Dr Girdhar Gyani, Director General, Association of Healthcare Providers (AHPI) talks about the challenges & opportunities in achieving UHC in India and also gives a possible solution for the same
India’s healthcare sector is gradually but surely taking a centre stage. India is committed to achieving Universal Health Coverage (UHC) for all its citizens by 2030. The launch of the flagship Ayushman Bharat Program in 2018 is potentially an important step in this direction with two major components viz Health and Wellness Centers (aiming to strengthen primary healthcare services) and Pradhan Mantri Jan Arogya Yojna (PMJAY) and insurance mechanism for secondary and tertiary hospitalisation for bottom 40 per cent of population.
Following is the gist of challenges & opportunities to realise UHC in letter and in spirit.
Shortage of basic healthcare infrastructure:
One of the primary challenges in India’s healthcare sector is the shortage of healthcare infrastructure. The private sector has approximately 1,185,242 beds while public sector has approximately 7,13,986 beds. This leaves India with an average of less than 1.4 beds per 1000 population, significantly lower than the WHO suggested norm of 3.5 beds per 1000 population. The government’s investment in healthcare stands at less than 2 per cent of GDP, and that of private sector just under 3 per cent of GDP, both together falling far short of the global average of 9.5 per cent of GDP spent. The shortage of beds and lack of adequate funding pose a fundamental challenge in providing health and wellness access to the masses.
Poor accessibility
More than inadequate availability of basic healthcare infrastructure, it is the grossly uneven accessibility, especially with urban-rural and rich-poor divide, which is found to be greater challenge. For example, state of Karnataka has 4.2 beds per 1000 population whereas state of Bihar has only 0.29 beds per 1000 population. Even within the states, there will be big unbalance from district to district and only handfuls of districts have tertiary/quaternity care facilities. This makes population to travel long distances within the state and even outside the state and in the process depriving of timely care.
Shortage of healthcare professionals
A shortage of healthcare professionals compounds the ongoing issue. While, the country has approximately 1.3 million registered allopathic doctors and 5,65,000 registered AYUSH doctors, but when it comes to having specialists, we are terribly short of them. For instance, there is shortages of surgeons, obstetricians and gynaecologists, general physicians, and paediatricians ranging from 74.2 per cent to 81.6 per cent of the required strength in the Community Health Centres (CHCs). Similarly, registered nursing personnel stands at 3.3 million, which does not meet requirement of 1/3 doctor-nurse ratio.
Lack of focus on promotive & preventive care
The healthcare system in India has traditionally been oriented towards curative care, with little focus on preventive care. This results in delayed diagnoses and a heavy financial burden on patients and on the overall system. Lack of awareness is also one of the reasons hindering the potential growth of preventive healthcare and spending on it.
Financial sustenance/out of pocket payment
More than 70 per cent of OPD, 60 per cent of IPD and 85 per cent of tertiary care services come through private sector. With launch of Ayushman Baharat PMJAY in year 2018 and coupled with already operative government insurance schemes like CGHS, ECHS, ESI etc., it is estimated that about 70 per cent of the population is receiving healthcare services either free or through contributory mode. Government utilises private hospitals in providing care to the beneficiaries from these schemes. The issue here is that rates for most of the procedures at which government reimburses to private hospitals is far lower than the operating expenses, due to which hospitals are finding difficult to sustain. This is one of the reasons which discourages private sector for new investment in tier-III towns.
The suggested steps to achieve Health for All:
- Apply innovative measures to increase supply of specialists by way of increased PG/ DNB/ Fellowships/ Diploma seats. This should be taken on highest priority.
- Establish referral system in the chain of public sector establishments. For example, AIIMS should cater to only tertiary and quaternity care. Where appropriate involve private sector to operate some of PHCs/ CHCs.
- Provide cheaper capital to the private sector in setting up of 100 bedded Ayushman Bharat tertiary care hospitals in tier-III towns.
- Provide electricity at industry rates as against commercial rates presently being levied.
- Provide single window clearance for numerous statutory compliances
- Allow CSR funding for setting up of private hospitals in deficient regions, which agree to operate at AYUSHMAN BHARAT rates.
- Government to restructure insurance schemes like CGHS/ PMJAY with rational rates for reimbursement. This will help more hospitals to get empanelled and meet the objective of government to provide tertiary care to population at large.
- Government may consider introducing co-payment for quaternity care procedures, which are available only at select hospitals and population will be more than willing to pay bit of extra component over and above what is given through schemes.
- Adopt strategies for skilling/ reskilling of doctors, nursing staff and Allied Healthcare Professionals. Introduce technology in the curriculum for all streams. Increased focus on internship.
- Focus on promotive and preventive healthcare by involving local bodies and NGOs
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