It’s time to transform the Indian healthcare system
No person shall be deprived of his life or personal liberty except according to a procedure established by law.
- Article 21 of the Constitution of India
The right to life is a fundamental right according to the constitution of India. The Supreme Court has a wider interpretation of Article 21 that is not limited to mere existence. It includes a citizen’s right to healthcare, livelihood, better standard of life, and hygienic condition. The state governments are obligated to provide the highest attainable health standards to its citizens.
Our country has both public and private providers. Below is a chart showing the structure of the healthcare system in India:
As you can see, the government healthcare system has three tiers:
Primary: This is supposed to be the first level of contact for individuals with the health system. It covers care for mother and child, immunization, family planning, prevention of endemic diseases, treatment of common diseases and injuries, health education, food and nutrition, and adequate supply of safe drinking water. These services are provided through community health centres, primary health centres (PHCs), and sub-centres.
Secondary: District hospitals are the secondary level of the health system. Patients from PHCs are referred here for treatment due to the limited infrastructure of the primary level.
Tertiary: Medical colleges and medical research institutes constitute this level. Patients from the secondary level are referred here if they need specialized medical personnel, specialized intensive care units, or advanced diagnostic services.
Inadequacies of public healthcare
In 2017, the United States and the United Kingdom spent 17.06% and 9.63% of its gross domestic product (GDP) respectively in healthcare; even our small neighbour country Nepal spends over 5.55% of its GDP. But India, the seventh-largest country and second-largest population, spends only 3.53% of its GDP on health.
India has one of the largest publicly financed HIV drug programs. Maternal and child health services, including immunization, are free of cost. We also have free diagnostic services and drugs for vector-borne diseases like malaria and dengue. Despite having a well-structured system, Indian public healthcare is lagging behind.
There are several reasons for this. Lack of funds going to public health, as seen above, is one of them. There are limited seats in government medical colleges and private medical education is an expensive affair. To compensate for the money spent on education, many doctors prefer working in the private sector. This also means that the doctors in the public sector are overburdened with work, thereby not being able to provide the best of services. The country also has a significant gap in skilled health workers. The available workers often go to the private sector due to higher pay. In short, the public healthcare system has a shortage of doctors, healthcare workforce, equipment, and drugs.
The rise of private players
Until the 1980s, private hospitals were mostly non-profits run by charitable organizations. The inefficiency of the public health sector, economic liberalization, growing middle class, and rise in medical tourism contributed to a steady increase in the number of private, for-profit healthcare in the past three decades. Most of the healthcare capacity added since 2005 were to the private sector or in partnership with the private sector. According to estimates, the private sector owned 63% of hospitals and employs 81% of doctors. They provide 80% outpatient care and 60% inpatient care in the country.
As the field of medicine is becoming more technology-driven, the smaller clinics and hospitals are finding it hard to offer affordable healthcare. Large corporations and wealthy individuals are some of the major providers of advanced healthcare. There is also a trend of hospitals dealing with niche issues such as fertility, maternity and childcare, cancer, renal, cardiac, and orthopaedics. These hospitals provide high-end services, making advanced treatments accessible and affordable only for foreigners and wealthy individuals. These also have to do with the fact that private hospitals are largely unregulated in terms of standardized cost and quality.
Indeed the private sector has made some impressive progress in terms of healthcare research and technology in the country. However, this happened at the cost of public sectors and the affordability of the wider population.
Inspiration from around the world
According to a report by the World Health Organisation, France ranks top in healthcare services. The Statutory Health Insurance (SHI) is mandatory for all residents of France. SHI is financed by the payroll tax, income tax, tobacco and alcohol tax, pharmaceutical industry and voluntary health insurance companies, and state subsidies. The government finances healthcare for undocumented immigrants who have applied for residence. Visitors to the country are covered for emergency care. SHI covers treatment in public/private hospitals and rehabilitation centres, outpatient care, prescribed diagnostic services, prescription drugs, medical appliances, prostheses, prescribed healthcare-related transportation, and home care. It partially covers long-term palliation and mental health care. Voluntary Health Insurance (VHI) is provided for dental, renal, and usual care among others. Low-income individuals (10% of the population) are entitled to free or state-sponsored VHI, free vision care, and free dental care.
Italy ranks second in the list. The National Health Service (NHS) coverage is universal. All citizens and legal foreign residents are covered under this scheme. Undocumented immigrants are covered for urgent and essential services. Visitors have to pay for the cost of treatment. The NHS is funded by corporate tax and value-added tax. Private insurance plays a limited role. Primary and inpatient care, and most health screening services are free of cost. Preventive medicine, outpatient specialist care, home care, primary care, palliation, treatment of chronic conditions, and life-saving drugs are covered under the NHS. Dental care is covered for children up to 16 years old, vulnerable populations, and people in economic and emergency need.
Reimagining India’s healthcare
Infant and maternal mortality in India have reduced in India over the last 20 years. The credit largely goes to the three-tiered public healthcare system we have in place. Even during the recent pandemic, we saw how the government hospitals in India, despite its lack of funds and staff, managed to effectively handle the situation to a large extent. These reinforce the importance of our public healthcare model. But we are still not completely equipped. We need to reshape the health system in a way that it is robust, collaborative, and ready to face another emergency like this.
The primary objective is to make healthcare free for citizens from the lower class and affordable to citizens from the middle class. For this, we need an increased budget for public health. The fiscal budget for 2019 was great for the health sector. We saw a 19.31% increase in allocation. The Ministry of Health and Family Welfare identified 82 district hospitals across 21 states to upgrade to medical colleges; some of them are already functional. The number of undergraduate and postgraduate medical seats were increased in the last academic year. However, this year’s allocation was just 6% more. To increase public health spending from 1.8% in 2018 to 2.5% in 2025, like the Prime Minister had suggested, the government has to be more prudent.
Another suggestion is to standardize medical costs in the private sector for the citizens. But this would take time due to bureaucratic delays. A better way is to impose social accountability in the private sector. Make certain basic services free for the poor. We could explore the setting up of medical institutions under a public-private partnership (PPP) to provide subsidized/free public healthcare facilities. For this, we need to introduce public policy initiatives that encourage PPPs and stimulate investment in healthcare. We also need to develop policies that safeguard the rights and dignity of the doctors and other healthcare staff and increase their numbers in the government workforce.
India also home to world-class pharmaceutical, biotechnology, and clinical trial, and medical technology companies. We have extremely talented researchers, scientists, technologists and innovators, and well-equipped hospitals that attract foreign patients and investment. A part of the healthcare budget should go to PPP initiatives for innovative medical research by providing fellowship and infrastructure for research.
Our country’s strength in innovative technologies is under-utilized in government healthcare. These brilliant minds can easily develop a comprehensive medical information system complete with guidelines, and protocols to encourage the use of evidence-based medicine. Forming an interconnected framework of local health committees consisting of health superintendents, local government officials, private institutions, district administration, and CSR representatives is another solution we can build with technology. This kind of communication platform can help health committees work closely and efficiently towards addressing the healthcare issues of a region.
Today it is evident that there will be a significant shortfall to match the intensive care needed for the COVID infected people in India. Both the centre and the state governments should step up the efforts and expand the existing facilities and improve their infrastructure. The rights of the healthcare providers and the support staff should be protected and respected. Technology should be used to our advantage.
The country has learned much from the pandemic outbreak. Now it’s time to tackle the existing issues to bring about a much needed positive change in the Indian healthcare system.
