By Dr Chandrakant Lahariya
There is a wider acceptance that access, availability and affordability of health services in India remain sub-optimal for most of the population. People often have to delay seeking health services because of different reasons including lack of finances to seek care. Alternatively, people go to unqualified providers, which lead to an unknown and undocumented impact on health outcomes. Furthermore, there are emerging challenges of non-communicable diseases which require additional preventive and promotive health services. Indian healthcare system is neither designed nor fully prepared yet.
This sector seems to have witnessed a lot of commotion in the last 15 years but the impact has not been commensurate. In the last decade, the outcome of government initiatives, be it Rashtriya Swasthya Bima Yojana (RSBY), National Health Mission (NHM), or a component in NHM such as Janani Suraksha Yojana (JSY), has been less than desired.
A laid-back approach
The challenges in the health sector in India are widely acknowledged and range from ‘policy flip-flops’ to ‘long planning to implementation phase’. The National Health Assurance Mission (NHAM) appeared as an urgent and pressing priority in mid-2014 and now is not being referred to at all.
This is a common experience with many examples. It took nearly five years to launch National Urban Health Mission since draft framework document was first prepared in 2008. The National Health Protection Scheme (NHPS) was announced in February 2016, to be implemented from 1 April 2017. Eighteen months later, only a component of this scheme, on elderly, has been launched and there is limited clarity on the next step. Similarly, the Union and state governments keep shifting the responsibility for poor health infrastructure, investment and outcomes on each other.
Upgrading the existing system
There are a few feasible solutions which have been agreed, over the years, by key stakeholders. However, their implementation till now has left much to the desire. Many of these are included in India’s National Health Policy (NHP) 2017 as well. Policy makers at both Union and state levels in India should consider facilitating the implementation of these solutions.
The weak primary healthcare system in both rural and urban India has been long recognized. The proposal in India’s new National Health Policy 2017, to upgrade the existing health sub-centres to health and wellness centres (HWC), is a practical solution. By the year 2022, establishing a network of fully functional 200,000 HWCs in rural areas and an agreed number of Mohalla/wards clinics in urban areas is a feasible solution. It would require additional funding, a roadmap and the desired political commitment at both the national and state level. It also means that every passing year 40,000 functioning HWCs are added until the year 2022. Swachh Bharat Mission has set up an example of a fast-paced and well-monitored government initiative. There could be lessons and approaches which could be learnt for setting up HWCs in India.
Key recommendations
Effective health service delivery would need addressing the shortage of health workforce. Past attempts to address these shortages have met partial success. The states have to rapidly adapt and expedite the process and make needful legislative provision for task shifting and engagement of AYUSH practitioners. They also have to train mid-level providers such as community health officer in service delivery.
The preventive and promotive health services are mostly provided by the government sector. The private sector has a limited incentive in the provision of these services. The government needs to have specific and dedicated budget for such services. In addition, the providers should be incentivised if they devote more time to patients and deliver specific services. Health staff needs to be specifically equipped, trained, encouraged and facilitated to deliver such services.
NHP 2017 recommends increasing total government spending in India for health to 2.5% of Gross Domestic Product (GDP) and to increase spending on health to eight percent of the state budget. Both these proposals would be essential for making the provision of healthcare services available and affordable to the people of India.
Healthcare for all
One approach for making progress is to implement these proposals as soon as possible. Ministers of health and finance should closely work together to increase the health sector budget by 50% of the previous year’s budget in first two years. This can make a good baseline for the health budget, which can be sustained by the annual increase rate by calculating the economic growth rate plus 10-20% of the previous year’s budget, at both levels. However, making health services affordable should not be entirely dependent on increased funding.
A few mechanisms have to be implemented alongside increased funding to ensure that the benefits reach the people to reduce out of pocket expenditures. Two supplementary mechanisms and relatively ‘low hanging fruits’ are removing any type of user fee from all government health facilities, especially for the primary level of care. Also, all Indian states should adopt the policy of universal provision of free medicines and diagnostics for all, supported by legislation. The provision of free medicines should be made available to all patients, irrespective of whether they attended a private or public health facility/provider. Free medicine scheme can also dramatically increase the absorption capacity of the health sector in India.
Digitizing healthcare
India is known as Information, Communication & Technology (ICT) hub and has achieved a number of enviable feats including providing Aadhaar Card to nearly 90% of citizens, in less than a decade. Contrasting this, there is no reliable and up to date data on availability and geographic distribution of approximately 800 thousand medical doctors and nearly two million other types of healthcare workers (excluding community health workers). ICT mechanisms should be explored to develop a real-time database on health infrastructure, providers and different types of health services, in both public and the private sector in India.
In the health sector, information and communication technology appears to be under-utilised and even the traditional focus on telemedicine is mostly on papers. ICT and Aadhaar Number information linkage have the potential to map all healthcare providers in the country.
There is a need for rapid up-scaling of select health interventions, which already have a wider agreement and can deliver results for the period of three to five years. This would contribute to a rapid increase in availability of health services in India and achieve goals in NHP 2017. It would be a fitting step in India’s journey towards Universal Health Coverage.
(An earlier version of this article was published in The Telegraph on 22 Aug 2017; Views are personal).
Featured Image Source: Visual Hunt
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