Dr Girdhar Gyani, director general and Dr Alexander Thomas, president, Association of Healthcare Porviders (India), analyse how the sector is facing financial unsustainability and suggest action points for the re-modeling of our health systems
Healthcare systems are facing one of the most challenging times in recent history. Developing countries have been working on agenda to have universal health coverage for their population to ensure that affordable and safe healthcare is made available and accessible for community at large.
This journey received a severe jolt by way of the COVID-19 pandemic in the very beginning of 2020 and is still tormenting across including most developed health systems. While it has taken heavy toll on human lives, it has made us realise, how poorly we have looked after our healthcare needs. We need to look at how we re-build our health systems, which are robust and resilient to combat the pandemic and similar calamities, besides ensuring universal health coverage in letter and spirit. Environment and climate change is making adverse impact on human health, which also needs to be accounted for.
Private healthcare sector in India holds overall 60 per cent Inpatient department (IPD) beds and 85 per cent tertiary care beds. Providing health care to the increasing population is just not possible without public and private sectors coming together. Achieving 3.5 beds and 1 doctor per 1000 population is key towards realisation of UHC. This will need enormous financial resources. Government intends to increase the healthcare spending to 2.5 per cent from 1.2 per cent of GDP, which will be too short an amount to meet the quantum of needs. Private sector has to inevitably play a significant role by partnering with Government by investing more by way of setting up of facilities in deficient regions. Preferably we need encouraging policy initiatives to enhance private investment in health sector so that this partnership can become robust. This is the only pragmatic approach to ensure the dream of UHC of the government in the days to come.
How to realise UHC?
In light of foregone, it can be said that while Government of India has honest intention to provide health for all, but at the same time have limited resources. A multipronged approach needs to be adopted. We have all along missed out on promotive, preventive part of healthcare and have been struggling with curative element. Government needs to reorient focus on prevention, detection, control and management of health for our population. Safe drinking water, sanitation and nutrition need to be treated foundation block for building robust health systems.
Health & Wellness centers envisaged under AYUSHMAN BHARAT have to be given high priority. Coming to the management part, we have to aggressively plan to have more specialists through normal education route through medical colleges, through DNB courses and through fellowship programmes. This is single most important aspect as without achieving adequate number of specialists, any amount of financial investment will not help in achieving ‘Health for all’.
Second point is to increase the number of hospital beds in general and in Tier-II/III cities in particular. Hon Prime Minister had emphasised opening of 3000 new hospitals in deficient regions. This can be possible by providing incentives for private sector. Considering that current sentiment is not favoring any new investment, government need to come forward in addressing the concerns of private sector in paving way for fresh incentives. These may include providing soft loans, electricity at industry tariffs and providing single window clearance.
While all the efforts by way of improving availability and accessibility will take time, it will be prudent to introduce information technology to compliment present meagre resources in terms of hospital beds and health care workforce including doctors and nurses. Home health similarly can be promoted in conjunction with hospitals to augment the bed capacity.
Financial sustainability
In-spite of huge shortage and urgent need, healthcare industry is not seeing any fresh investment. Financial sustainability has emerged as single most important impediment in attracting fresh investment. Hospitals till recently were getting majority of patients paying from out of pocket at the market rates. Hospitals were managing through partial cross subsidising from the cash paying patients and compensating for lower tariffs in the government schemes like CGHS/ECHS/ ESI etc.
This situation is rapidly changing. CGHS tariffs fixed in the year 2014 have not been revised, whereas expenditure due to normal inflation, rise in salary etc. has gone up considerably. The margins from pharmacy and consumables has drastically been reduced. All this has telling impact on financial sustainability of hospitals.
Over and above, we have PMJAY, where rates for various medical procedures are much lower and do not meet even the minimum operational cost. The EBIDITA which was about 20 per cent till recently, is going down to single digit, pushing hospitals to imminent financial unsustainability. Single most important reason for this has been unviable rates fixed in the government run schemes including CGHS and PMJAY, without following any scientific basis. Private insurance companies including GIPSA are trying to adopt rates specified under PMJAY. All these issues are virtually sounding death kneel for private healthcare industry.
Conclusion
The COVID-19 pandemic has made us realise that healthcare needs far greater attention, almost aimed at ‘Radical Remodeling’ of current health systems in the country. Public health structure which is supposed to be first line of defense in pandemics, has been found wanting with shortage of critical care beds, doctors and nursing staff. We need to evaluate strengths and weaknesses of private and public systems and create synergy as ‘win-win’ situation. Following are suggested action points in re-modeling of our health systems;
- Focus on promotive, preventive & primary health aspects including; safe drinking water, sanitation & nutritional needs of society. Expedite setting up of Health & Wellness Centers as envisaged in AYUSHMAN BHARAT. Involve private sector and NGOs.
- Strengthen public health systems in terms of delivery of value- based services to community at large. An efficient and accountable public health system should compete with private sector.
- Incentivise private sector to establish hospitals in deficient areas including tier-iii cities. Such investment may be even covered under CSR. Formalise the Home Health services as a viable option to augment hospital beds.
- Increase the number of PG seats to make good acute shortage of specialist doctors
- Restructure government health schemes including CGHS, PMJAY etc. by working out scientific study on costing to fix prices of medical procedures for reimbursement to private empaneled hospitals. Introduce co-payment as appropriate.
- Fast track implementation of National Digital Health Mission and promote use of medical and information technology.
- Promotion and integration of AYUSH with modern medicine as appropriate.
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