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What the new govt can do to set the health system right

LiveMint logoLiveMint 25-05-2014 Rakesh Sarwal

Today people complain about rudimentary and poor quality of healthcare services in government facilities, while the private sector’s services are seen as costly and often irrational. There is no organized attempt to contain health risks in the environment, or to help people build positive healthy behaviour. Drugs, which comprise a major part of households’ out-of-pocket spending, are often prescribed in an irrational manner.

While there has been some improvement in population-level indicators such as infant mortality, malnutrition levels remains stubbornly high. Illness today is catastrophic for those on the fringe, costly and hassle-filled experience for others.

What are the key critical things that central government can do to set the system right?

Although health is a state subject, the central government has a large sway on setting priorities, medical education, research and practice and regulation. Some key action in these areas can correct distortions and make India’s health sector responsive to people’s needs. The new government has a historic mandate and responsibility to take corrective action. These include:

Medicines: Recent stock-out of tuberculosis drugs points to the need for a professional, autonomous and efficient procurement agency to streamline the procurement system, which the cabinet had approved in September 2011. The Central Procurement Agency has had token budget outlays and has not been yet made operational. By activating the agency for all central government purchases of medicines and diagnostics, making its services available to states seeking so, the new government will ensure that all central programmes and facilities have essential supplies in place at lower costs.

Information systems: No major programme or project can be effective without a robust information system. In contrast, we have a 12-year lag in data on cause of death, an eight-year lag on malnutrition data, a three-year lag for maternal mortality and vital registrations, despite the existence of a host of information systems. The new government should build a unified health information system (HIS) that gives status of health of all citizens from womb to tomb, by combining existing systems. The unified HIS can also generate birth and death registration certificates. This will also help universalize coverage under civil registration system from the existing 82% for births and 67% for deaths (2010).

Allied health professionals: Even though evidence points to the enormous contribution that allied health professionals can make, this sector has not received due attention. Their numbers, quality and field of practice needs expansion. This requires a central agency which will set standards, frame syllabus, accredit training facilities and regulate their practice. The proposed National Council for Human Resources in Health law addressed many of these gaps but faced stiff criticism of the parliamentary standing committee in 2012. The new government should revive the draft legislation after addressing the concerns.

This move will also open vast avenues for training, employment and practice of allied health professionals in public and private settings. Meanwhile, modalities of a bridge course for practitioners of alternate systems such as Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) to train them in emergency and primary medicine can be finalized. Once offered, such bridge course can make a large number of over 700,000 AYUSH practitioners available for health service delivery in under-served areas.

Blood transfusion: Unbanked direct blood transfusion is necessary to service the need for blood in peripheral facilities without access to a blood bank. It is allowed only in the armed forces, and should be permitted in all health facilitates where services of blood banks are not easily available. An amendment in the drugs and cosmetics rules would be enough to accomplish this change.

Tobacco abuse: Recent surveys estimate that 34.6% of adults (47.9% of males and 20.3% of females) use tobacco in some form. Increasing use of tobacco, particularly among the youth in India, is emerging as the main preventable cause of non-communicable disease. Raising of taxes on cigarettes is known to discourage smoking, and is a key public health measure with far reaching positive health implications. This move, which can be combined with extensive awareness generation, requires a decisive government and should be taken up early on.

Service delivery: The current health spending by the government—both at the Centre and the state—is `963 per capita (2012-13) or `4,813 per family. Even though low (1.07% of gross domestic product) by all standards, current spending does not translate into a core essential health package for most people in the country, which was estimated to cost `3,500 per family in 2005.

The reasons lie in manner of organization and financing of programmes. Instead of creating a pool of resources for purchasing a set of core services, the government funds go down for individual disease control programmes, separately for AYUSH and AIDS control, and maintenance of hospitals and facilities. While some of the available government funds would need to be set apart for committed and new capital expenditure, a large portion can be pooled and made available to the states.

Another problem with present system is that the government as the financier, service provider and policy maker creates a conflict of interest and perpetuation of indifferent services. It is now well-recognized that splitting of provider and financier roles of the government leads to gains in efficiency. As the financier, the government has the choice to purchase services from any provider, public or private. Quality of service can be improved through pay-for-performance contracts with facilities, which brings accountability. This has been successfully done globally.

Hospitals, in turn, need autonomy, both financial and administrative, to manage their resources and deliver efficient services. The central government can lead the way by creating a Health Assurance Corporation to manage the pooled funds of schemes directly implemented by it like Employees’ State Insurance Corp. and Central Government Health Scheme and provide autonomy to its departmental-run hospitals, which can be contracted for provision of a package of services.

Preventive and primary care requires long-term association and are not easily amenable to contracting and thus can be discharged by public facilities only. Private hospitals can be contracted for secondary and tertiary care. Every health facility would need to be accredited and its performance measured and publicized. Once set. the states would emulate this model for all families.

Health insurance: A typical household of five spends `6,500 per year on healthcare (National Sample Survey Office, 2011-12). Most of it is out-of-pocket, with drugs making up 70%. Household’s expenditure can fetch more health and care if it were through prepayment, pooled and used to buy quality services at lower cost. The central government can offer a low-cost insurance product to meet this need. As a first step, the Rashtriya Swasthya Bima Yojna (national health insurance scheme) should be made open to all those willing to pay the small premium of `750 for a cover of `30,000 per family per year.

Tele-medicine: A national tele-medicine portal connecting all medical colleges and tertiary hospitals can be created, which will offer consultations to health facilities in its jurisdiction.

Specialized assessment agency: Most countries contain healthcare costs and ensure quality of care through specialized agencies, which assess available treatments for their necessity and cost-effectiveness, and make recommendations. We urgently need such a system. The new government can get a health guidelines and cost-effectiveness agency operational under the department of health research to assess and recommend best therapy for each of the common conditions, frame standard guidelines suited to Indian conditions, which will then be followed in framing the health package.

Public health: While service delivery can be hived off into autonomous bodies, core government functions of disease prevention, sanitation, regulation of food and drugs, behavioural change communication, outcome monitoring and health information systems require a specialized cadre. This is public health, which has seen a decline since independence with resultant neglect of such vital functions. The public health sub-cadre of the Central Health Service needs to be strengthened and assigned responsibility for these core tasks. The states can similarly be incentivized to work towards their own State Public Health Cadre.

The suggested measures will assure a core essential health package including medicines to all, give households an option to top it up with a basic insurance package, effective management of health risks and environment, and build information systems to measure and monitor. It will meet the commitment of the Bharatiya Janata Party in its election manifesto of health assurance to all Indians.

The author is a civil servant and health adviser in the Planning Commission. The views expressed are personal.

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