Most people in India buy healthcare in the same manner as they buy any other goods and services such as food, clothes, education etc. That is why they pay for healthcare in the same manner as they pay for various other goods and services—at the time of purchase and from their own pocket. No wonder then that nearly 60% of total healthcare expenditure in India is paid directly by the households, predominantly at the point of care.
Why should purchase of healthcare be any different from that of other goods and services? Well, unlike other goods and services whose consumption by any particular household is known and predictable, there is uncertainty in the consumption of healthcare services by any household. Typically, a household may or may not need healthcare services in any given period. This opens up a scope for social solidarity among the population. That is, everybody pays small, little amount to meet the health expenses of those members who actually fall sick in any given period. This solidarity could happen explicitly through a formal insurance mechanism or implicitly through a tax-financed provision of healthcare. The world over healthcare is organised around the principle of social solidarity.
Emerging solidarity in hospital care
For hospital care, whose need for any individual is typically more uncertain (than outpatient care) and is therefore eminently insurable, the government is all set to revamp the ongoing health insurance scheme—Rashtriya Swasthya Bima Yojana—for the poor and the vulnerable. Those who are part of the organised sector, are mandatorily covered by their employers. For the non-poor who are not a part of the organised sector, the options available for financing hospital care are (i) to buy insurance from the private insurance market, (ii) to avail subsidised care from public hospitals and (iii) to pay upfront for the care from a private hospital. Under its Pradhan Mantri Swasthya Suraksha Yojana, the central government is investing heavily to strengthen public hospitals that provide highly subsidised care to all sections of society. As this happens overtime and as private health insurance market evolves further, options (i) and (ii), entailing solidarity, may become the dominant options for the non-poor, unorganised sector workers.
Primary healthcare—the weak link
When the primary health care—which is another important piece in the care continuum and includes elements of preventive and promotive care—is publicly funded through taxes, social solidarity gets built into it. The importance of primary care can’t be overemphasised. Primary care is needed more often and by a majority of the population. Also, a robust primary care system by detecting ailments early on in a disease cycle tends to mitigate the need for hospitalisation.
In India, unfortunately, the primary care has remained a weak link in the larger design of healthcare system because of lack of priority accorded to it by the states. Despite a vast network of public health facilities at primary level—consisting of over 1.5 lakh sub-centres, over 25,000 primary health centres, and over 5,000 community health centres—the share of public facilities in total non-hospitalised cases has remained quite low: only 28% and 21% in rural and urban areas, respectively in 2014. The dominant role of private providers in the non-hospitalised care has its pernicious effects on household finances. Clearly, the current primary care system in India needs retooling.
The central government-led programs to make drugs and diagnostics available at reasonable prices is an important step in the right direction. But in a large federal country like India, the primary healthcare by its very nature—care that is to be provided at facility, community and household level throughout the country—has to be led by individual states and delivered by the district and block authorities.
Prioritisation of primary care is not just a question of more public funding but also getting the delivery model right. And getting it right is as much a question of providing right package of services that addresses the leading causes of morbidity and mortality as of ensuring continuum of care by referring patients to higher level of health facilities as well as of providing services in a cost-effective manner, leveraging the advances in medical and digital technologies that are altering the way healthcare can be organised, delivered, monitored, and tracked. This calls for piloting several different models of primary care in the country.
This quest for finding an appropriate delivery model must be fulfilled through systematic piloting of various alternate care delivery models, as opposed to doing a discreet pilot here and there. This discovery of care delivery model(s) must precede committing a large resource envelop to the primary healthcare in India, which is inarguably low and needs to be stepped up. But let us not be so impatient as to bypass this necessary “piloting” phase. In bypassing this “piloting” phase we run the risk of making the similar mistake as we did under the National Rural Health Mission that delivered much below its promised goals.
Let our impatience not undermine the cause that we so dearly espouse. For if we fail in fixing the primary care piece, we fail in the larger design of healthcare in India.
The author is a development economist, formerly with Bill and Melinda Gates Foundation and the World Bank.
Views are personal