India's ailing healthcare system

Instead of first freeing the country's healthcare system from corruption and malpractices, the Narendra Modi-led NDA government at the Centre has set its eyes on expanding access to healthcare facilities at a rapid pace, particularly to include the poor and vulnerable.

The recently announced Pradhan Mantri Jan Arogya Abhiyan (Ayushman Bharat – National Health Protection Mission), which will roll out on September 25 to provide financial protection to 10.74 crore poor and deprived rural families, and identified occupational categories of urban workers' families with a benefit cover of Rs. 500,000 per family per year on a family floater basis covering secondary and tertiary care, is a step in that direction.

Considering that high medical costs in the country are a back-breaking financial burden on a large number of Indians, the intent behind the government's efforts to provide health for all and a universal health coverage certainly can't be questioned.

According to a recently published research paper based on cross-sectional analysis of National Sample Survey Office data, 55 million Indians were pushed into poverty in a single year because of having to fund their own health care, and of this, 38 million fell below the poverty line due to spending on medicines alone.

Though the healthcare sector is among the largest and fastest growing sectors in the country, with expectations to reach $280 billion by 2020, it is characterised by several challenges such as high out-of-pocket expenditure, low financial protection, and abysmally low health insurance coverage. It is estimated that 62.58 per cent of the country's population has to pay for their own health and hospitalisation expenses.

It is true that the two components of Ayushman Bharat, namely the creation of 1,50,000 health and wellness centres and the NHPM, are proposed to be implemented at an unprecedented scale, and if successful could bring a paradigm shift in the health sector in the future. But it can't be ignored that there already exists a host of centrally sponsored schemes for delivery of health services through primary, secondary, and tertiary care. Many of these have proved to be ineffective due to various reasons.

Schemes among the central sector already in existence are Pradhan Mantri Swasthya Suraksha Yojana, National AIDS and STD control program, family welfare schemes, National Pharmacovigilance program, development of nursing services, health sector disaster preparedness and response, impacting research innovation and technology scheme, National Organ Transplant program, and the Swachhta Action Plan.

The centrally sponsored schemes include the national rural and urban health missions, several tertiary care programs covering mental health, capacity building of trauma centres, health care for elderly, tobacco control, drug de-addiction, prevention and control of diseases such as cancer, diabetes, cardiovascular-related ailments, stroke as well as blindness, and human resources for health and medical education. The Rashtriya Swasthya Bima Yojana, which covered below poverty line households and certain defined categories of unorganised workers, was also an initiative under the centrally sponsored schemes and has now been subsumed in AB-NHPM.

Despite the government's numerous headline-grabbing healthcare initiatives, primarily aimed at maximising access to healthcare facilities and services, it is quite ironic that the quality of the existing healthcare services that people of the country have access to continue to be far below global standards. In other words, the government seems more concerned with numbers rather than the actual state of the healthcare facilities and the quality of the services available. One of the main reasons why the government's initiatives have so far failed to make any significant dent on the health care system is because the country relies heavily on the private healthcare sector, which, sadly, has become riddled with corruption and malpractices.

The dominance of private healthcare in the country can be gauged from information provided about the sector by the India Brand Equity Foundation. Quoting data from various sources such as RNCOS, Grant Thornton, LSI Financial Services and OECD, it said that large investments by private sector players were likely to contribute significantly to the development of the country's hospital industry, which comprised around 80 per cent of the total market. Private healthcare accounted for almost 74 per cent of the country's total healthcare expenditure, IBEF said, adding that the private sector's share in hospitals and hospital beds was estimated at 74 per cent and 40 per cent respectively.

Even as the private sector continues to tighten its grip on the Indian healthcare industry, obviously due to prospects of high return, there are growing concerns that cases of corruption, negligence, unethical medical practices, and fleecing involving private healthcare providers would increase sharply in the coming period. As of now, the country's healthcare system provides little support to patients and their families, who are the victims in such cases. Unfortunately, there has been no inclination on the part of the government till now to change that.

The healthcare system in India is believed to be one of the most corrupt in the world. A book titled 'Healers or Predators? – Healthcare corruption in India', which was launched a couple of months back, highlights the extent of corruption that exists in this life-sustaining sector. Containing essays edited by eminent doctors Samiran Nundy and Sanjay Nagral, and former Union Health Secretary Keshav Desiraju, it brings out the many facets of corruption in the healthcare sector - from exorbitant billing by corporate hospitals to non-merit-based selection in medical colleges to questionable practices in organ transplantation.

The government should realise that the frequent launch of healthcare schemes alone would not help create a robust healthcare system. While such schemes may attract the attention of voters, they would not really help clean up the rot that had set in within the system and rendered it ineffective. Certainly, the goal of ensuring healthy lives and promoting well-being at all ages, which is one of the 17 Sustainable Development Goals of the 2030 Agenda for Sustainable Development that had been adopted by global leaders in September 2015 and came into force in January 2016, would be impossible to achieve with such a hollow healthcare system.

A recent editorial published in The Lancet, the prestigious medical journal, said that the burden of mortality attributable to poor care was larger than that due to lack of access to care. Quoting Avedis Donabedian's Milbank Quarterly paper in 1966, it pointed out that an ethical approach towards people was the foundation of a health system's success. Highlighting the need to make people central to all measures of quality, the editorial stressed that patients were mainly concerned with getting better while being treated with care and respect, further adding it was otherwise unlikely that health services would be used even if nominally accessible.

The government must acknowledge that the expansion of universal health coverage, though essential, can't be achieved without first developing a strong and comprehensive framework for regulating the healthcare sector in the country. Such a measure would not only lead to greater accountability and transparency in the system, restoring people's trust and confidence in health care providers, but more importantly, improve the overall quality of healthcare.

(The views expressed are strictly personal)