The 12th five year plan document once again pitched for Universal Healthcare on the national agenda. Though, India embraced this vision at its independence it has never had the political will, due to other pressing priorities like poverty eradication, food and shelter etc., to make committed allocation of planned funds towards achieving this end. The economic advancement in the country has enabled the government to clearly articulate its intent to increase the public financing of health to 2.5 per cent of India’s GDP in the 12th plan to ensure affordable, accessible quality healthcare. However, chances of a quantum increase in funding are bleak, even in the 12th plan period, with the fiscal deficit hitting 5.9 per cent of GDP, levels not seen since 1991.
A welfare state should ideally ensure adequate quality healthcare provisions to every citizen. However, if we do a reality check in India, then we find that private out-of-pocket (OOP) expenditure forms 71 per cent of the total expenditure on health. 78 per cent of outpatient and 60 per cent of inpatients are being serviced by private providers. What is more interesting is the fact that private providers have only 20 per cent of the existing health infrastructure. India spent only 5.2 per cent of the GDP on healthcare where more than 80 per cent (4.3 per cent of GDP) of it came from the private sector alone and was valued at around Rs one lakh crore. Even where public health facilities are available, nearly 70 per cent of the population do not use them as they perceive that these deliver low quality care, while 47 per cent of people do not use these facilities as they are not located nearby. This is despite the fact that private healthcare can be very expensive compared to treatment at public facilities. Clearly, other than select exceptions, the people at large have little faith in the existing state healthcare delivery.
In the rural public healthcare infrastructure, primary healthcare facilities lack appropriate health infrastructure, trained health workers, availability of diagnostic facilities, drugs and proper management structure. At the same time, the district hospitals providing secondary facilities provide low quality of care due to high patient footfall and overworked staff. Low accountability and poor governance further compound the challenges. They are also inconveniently located, leading to poor access. A person in rural India has to travel an average distance of 19 km to reach an in-patient healthcare facility which is arduous due to poor infrastructure. This is three times the distance a person would need to travel to a facility in urban India. There are limited numbers of tertiary care facilities in the public system which are also concentrated mostly in the five southern states of India. Although government is under the process of setting up about 10 AIIMS-like institutions across India, these alone will not be sufficient to meet the demand for tertiary level healthcare.
The inadequate public healthcare delivery has over the years led to burgeoning of private healthcare providers which by estimates constitute 15-20 lakh providers spread across the country in an unregulated environment. Majority of the providers are less than 30-bed facilities that are not even registered, giving rise to lack of standardisation in the quality of healthcare delivery. In the last decade, large private and corporate sector super-speciality hospitals have come up in metros, and some expansion of secondary care hospitals have been done in the tier II cities. The practice of visiting a general practitioner for primary care is disappearing from the Indian healthcare scenario, thereby burdening the tertiary care hospitals with primary care cases. For optimal utilisation of existing healthcare facilities in the public and the private sector, there is an urgent need to develop a referral mechanism so that the issue of over-congestion of urban tertiary care centers is effectively tackled. The implementation of Clinical Establishment Act 2010 can facilitate this.
While the country has to undoubtedly aspire towards universal healthcare in a defined time-frame, the roadmap needs to be created after taking into consideration various aspects such as communicable and non-communicable disease burden, infrastructure availability, healthcare financing, human resource gaps, quality improvement mechanisms and reforms in institutional and policy framework. This would, in the long run, lead to a fair and robust mix of public-private delivery system with the public system geared towards preventive and primary healthcare, immunisation programmes, NRHM, URHM and disease control programmes. The private providers, including the corporate chains, would have a greater role in secondary and tertiary care. With 80 per cent of infrastructure in public sector and 80 per cent of doctors in private sector, there is immense scope for public-private partnerships to be leveraged for healthcare delivery provision.
FICCI Health Services Committee comprising multi stakeholders from the health services domain has been diligently working on the areas highlighted below to suggest collaborative actions that will positively impact the quality of healthcare system and delivery in the country.
Skill development: FICCI’s taskforce on skill gaps is collaborating with AICTE to develop 12 vocational courses in the allied healthcare domain. These training programmes are tailored according to the seven levels under its national vocational education qualification framework (NVEQF) starting from Grade IX of CBSE. The framework allows lateral entry and exit as well as vertical mobility for the students. At the same time, it promotes an all-inclusive approach to vocational education. It also draws on skill development as a potent tool for empowerment of the economically weaker sections.
Standardisation: With standardisation of delivery as the aim, FICCI coordinated the development of national standard treatment guidelines for twenty specialities which covered nearly 250 conditions under its ambit. This single standardisation measure would lead to standardisation in clinical practice and ensure more predictable quality outcomes. The final guidelines are in process of being completed and would be released soon by MoH&FW. Similarly, a number of initiatives were taken in the health insurance domain viz. standard billing and discharge summary format, payer provider contracts, quality indicators and essential criteria for hospital empanelment.
Awareness on accreditation: FICCI’s initiative in increasing awareness towards accreditation and the benefits associated with the same is also showing results. While NABH has existed for more than five years and NABL for about two decade now, movement towards accreditation in hospitals and labs has been painfully slow. Through a series of awareness campaigns in collaboration with NABL across the country, attempts are being made to create awareness amongst physicians and smaller labs about the benefits of accreditation.
NCDs: With the country still grappling with the burden of communicable diseases, the rising trend in non-communicable diseases, is presenting a difficult challenge to the health system. Comprehensive awareness, screening and management strategies to tackle the growing menace of NCDs is the way forward. FICCI’s task-force on NCDs prevention and management has taken up the task to make attempts in this regard.
Innovation: The FICCI Health Services Innovation Task Force has initiated efforts to build an enabling ecosystem for innovators and provide a platform for the Industry which include Institutions in the Public Health Sector, to bridge and promote innovative practices in health and share knowledge through a structured approach.
The need of the hour is a collaborative approach between the public and the private sector to collectively face the challenges and build on each other’s strengths. Government should leverage and build on the industry initiatives while planning for the nation. The private sector should self regulate and work in sync with the government to create a synergy with the aim to provide quality healthcare delivery affordable to all segments of societies. The path towards universal healthcare should be a path of small incremental steps of purpose rather than abrupt change and resultant disorientation. There is no reason to believe that private healthcare system cannot co-exist and flourish along with a public healthcare system.
All these issues and more will be deliberated in FICCI-HEAL 2012 to be held on Aug 27-29, 2012 in New Delhi. The theme of the Conference is “Universal Healthcare: Dream or Reality?”
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