By Devasheesh Mathur
As the election hullabaloo increases, there are areas of public health that are likely to be overlooked in the aftermath of the last five years of intense governance, or be overshadowed by Ayushman Bharat. However, the proof of the pudding of the world’s largest health coverage scheme is still awaited and there exist glaring gaps in public health.
Public health in India is esoteric and democratisation of it is a distant dream yet very critical for us. Amartya Sen and Jean Drèze called India ‘An Uncertain Glory’ in the book with the same title, as we are only better than Sub-Saharan Africa and failed states when it comes to public health figures. With myriad government schemes being launched, we are making headways into breaking the scourge of iron triangle—cost, access and quality. But our healthcare delivery is largely piecemeal and the risk with PMJAY is it might increase access keeping costs low, but with a big impact on quality. To avoid this pitfall, it would be helpful for the future government to have a strategy in place, which goes beyond realpolitik.
The key to have a sustainable strategy for healthcare is to strategically build public value, which is a combination of operational capacity and legitimacy. Often, politicians ignore the former for instant gratification and at the cost of alienating the bureaucracy, while the bureaucracy misses legitimacy because of the curse of street-level bureaucracy that misshapes policy at ground-level implementation. Public value is created by gaining legitimacy and building operational capacity—both of which the current government has been projected to be doing, and yet they have miles to go.
The public value approach would allow a transition from an ad hoc managerial approach to a well-thought-out investment approach, which would ensure sustainability of health programmes. An anthology of these strategies would make for an impactful manifesto for any political party.
Impact Investment: To begin with a cliché, we need to invest more in research and change the paradigm to what venture capitalists call as ‘impact investment’. We need to prioritise public health problems by urgency as well as the ability to prompt people to act collectively. For instance, the semi-success of the Swachh Bharat Abhiyan has awakened a section of the society who can take it forward.
One might argue in favour of the CSR Act; however, the problem begins if CSR activity is not aligned well with the organisation’s purpose of doing business or the organisation treats it as an accounting problem affecting the legitimacy of the project. Hence, small and medium start-ups should be backed which would satisfy hyperlocal healthcare needs and incubating them would ensure scalability.
FDI: Distribution networks are the weak link in healthcare delivery including health insurance. Experiences from RSBY point to the inclusion of more and more private insurers who are allowed to erect networks and brokers of their own. For this, we should allow maximum possible FDI as our insurance coverage is abysmal. Our universities and centres of excellence, most of which are autonomous, need more funds to tackle problems of today with an eye on tomorrow.
Redefine quality: Can we envision a healthcare system, which, instead of trying to redistribute quality by measuring health outcomes in identical ways for everyone and assigning health providers equally to bring everyone at par, redefines health as per each community? The National Health Mission had envisioned ‘decentralised centralisation’ and created democratic institutions like Rogi Kalyan Samitis and ASHAs, but the need is to usher synergy and build in legitimacy in them.
Healthcare cadre: It’s time we create a special healthcare cadre within the civil services, which admits people who are formally trained in public health; medically-trained civil servants are better placed to innovate in public health. It should be simple maths—trained health personnel leads to better understanding of the landscape, which leads to more legitimacy of the ideas, as opposed to generalist administrators merely focusing on operational efficiency.
If we were to achieve the WHO recommended indicators of physician, nurses and beds per 1,000 people, we need an investment of `1,62,500 crore over 15 years. Public expenditure on health needs an impetus. However, we should be strategic in our planning and go beyond electoral politics. It’s time we adopt ‘impact investment approach’ rather than ‘managerial approach’, which harps on citizen-centricity and customer satisfaction. We need to start investing in creating knowledge networks that are inclusive of civil society and for-profit organisations driven by committed healthcare cadre. Citizens should be empowered to become co-creators of public services and not merely customers.
The author is faculty member, Goa Institute of Management