices or free to those who cannot afford it. Centres manned by primary care physicians can provide outpatient care, including diagnostic facilities and medicines. They can be filters for NHPS. Polyclinics with specialists and higher level of diagnostic facilities can be established for referrals from primary centres. Every beneficiary of NHPS must consult a primary care physician. Treatment at the polyclinic by a specialist should be only on referral from the primary centre.
- ii) Ideally, all district hospitals should have equipment at par with private tertiary care hospitals. Further up the value chain, medical college hospitals should be equipped to be at par with private multi-super speciality hospitals. These can be tweaked to demographics.
iii) Admission of any NHPS member to a hospital should be only on referral from the primary care centre or the specialist, except in emergencies such as accidents. Referral will be responsible for preventing unnecessary hospitalisations.
- iv) Empanelled hospitals should be graded according to their infrastructure available and quality of care provided. The Government should create a National Health Regulatory Authority replicated across States. This would bring in uniformity in the healthcare sector.
- v) Ambulatory surgery centres can be useful in lightening the load on hospitals.
Rationalising treatment or surgical procedures and use of generic medicines and diagnostics will reduce healthcare costs. This will also stabilise premiums of NHPS and ensure continuous improvements in terms of coverage. Just launching NHPS without integrating wellness centres and Government infrastructure will not yield the desired result. We need strong planning, regulations, simple and efficient processes, and continuous monitoring through advanced technological platforms. We must prioritise critical initiatives essential to realising goals; Ayushman Bharat must be contextualised and synchronised. It must express itself with a reform agenda hinging on improved governance and enforcement of regulations.
Success will depend upon focusing on health and not merely sickness. Reducing our disease burden through robust primary care, focus on allied determinants of health, quality outdoor and indoor services in public hospitals and leveraging indigenous schools of medicine and technology will help check farcical and wasteful expenditure. Instead of shrinking its role in healthcare provision, participation of the Government system must be increased progressively. Everyone watches eagerly as Ayushman Bharat takes wing. Everyone will have to ensure it soars and stays aloft, for it is the universal and overarching umbrella of healthcare for all.
Writer: Naresh Trehan
Courtesy: The Pioneer