With the electoral season on, it is going to be raining manifestos. Manifestos are useful documents as they reflect the thinking and priorities of the political parties, besides enabling people to hold the elected party accountable. Given the high stakes and the trend towards current competitive welfarism, the manifestos for 2024 are expected to contain wild promises. It will be interesting to see what space will be accorded to health, education and jobs in the current discourse blinded with temples and distributing consumer goods.
The political outlook
The health section in the 2014 and 2019 manifestos of the Bharatiya Janata Party (BJP) and the Indian National Congress showed commonalities and differentials. Both mentioned revamping the primary health system, ensuring universal health care, expanding human resources, increasing use of technology and so on. The differential was with the Congress underscoring health as a public good that citizens are entitled to as a right and the States’ obligation to provide, while the BJP saw health as a commodity, provided through public private partnerships with market based pricing moderated by social health insurance.
After years of stagnation, the United Progressive Alliance (UPA) and the National Democratic Alliance (NDA), have pushed the needle forward. Under the UPA, the National Rural Health Mission, with three times increased funding, aimed to strengthen the delivery capacity in rural India. Five thousand technical personnel and a million community health workers were deployed and the first large scale pay for performance introduced alongside the first social health insurance programme covering 80% of the population in Andhra Pradesh rapidly expanding to another 13 States.
The NDA ensured continuity of policy by scrapping the Medical Council of India (MCI) and establishing the National Medical Commission (NMC), further strengthened the rural health infrastructure with capital investment, expanded social health insurance and established the National Health Authority to undertake strategic purchasing of services from the public and private sector. The NDA also set up an additional 317 medical colleges and doubled medical seats to 1,09,948. While in gross amounts Budgets increased, in terms of proportion to GDP, public spending under the UPA and NPA hovered around an average of 1.2%.
As can be seen the measures, though impressive, were incremental and did not address the serious issues of reforming the very architecture of the health system that had over years become distorted and dysfunctional. Twenty years is a long time. Other countries of similar economic strength achieved significant outcomes within half the time span. Thailand for example, introduced Universal Health Coverage in 2000, drastically reducing peoples’ financial burdens; reduced disease incidence, maternal and infant mortality and consolidated the dominance of the public delivery system, particularly for primary and secondary care. Turkey too introduced, in 2003, its Health Transformation Program under which dual practice (where a government doctor could also do private practice) was banned, strengthened public health infrastructure by adding 50,000 hospital beds and doubling the number of nurses and doctors, and the private sector presence restricted to 20%.
With India’s maternal mortality three times more than the global average of 38 per one lakh births, India has a long way to go. The primary and secondary health infrastructure is weak with severe shortages of human resources. States such as Bihar still have one doctor serving per 20,000 population. While so, policy focus seems to be shifting towards medical care in tertiary centres, though 95% of ailments and disease reduction can be handled at the primary and secondary level.
Resilient integrated primary health care
Strengthening the base is critical as it is here that community surveillance and demographic data alongside the disease profile of the designated populations get integrated which then enables planning for the right skill mix required to address current and future health needs of the populations. Mapping and accrediting good health facilities enable expanding access points. Spelling out the package of services and making communities aware of their entitlements helps increase accountability. Undertaking such actions in a coordinated and appropriately sequenced manner requires strong local capacity to regulate patient flows and continuity of patient care.
Successful examples of such reform processes show deliberate intent executed to a plan. Thailand’s launch of the Universal Health Coverage in 2000 was the end of a planned strategy. For years Thailand had a strong HR policy in place. For five years prior to 2000, Thailand dedicated three quarters of its Budget to building the provincial level health infrastructure with a capacity to provide quality care. Compared to that, India’s strategy for UHC has hinged on purchasing services from a private sector operating on the inflationary a fee for service model within the backdrop of severe supply shortages in the system, particularly of specialists and nurses. Due to extensive market failures, worsened by poor capacity to govern, looking to the private sector to deliver is not smart.
Given our political economy, reforming and restructuring our health system is not easy. Not only do we need a strong political leadership that is willing to shed its preoccupation with high-end hospitals, hi-tech diagnostics and digitisation but also have the courage to bite the bullet to undertake reforms in a synchronised fashion starting from the base. Designing and putting in place a system ‘fit for purpose’ would imply bringing about changes in the medical curriculum, so that doctors work in teams and in rural areas (a recommendation that Mudaliar made in his report of 1959). Having more equitable admission policies and HR policies, such as banning dual practice, delegating functions, creating new cadres and building teams with clarity in their functions will ensure a community/patient outcome-based health system. Establishing IT and monitoring systems that evaluate performance based on outcome data linked to financing will enhance efficiencies and optimise investment. The implication of such a system is that it is predicated on the concepts of decentralisation and operational flexibilities within a proactive, accountability framework that respects the values of equity, human dignity and trust.
The challenge ahead
The challenge is to understand the current system of health care and have the imagination to design the process of reform while building the implementation capacity at the district level by training and upskilling existing staff. Simultaneously, there must be an infusion of new institutional and organisational capacities and resources. Building such a process will take time as every States has a different level of capability. Done well, it can reduce demand for hospitalisation by at least 30%, disease incidence (by bringing in lifestyle changes in the diets we follow and exercises we do), and out-of-pocket expenditures that are likely to increase due to more than 20% of young Indians suffering from multimorbidities and an ageing population — together consuming more drugs and diagnostics.
Can our political parties commit themselves to such a process in their manifestos? Or, is that a big ask, is the question.
K. Sujatha Rao is former Union Health Secretary, Government of India
