As the world continues to reel under the far reaching and unprecedented impact of the global pandemic triggered by the Corona virus, importance of health and healthcare systems for survival of human race is being realized by people all over the world. Pandemic has also revealed a critical and compelling need to assess and improvise the healthcare systems in low resourced settings like those in Indian rural setups or urban slums.
The challenge to manage the healthcare becomes more daunting with poor socio-economic, conditions along with cultural, political and geographical diversities and excessive population, where the systems inadvertently crack under various such pressures. Health systems are generally considered to be an interrelated connection between six ‘building-blocks’ of service delivery, medical equipment, manpower or health workforce, information, financing and stewardship or coordinated leadership.
In the Indian context, the pandemic has exposed long-standing weaknesses in our system, intensifying in face of the emergency. Our healthcare system suffers major inadequacies. A part of the reason for this is that India spends merely 1.28 percent of its GDP on health, as per the National Health Profile-2019 report. Our spending on healthcare is substantially lower than that of most other countries, including some of our neighbours (for example, Bhutan spends 2.5 percent of its GDP and Sri Lanka spends 1.6 percent of its GDP on healthcare.)
Some of the challenges of our healthcare system are lack of awareness, lack of access, workforce shortages; and lack of affordability and accountability. Further, as noted by the Harvard School of Public Health, our “underfunded healthcare system in many cases are inefficiently run.” A recent study by the Centre for Disease Dynamics, Economics and Policy estimated that for India’s total population of 130 Crore, the country only has “1.9 million hospital beds, 95 thousand ICU beds and 48,000 ventilators”. Such deep-rooted and extensive issues make India frightfully vulnerable to any healthcare crisis, like the one we are currently experiencing.
Adding to the chaos, a market-driven and market-led system that controls supplies of almost all critical inputs for medical care—drugs and other medical supplies including diagnostic kits, protective equipment and even patient transportation—and poor regulatory oversight by governments has resulted in frequent instances of shortages in supply, skewed distribution of essential inputs and resultant spikes in their prices.
We also witnessed cases of demands of bribes by ambulance driver outside Delhi’s largest hospitals for transferring patients to the medical units. All these discrepancies and anomalies floated up during the COVID scrutiny by people, media houses and even government and all got together to uphold the ‘Godly Profession’ once again.
Building a robust healthcare infrastructure should be the ultimate goal of any nation. If the government cannot do so directly, it should create a policy environment to allow private players to do so. Building such infrastructure will also contribute to creating employment, and can also be a destination for foreign direct investment.
To achieve this, standardization and regulation is the key. A stable policy framework across states to reduce, if not nullify, the uncertainty and its seriously detrimental effects is needed. This standardization has to be complemented by a significant level of deregulation. In order to avoid any misuse of this approach by the private sector, a grievance cell comprised of independent experts can be set up in each state.
Taking action against the crisis, our government has proposed an outlay of INR 2,23,846 Crore for health and well-being, an increase of 137 per cent from the previous year, with INR 35,000 Crore earmarked for COVID-19 vaccine in the coming fiscal. Primary healthcare, one of the most critical elements of healthcare provision in an efficient and equitable system, is now getting strengthened with even the previously neglected urban healthcare component receiving attention and resources. Nearly INR 64,180 Crore will be invested over six years to improve primary, secondary and tertiary healthcare, as part of the newly announced PM Atma Nirbhar Swasth Bharat Yojana.
This will be in addition to National Health Mission. Certain amount from the budget will be used for establishing critical care hospital blocks in 602 districts and 12 central institutions. The budget also mentions the introduction of the National Commission for Allied Healthcare Professionals Bill, along with the soon to be introduced National Nursing and Midwifery Commission Bill. The regulatory improvements and institutional restructuring that have been proposed, will hopefully contribute to improving health outcomes and enhancing economic growth.
Government should be increasingly proactive in setting up hospitals, clinics, and other such healthcare facilities. It can do so by reverse auctioning land, reducing red tape, and taking a strong stand against local troublemakers. Further, the subject of ‘health’ should also be moved from the State to the Concurrent list, as rightly suggested by a high-level group (HLG) constituted by the 15th Finance Commission.
In the urban areas, large hospitals should be set up on a Public-Private Partnership (PPP) basis. For instance, the Punjab government in Mohali announced a PPP tender on a revenue sharing basis, which the Max Hospital chain won and then created a super-specialty centre. Countries such as the UK and Australia too have their own approach to PPPs, wherein they focus on the “development/rehabilitation of facilities and facilities management”.
The World Bank also notes that “India has adopted more comprehensive service delivery PPPs, where not only are the facilities developed and improved by the concessionaire but services are provided.” A ‘Build-Own-Operate-Transfer’ (B.O.O.T) model would undoubtedly be beneficial to all stakeholders. In addition to this, however, the private sector players should also commit a certain, flexible percentage (e.g. 25 percent) of their entire treatment to the Ayushman Bharat Schemes , and provide services at low fees to the poor. On the whole, an enabling structure must be put in improved private sector participation will bode well for an overall improvement in healthcare delivery and deep implementation of the healthcare policies too.
It will be important to shift our focus towards the quality of implementation of the new programmes and schemes as well as on fostering convergence across health programmes. Our efforts should lead to creation of a robust, collaborative ecosystem for the public and private healthcare providers to work together in quest of desirable outcomes. In the face of the current health exigency, all these new initiatives have to be implemented with utmost diligence and seriousness to reach out to the last mile. Unless all are safe, no one is safe!