The critical issues are health finance and Human Resources (HHR). The Srinath Reddy committee recommended 2.5% of GDP (about 1.2% till last FY) for providing a free Universal Health Care (UHC) package supported through tax source. However this ambitious plan requires above 5% of GDP. This is achievable only through pooling of private and public health-spending. Good SHI systems are functioning in Germany, South Korea and China etc. SHI can negotiate our diversity and provide some space for control/ participation by users including middle classes. The current private spending (about 2500/ Rs PCPI) needs to be harnessed as pre-payment for SHI. The SHI requires small co- payments at the point of service. BPL families can get free UHC from Govt support. The SHI model is way different from the miserable US care based on private insurance, not to mention its high costs (at 16% of US GDP).
HHR is another complex front. About 60% of basic specialist positions in rural hospitals are vacant, negating the quality concerns in referral care. We failed to get enough doctors even in urban public hospitals that are already scant. This is due to gaps in training infrastructure, poor working conditions and employment terms. It is time to end the chronic neglect of AYUSH and paramedic HHR. About 7 lakh ASHAs get below Rs 1000 a month. No UHC is possible without good HHR management.
Here are some easier things. The first is taking primary care deeper in rural and urban units. Trained paramedics can handle some 50 common health problems. Through this we can upgrade ASHAs, informal providers and create a million jobs. The ambulance network is a good development, and we need paramedics here too. AYUSH doctors can manage the existing subcenters. The rural doctor course (BRMS) is a lesser alternative. Handing over the nearly one lakh subcenters to panchayats will also open a new front for local action in primary care. A wide primary care network will ensure preventive programs and reduce hospital-workloads and hence total costs. No UHC is possible unless we have this gate-keeper system. The small family and spacing of births should again be an important primary care concern. It is both a cause and effect of underdevelopment, among other factors. But let us do it without coercion or bribes. Also, primary care calls for a national open source on health in all languages.
On the disease control and prevention front we need to act on under nutrition, urban obesity, diabetes and hypertension, trauma, drug abuse, occupational hazards, cancers and joint problems. The old foes like TB and malaria need a relook. And we cannot neglect water and sanitation anymore.
Indian systems of medicine and Homeopathy (AYUSH) have great internal worth and cost advantages. AYUSH doctors can manage all health subcenters after a bridge course in modern public health. This will meet primary care needs, deploy existing HR, avoid interpathy conflict and harness valuable national resources, besides ensuring that Indian health system remains pluralist.
The core issue of UHC will be affordable hospital care. Hospitals in the secondary level (having 4-6 basic specialties) in public and private sectors will offer the quantum of care. The UHC package rates and care-share by public hospitals will soften prices. Medical college hospitals should work as tertiary care centers and district hubs for all local health networks. States should encourage charitable hospitals to offer affordable services and there are shining examples all over India. Drugs and technology take a major chunk of heath costs. We need to promote good practices for proper use of generics, vaccines, lab tests and medical technology. IT, including telemedicine can save costs and improve outcomes.
Several health laws and rules need to be reviewed. The new clinical establishment act (CEA) needs to involve provider associations and avoid inspector raj. The CEA may jeopardize the small establishments by unrealistic norm-setting, care is therefore necessary. The MCI itself needs a remake for a pragmatic HHR policy including AYUSH and paramedics. SHI needs a proper hospital regulation/accreditation system. The PNDT act is merely preventing ultrasound machines rather than sex determination. SHI will also need a supporting legal framework. Finally, health care is a federal subject. States vary widely in needs and resources. This is where major initiative and action is necessary.
Dr Shyam Ashtekar (MD)
The author worked as a former Director of the School of Health Sciences in Maharashtra Open University
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