The concept of universal health coverage (UHC) suggests the provision of promotive, preventive, curative, rehabilitative, and palliative health services to all people and communities so as to ensure their well-being without causing them financial hardship. This requires proper financing and human resources for meeting the needs of the economically disadvantaged population in terms of medicine, diagnostics, and service costs.
Government financing is a prerequisite for ensuring UHC since individual voluntary payment insurance schemes prove insufficient for UHC even in the developed countries. In developing countries, provision of adequate financing poses the major challenge to provision of health services to all resulting in lack of access to health care for the marginal strata of society. The estimates show that out of 132 of low- and middle-income countries, only 37 will be able to attain the target of 5 per cent spending of gross domestic product (GDP) on health by 2040. The total expenditure on health care in India in 2013–14 was nearly 4.02 per cent of GDP, out of which the government’s share was 1.15 per cent against the global average of 5.99 per cent. insurance covers less than a quarter of the Indian population accounting for only around 1.5–2 per cent of the total healthcare expenditure in India. As a result, out-of-pocket expenses constitute a major share of total healthcare costs in India—about 69 per cent.
State of Primary Health Care
According to World Health Organization’s 2018 data, the non-communicable diseases (NCDs) kill 41 million people each year globally. Some 15 million people among them are between the ages of 30 and 69 years and belong to low- and middle-income countries, which focus more on treating infectious diseases. The major NCDs causing early deaths include heart attacks, stroke, cancers, chronic respiratory diseases, asthma, and diabetes. The main hurdle in treating NCDs is posed by the lack of trained physicians at the primary healthcare level where diseases can be prevented and detected early so that timely treatment is given.
Primary healthcare services play a crucial role in disease management and prevention, more so in our country with a population of over one billion. But the state of primary health care remains dismal in India. Therefore, there is a high burden on tertiary centres.
Condition of Idea’s Health System
Despite being one of the fastest-growing economies in the world, India’s health system remains in shambles. There is a shortfall of 20 per cent sub-centres, 22 per cent public health centres, and 32 per cent community health centres. The WHO ranking of global health systems ranks India at 112th position, below Iraq and Venezuela mainly due to shortage of doctors.
Shortage of skilled human resources is another major hurdle in the path of achieving UHC. India has only 0.7 physicians per 1,000 persons and 1.8 nurses/midwives per 1,000 persons against the prescribed standards of 1 : 1000 and 4 : 1000 respectively. More than the number of healthcare professionals, it is their distribution which is rather lopsided.
As per a study by researchers from the Indian Institute of Public Health (IIPH), Gurugram, the real problem lies in the distribution of health workers in India.
Though the overall size of health workers’ population in India is lesser in comparison to developed countries, these numbers are near to the World Health Organization’s (WHO) minimum requirement of 22.8 doctors and nurses per 10,000 population.
The health workforce in India broadly comprises eight categories: doctors (allopathic, alternative medicine); nursing and midwifery professionals; public health professionals; pharmacists; dentists; paramedical workers (allied health professionals); grass-root workers; and support staff.
The bulk of doctors and nurses are found in major cities, resulting in their absence or very low presence in rural areas as well as in poor states of the country. Despite 71 per cent of the country being predominantly rural, it comprises only 34 per cent of doctors and 33 per cent of nurses in the country. More than 80 per cent of the doctors and 70 per cent of the paramedics work in the private sector.
As per a WHO database, the health sector employs five million workers in India, but there remains a low density of health professionals compared to Sri Lanka, China, Thailand, United Kingdom, and Brazil. This has placed the country into the ‘critical shortage of healthcare providers’ category. In this context, Delhi, Kerala, Punjab, and Gujarat are placed favourably while Bihar, Jharkhand, Uttar Pradesh, and Rajasthan remain at the bottom.
According to a study in the British Medical Journal (BMJ), reported in May 2019, around 54 per cent of health professionals in India (doctors, nurses, midwives, lab technicians and other paramedics) do not have the required qualifications; 20 per cent of doctors who happen to be adequately qualified are not in the current workforce.
It means there is an immense need to transform Indian health care so that India could serve its population in the situation of the rising burden of diseases along with poor coverage by public health. Provision of Universal Health Coverage (UHC) is of utmost importance in this regard. The main hurdles in the path of achieving UHC in India relate to inadequate public health care financing and lack of skilled human resources.
So, in order to develop a robust healthcare system the budgetary allocation towards healthcare witnessed a considerable increase. There is a national health protection scheme targeting low-income households, upgradation of primary health care and expansion of the health workforce.
Ayushman Bharat Scheme
On September 23, 2018, the Union Budget 2018 announced the launch of the Ayushman Bharat (National Health Protection Scheme or NHPS) to provide coverage of up to ` 500,000 to a family a year for secondary and tertiary-care hospitalisation to almost 100 million low-income families in India. Multiple schemes were subsumed to form it, including Rashtriya Swasthya Bima Yojana (RSBY), Senior Citizen Health Insurance Scheme (SCHIS), Central Government Health Scheme (CGHS), and Employees’ State Insurance Scheme (ESIS), etc.
The scheme comprises mainly two components: Pradhan Mantri Jan Arogya Yojana (PM-JAY) and Health and Wellness Centres (HWCs), which are to be the foundation of the health system. The PM-JAY is a publicly financed health insurance scheme for the rural poor and selected occupational category of urban population.
The scheme provides cashless treatment to patients from empanelled government and private hospitals. The rate of insurance is to be based on the package rates prescribed by the government for 1,354 ailments.
The scheme has allocated ` 1200 crore for 1.5 lakh HWCs. These centres were established for the purpose of administering comprehensive health care, including non-communicable diseases and maternal and child health services, besides providing essential medicines and diagnostic services free of cost. The government also upgraded the existing public health centres to health and wellness centres. The services, provided at these centres, include pregnancy care and maternal health services, neonatal and infant health services; child health; treatment for chronic communicable diseases and non-communicable diseases; management of mental illness, dental care; and geriatric care emergency medicine.
The families covered under the scheme are based on the socio-economic caste census (SECC), 2011. In order to avail the scheme, a person’s name must feature in the SECC database and the person must provide proof of identity to enrol. In rural areas, households living in one room kuccha house, those with no adult members, those headed by women, those belonging to SC/ST, the homeless, and landless are some of the beneficiaries. Similarly, the beneficiaries in the cities include rag pickers, street vendors, domestic help, sanitation workers, etc.
HWCs The health and wellness centres (HWCs) are meant to give an overhaul to the healthcare delivery system in the country. Some 1,50,000 HWCs are to be set up by transforming the existing sub-centres (SC) and primary health centres (PHCs). Two kinds of HWC have been envisaged: one (at SC level) managed by multipurpose workers and another (at PHC level) comprising a new cadre of health provider, i.e., mid-level healthcare provider (MLHP), who could be a community health officer with a B.Sc. in community health, a nurse (B.Sc. or general nursing and midwifery, GNM, or an Ayush practitioner. In the latter case, all essential services of existing PHC are included along with addition of prevention, screening, and management of non-communicable diseases, basic oral health care, common ophthalmic and ENT problems, mental illness, elderly care, and palliative healthcare services.
The inclusion of Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) practitioners for primary healthcare delivery in rural areas would promote on holistic approach towards health and bridge gaps that exist.
However, concerns exist regarding the workability of HWCs. For one, their objective is too ambitious and the lay-out plan of HWCs seems devoid of learning from experience of health systems development in the past and the complexities involved. The HWC plan has not taken into consideration the heterogeneity of the health development scenario in states and their health systems. The Bhore Committee, in 1946, had presented recommendations on distribution and coverage of healthcare facilities—a matter that continues to be a problem in states. Moreover, the challenges of ensuring primary health care have only increased over time.
NITI Aayog Health Index
The second edition of the Health Index, released by the NITI Aayog in mid-2019 (Health Index 2019), revealed that there are wide variations in the state of health across the country due to regional variations. The state of health continues to be poor despite considerable progress made in life expectancy and maternal and child mortality. Even the states in the category of ‘high-performing and improving’ are not registering better outcomes under all parameters.
The 1st edition (round) of the Health Index was released in February 2018, which measured annual and incremental performances of states and union territories from 2014–15 (base year) to 2015–16 (reference year).
The report titled ‘Healthy States, Progressive India Report on Rank of States and UTs’, presented the Health Index taking into account the period from 2015–16 (base year) to 2017–18 (reference year).
The index has measured 23 wide-ranging health indictors that include neo-natal mortality rate, under-5 mortality rate, institutional deliveries, sex ratio at birth, immunistion coverage as also inputs relating to governance, such as stability of tenure for top medical officers, vacancies in public health facilities, number of accredited health facilities, and time taken for fund transfer by the National Health Mission (NHM), etc.
Kerala (74.01 on 100) remains at the top (1st rank) in terms of health performance on various parameters. Mizoram is the best performing small state. It is followed by Andhra Pradesh (65.13), and Maharashtra (63.99). The 4th, 5th, and 6th positions were given to Gujarat (63.52), Punjab (63.01), and Himachal Pradesh (62.41).
However, Uttar Pradesh (28.61, 21st rank), Bihar (32.11, 20th rank), Odisha (35.97, 19th rank), Madhya Pradesh (38.39, 18th rank), and Uttarakhand (40.20, 17th rank) remain the worst performers.
Criticism and Concerns
The government agenda for UHC has also faced certain challenges and criticism. A common refrain is that the government should focus more on public health issues and preventive and promotive care, rather than over-emphasising cure. The private sector is poorly regulated and so, the government should first strengthen regulations and ensure they are enforced before involving private players in a major way in PPPs. Another concern is that ABPM-JAY is an insurance-based scheme which will enrich the insurance companies. It may well increase the cost of care (government hospitals have been providing services for free anyway over the years and this has benefitted the poor). Moreover, several states have their ongoing schemes and they do not gain much by joining AB-PMJAY.
The objectives of Ayushman Bharat are ambitious and the scheme itself has been implemented in haste. It poses threats of diverting the limited resources that are available in the health sector in different ways—from (i) the public to the private sector; (ii) preventive and promotive health services to predominantly curative services; (iii) primary to secondary and tertiary care services; and (iv) poor performing states to some extent to those that perform better on health sector.
Simply shifting the responsibilities to the private sector, for instance, cannot address the challenges of the health system in the country. A clear blueprint is essential to address the existing problems by establishing a regulatory framework for the private sector, protecting the rights of the people in such government schemes and improving the level of preparedness of the country in dealing with challenges as and when they arise.
Some Key Takeaways of the Report
Some of the key takeaways of the report are as follows:
(i) Annual Incremental Performance
* Haryana, Rajasthan, and Jharkhand are the top 3 among larger states.
* Tripura and Manipur are the top 2 among smaller states.
* Sikkim and Arunachal Pradesh showed biggest decrease in overall health index scores.
* There is disparity among neonatal mortality rate (NMR): Kerala’s (NMR) probability of an infant dying in first 20 days of birth is 6 less than one-fifth of that of Odisha (35 and 32) and Madhya Pradesh (34 and 32) in 2015 and 2016.
* Kerala and Tamil Nadu reached sustainable development goal (SDG) of 12 or less neonatal deaths by 2030, whereas Maharashtra and Punjab respectively reached the 15 and 13.
* NMR declined in all states except Uttarakhand (went up from 28 in 2015 to 30 in 2016.
Under-5 Mortality Rate (U5MR) Madhya Pradesh and Assam remained at the top (62, 52) and (62, 35). On the other hand, whereas in Kerala it remained at the lowest (13, 11). other states like Tamil Nadu (20, 19); Maharashtra (24, 21), Punjab (27, 24) achieved SDG U5MR goal of 25 in 2015 and 2016.
Sex Ratio at Birth (SRB) Chhattisgarh (963) and Kerala (967)—only 2 states with SRB over 950 girls for every 1,000 boys; Haryana remained at the lowest at 832.
Immunisation Hundred per cent immunization was done in Jammu and Kashmir, Kerala, Jharkhand, and Andhra Pradesh. Among smaller states, Manipur and Mizoram got full immunisation, and Andaman and Nicobar and Lakshadweep, among Union territories.
* Ten states and UTs (other than these above) have full immunization levels of 90 per cent or above.
* In Odisha, Nagaland, and Daman and Diu immunisation coverage remained less than 60 per cent in 2017–18.
Bihar’s deterioration was primarily due to performance related to low birth weight, sex ratio at birth, TB treatment success, quality accreditation of public health facilities and time taken for National Health Mission Fund transfer. Odisha’s poor performance has been linked to worsening of the full immunization rate and TB treatment rate. Madhya Pradesh has seen a reduction in level of birth registration and TB treatment success rate, according to the report.
Auto-natalcare and Institutional Deliveries (births at health facilities):
* Only 6 states/UTs with over 90 per cent deliveries in private/public health facilities—Telangana, Gujarat, Kerala, Mizoram, Puducherry, Chandigarh only around 50 per cent of total deliveries in health facilities: Uttar Pradesh, Nagaland, and Daman and Diu.
* Among 21 states, 13 with over 70 per cent of ante-natalcare registered in the 1st trimester of pregnancy; almost all states except Uttar Pradesh, Telangana, Uttarakhand, and Madhya Pradesh showing incremental progress in registration of pregnant women in the 1st semester.
The report asked the central government to spend 2.5 per cent of GDP on health. state governments should raise their health spending from an average of 4.7 per cent to 8 per cent of their budget (net state domestic product) on health. It noted a general positive correlation between the health index scores and the level of economic development registered by the states and UTs based on per capita net state domestic product (NSDP).
The index helps in identifying the problem areas as well as positive outcomes and thus provides an opportunity for states to learn from the experience of other states and come out with solutions.
The outcomes of the index indicate the need to improve healthcare infrastructure and increase the numbers of qualified health personnel as well as to invest considerably on health, sanitation, drinking water supply, and air quality.
The health index motivates states to improve their performance if public health becomes part of mainstream politics. Several states lag behind when it comes to establishing a primary healthcare system with well-equipped public health centres as the basic unit.
However, the index does not capture many dimensions relating to non-communicable diseases, infectious diseases, and mental health conditions. This is seen as a major drawback of the index. Moreover, it does not include, importantly, uniformly reliable data from the private sector that is growing on daily basis.
Ensuring Health care to Poor
Poverty leads to a massive number of people belonging to marginal sections becoming vulnerable to outbreak of diseases and poor health. The problem becomes compounded due to lack of access to basic facilities like hospital and medicines.
A glaring instance, in this regard, is the death of children in Bihar in 2019 due to Acute Encephalitis Syndrome (AES). The incidence of deaths revealed the tragic state of health, nutrition, education, and sanitation which remains pathetic even today for 36 crore Indians. States like Bihar, Uttar Pradesh, Jharkhand, and Madhya Pradesh score abysmally on these counts and more than half of India’s poor live in these four states.
Due to lack of adequate spending on resources and infrastructure, health care is in a state of emergency. shortage of doctors and paramedical staff results in poor patient care. Improper management and ill-trained staff are other pitfalls affecting the public health sector. There are many instances when patients are misdiagnosed and treated.
This critical state of public health care in the country calls for an overall revamp so that a large majority of the population is able to have access to decent health care.
There is a widening gap between demand and supply of health resources in India. The density of doctors and nurses and midwives per 10,000 population is 20.6, as per the National Sample Survey and 26.7 according to the registry data.
The country has a shortfall of around 82 per cent in specialists, almost 40 per cent in laboratory technicians and a 12–16 per cent shortage of nurses and pharmacist at community and public health centres (CHCs and PHCs).
The success of Ayushman Bharat also depends on the health related infrastructure at primary health centres in rural areas. As such, it is highly imperative for the state governments to revamp the rural health facilities and improve the service conditions of doctors and medical staff generally.
As per the Global Nutrition Report, released in 2018, 24 per cent of the world’s total malnourished population lives in India. Of the total malnourished children, about 30 per cent live in India. There is a strong correlation between nutrition and incidence of disease—malnourished children are most prone to diseases like AES.
In recent times, health care has seen a new downslide. Doctors’ strike, violence by patients’ families and an increase in suicides by doctors, a number of children dying of diseases, ill-prepared hospitals, and numerous instances of hospitals administering wrong treatment are some of the reasons of death of patients.
AES Outbreak in Bihar
In mid-2019, reports on the death of over 100 children in Bihar due to Acute Encephalitis Syndrome (AES) rang alarm bells. It exposed the poor state of public health in the country and highlighted the emergency situation in poor states especially when there are disease outbreaks. Doctors in Muzaffarpur’s Shri Krishna Medical College and Hospital confirmed that 80 per cent of the children brought to them were malnourished.
Seasonal AES and JE outbreaks occur annually in Bihar and Uttar Pradesh from around June to September. So, temporary encephalitis wards are formed in regional medicine colleges, patient treated with urgency, national labs work overtime and episdomiological studies are commissioned.
There are also problems related to infrastructure with the need to modernise primary health centres and upgradation of laboratories test infectious diseases, and need for digitisation of HR data.
AES and JE
AES cases in litchi-cultivated areas in Bihar were misdiagnosed as Japanese encephalitis till late 1990s as both the diseases are seasonal outbreaks and have similar symptoms. They were all reported as JE cases. In 2006, a JE laboratory network that was set up confirmed that only 15–20 per cent of encephalitis cases were JE! Since 2006, vaccination of at risk populations for JE resulted in JE cases seeing a drop. Now, AES cases are far more than JE. In 2018, there were 1,678 JE cases with 182 deaths, compared to 11,388 AES cases with 636 deaths.
JE is caused by a virus of the flavivirus family that includes dengue, zika, and yellow fever viruses. In contrast, AES is caused by a range of factors which include toxins found in unripe lychees, viruses, bacteria, fungi, and chemical poisons. Both diseases affect mostly children. JE strikes children less than 15 years of age even as adults are known to be affected (in 2013, in Assam, adults accounted for some 80 per cent of confirmed JE patients). AES, on the other hand, mostly affects children less than 10 years old who are malnourished.
Outbreak Elsewhere In 2016, Odisha saw similar AES deaths in Malkangiri. More than 103 children died due to JE and AES outbreak, however, since the next year, measures have ensured that no child dies due to it. To prevent AES, regular clearing of Cassia occidentalis bushes were carried out. Tribal families were warned of its poisonous beans by village communities and health workers. The district headquarters hospital innovated and ASHA volunteers and anganwadi workers provided special kits to administer medication in case of emergency.
In 2018, Nipah virus outbreak in Kerala resulted in death of 17 patients. Traced to fruit bats, the outbreak was centred in Mallappuram and Kozhikode districts. A motivated public health response checked spread of infection and in 2019, no casualty was reported.
The need is to learn from experience and take concrete steps to tackle disease outbreaks.
About AES
Acute encephalitis syndrome (AES) is mostly suspected to occur from infection from scrub typhus (Orientalia tsutsugamushi) or toxicity from unripe lychee seeds that cause severe hypoglycaemia (low blood sugar levels), coma and death in malnourished children.
The toxin, methylenecycloproplyglycine (MCPG), also called hypoglycin A, was confirmed to be the cause of the death in 2017. Scrub typhus infection was found in around 20 per cent of AES cases in Assam in 2016 and 62.7 per cent of cases in Gorakhpur in 2016.
There is inflammation of the membrane of the brain that leads to sudden fever, disorientation, headache, tremors, seizures, weakness, and death. Around 30 per cent of those affected die and those who pull through may develop some kind of permanent behavioural, mental, or neurological problems like partial paralysis, recurrent seizures, and affected speech.
Giving children sugar to normalise their plummeting blood glucose level may lead to recovery. Infusing 5 per cent or 10 per cent (for severe) dextrose within 4 hours of the onset of the illness has led to rapid recovery.
One of the prevention strategies is ensuring malnourished children do not go to sleep on an empty stomach; well nourished children may not be affected by the illness even if they go to bed on an empty stomach. This is because malnourished children do not have sufficient glucose reserve in their bodies in the form of glycogen and glucose production from non-carbohydrate resource is blocked. There is low blood sugar level.
Early treatment of patients having acute febrile illness with antimicrobial drugs is necessary before the illness affects the central nervous system.
Analysis Lack of basic health facilities is seen as the root cause of the outbreak of AES. In Muzaffarpur, Bihar, 90.14 per cent of the total population is classified as rural, with 24 per cent of them living below the poverty line (2011 census). On the cleanliness index, Muzaffarpur had 348th place in 2018. The heat, malnourishment, unclean conditions are all blamed for providing the environment for the illness to occur. Some 36 crore people in the country are deprived of basic health, nutrition, and sanitation facilities, with Bihar, Jharkhand, Uttar Pradesh, and Madhya Pradesh are at top in this regard.
Bihar has a poor record in ensuring adequate nutrition for the poorest. As per National Family Health Survey (NFHS) figures for 2915-16, 48 per cent of children in the state were stunted compared to the national average of 38 per cent. Spending on, and implementation of, schemes that provide nutritious food to children and expectant mothers is poor. Moreover, according to the survey, two-thirds of eligible children in the schemes did not get healthy meals. There is also distrust in the public health system. Understaffed hospitals, doctors refusing to work in rural areas, fear of violence against doctors in case children die in the primary healthcare centres, are all contributing factors. Disease outbreaks are not identified easily and known diseases are harder to treat.
In June 2019, the Union Health Ministry announced formation of a multi-disciplinary team to collect clinical, nutritional and epidemiological information from AES patients hospitalised since May 18. The team has been deployed at the SKMCH for making a viorology lab operational—something that has been on the cards for a decade.
The state was asked to switch to daily surveillance and monitoring for early detection of the illness. The state government has also started a social audit along with a house-to- house survey and campaign. Prospective patients were moved to the nearest PHC. These were surprise checks at PHCs by senior deputy collectors and early morning inspection of anganwadi centres by SDCs and child development project officials. Distribution of ORS to houses in the affected villages was undertaken to address the problem.
Towards an Efficient Healthcare System
The immediate priority in order to fix the country’s dysfunctional and inefficient healthcare system should be to start with ensuring availability of clean drinking water, sanitation, and nutrition in rural areas, in particular.
For achieving policy objectives in healthcare in terms of provision of nutrition sanitation, and building a resilient healthcare infrastructure, the spending on health care must be increased to a considerable proportion of GDP. Public health workers urge the centre to increase budgetary allocation over 5 per cent of GDP to have better infrastructure, training services, and resources,
Under investment in government health care makes patients seek services from corporate healthcare which priorities profit over care.
As there is a huge problem of acute shortage and inequitable distribution of skilled health workers, members from medical fraternity suggest that district and private hospitals be converted to teaching ones to expand the doctor base and encourage those from the region to stay on and serve the local people.
Training of doctors, para-medics forms a very crucial step of the entire process.
Attracting Health Care Workers to Rural Areas
There is a need to attract more healthcare workers to public health, especially to rural areas. Most of the doctors remain hesitant to working in non-urban centres due to reasons like lack of medical infrastructure, safety, and sanitation issues. Despite various attempts by governments to ensure that doctors serve in rural areas, there has been little success in this regards.
There is view that favours mandatory rural service for doctors. Tamil Nadu and Odisha have had some form of required rural service for medical students; some other states are working in the same direction.
A Supreme Court directive in this regard in May 2019 asked state governments to compulsorily implement the condition of serving in rural areas on those medical students who seek admission to post-graduate and specialised medical courses. It will thus be mandatory for doctors to serve in public hospitals in rural India for two years after getting degrees in advanced medical science. The Supreme Court conveyed a strong message while issuing this directive: “The government spends a huge sum of money on each medical student. The condition is not illegal or arbitrary and is meant to ensure that specialist healthcare is extended to rural areas.”
Failing to adhere to the condition will result in imposition of a penalty of ` 20 lakh.
The other view is that in place adopting coercive measures, the focus should be on improving working conditions in rural areas and incentivising doctors with monetary benefits.
The success of Ayushman Bharat also depends on the health related infrastructure at primary health centres in rural areas. As such, it is highly imperative for the state governments to revamp the rural health facilities and improve the service conditions of doctors and medical staff generally.
box
NSS Study on Health Workers
A study conducted by the National Sample Survey (NSS) states that India has 20.6 health workers per 20,000 people—less than WHO’s minimum threshold of 22.8 though the numbers have increased from 2012 when it was 79 per 10,000 people.
The distribution of health workers is uneven between rural and urban areas, according to the study released in May 2019. Rural areas have only 36 per cent of health workers though they have some 71 per cent of the population of the country. The highest concentration of health workers is in Delhi, followed by Kerala, Punjab, and Haryana.
What is alarming is that about 25 per cent of working health professionals do not have the required qualifications as laid down by professional councils.
The study emphasizes head for policy focus on enhancing quality of health workers and professionally qualified people in the health sector workforce.
box closed
A good diagnostic system is a very important tool to ascertain the real cause behind a seasonal illness like the one that strikes Muzaffarpur every year. Trained staff is required to recognise and manage illness, but because staff keeps changing, it becomes imperative to have standard operating procedures (SOP) and a preventive strategy to act before an outbreak.
Other important remedies are to increase the number of functional PHCs and sub-health centres, enhancing the cadres of accredited social health activist (ASHA) workers, strict supervision of nutrition programmes, and addressing the problem arising due to mal-distribution of doctors and medical colleges.
To achieve universal health coverage in the country, a paradigm shift is on the anvil. It needs to include some important aspects in particular, as discussed below.
(1) The shift from simply ‘medical coverage’ to achieving holistic health from provision of essential to quality health care has been emphasised. Thus, the sub-centres (SCs) are being transformed into HWCs, with various services to be provided at these centres. In states, this kind of thrust has resulted in some unique models of healthcare initiatives such as the Electronic Urban Health Centre model in Andhra Pradesh the provides specialist care at the urban health centre level with emphasis on patients’ satisfaction; and boat clinics in Assam that caters to residents living in remote islands of the state.
(2) The focus has been renewed on systems beyond medicine on hygiene sanitation—through Swachh Bharat Abhiyan, Open defecation-free India; provision of clean fuels, such as through Ujjwala Yojana; housing—Pradhan Mantri Awas Yojana. These initiatives influence the health of the poor and underserved.
(3) There is a sustained focus on improving female health by campaigning against female foeticide, education of the girl child (through ‘Beti Bachao Beti Padhao), promoting menstrual hygiene, construction of toilets in schools, prevention and control of anaemia through distribution of weekly iron-folic acid tablets in schools, etc. There is also a focus on protecting maternal health. The Maternal Death Surveillance Response Programme that aims to improve quality of maternal-death reporting with appropriate capacity building. The LAQSHYA programme is for improving labour room quality standards.
(4) Various ICT applications in health care are being explored, including telemedicine, vaccine and drug inventory control and storage, providing health related information through apps and messaging services like Swachh Bharat app, Diabetes:M text messaging service, KILKARI recorded voice calls; and drug adherence in TB.
(5) Promotion of generic medicines and cheaper implants would lower out-of-pocket costs and aid in medication adherence in patients (priortisation towards bringing down routine treatment costs.)
(6) Public-Private Partnership (PPP) can significantly improve health service delivery and expand coverage, especially in critical national health programmes such as for TB treatment where it can play an important role in drug adherence and cure rates. But certain steps are necessary to establish successful PPP.
(1) There should be an institutional structure to foster, monitor and oversee PPPs.
(2) Representatives from public-private and not for profit sector, for equitable representation of partners in the institutional framework are needed.
(3) There should be provision of allocation and risk sharing for entry and interest of the private player.
(4) It is important to regulate user fees under PPPs.
(7) Role of public health professionals in realising the objectives of UHC is significant in relation to activities involving screening for non-communicable diseases, behavioural change communication, providing curative services and providing epidemiological expertise disease outbreak investigations.
To enhance UHC in India, the budgetary outlay has to be increased, application of ICT emphasised for bridging the gap in health care for those remotely placed, and promotion of efficient allocation and use of available resources.
Health sector is often caught in the politics between the centre and the states resulting in crises. Where budgetary allocation is concerned, for instance, public health workers want the centre to increase it to over 5 per cent of GDP so that meaningful investment can be made in infrastructure, services, training, and resources. The government has expressed its willingness to increase it to 2.5 per cent by 2025 but then it wants states to increase their health expenditure as well—to 8 per cent of the total state spending by 2020. And the states have no clue as to where the additional funds will come from.
Use of Digital Technology for Universal Health Coverage
The use of information and communication technology (ICT), or digital health care is quite significant for bridging the gap for those lacking access to quality health care and reaching the unreached. Various ICT-based applications such as telemedicine, vaccine and drug inventory control and storage (Electronic Vaccine Intelligence Network), training of health workers, blockchain technology, etc., are being explored in India.
Government Programmes
- Telemedicine is a fast-emerging trend that major Indian hospitals are taking up. Such services in India are valued at about $7.5 million at present (mid-2019) and it is expected to grow at 20 per cent.
- Blockchain Technology utilises inter-operability in health care providing organisations and sets up decentralised record systems with multiple locations. The information can be conveniently shared with stakeholders in the healthcare sector. Data on medicial history of patients, immunisation record, procedure and services availed by them, etc. can be captured through this technology. The information, recorded and encrypted, comes as one single record thus reducing duplication of data and ensuring its security. Overhead costs are brought down as there are no administrators or other third party intervention. Use of blockchain technologies in pharmaceutical supply chains helps in tracing a medicine throughout the entire supply chain, eliminating counterfeit medicines, and so on.
- Start-ups in the healthcare sector are seen as capable of revolutionising health care in villages and small towns by providing affordable and easily accessible healthcare solutions through innovation and technology use. Start-ups are already much involved in health monitoring and fitness, delivery of medicines, and home healthcare services. Their speciality includes providing personalised service to consumers and promoting quality-driven care. And attempt is to connect consumers, physicians, and hospitals with diagnostic labs and link data communication and payments.
These technologies have the potential to transform healthcare in India. Technology has already revolutionised the delivery of healthcare models by increasing the quality of delivery, reducing the cost as well turnaround time of work flow. For instance, telemedicine is an effective way to deal with the problem of less accessibility of doctors in semi-urban and rural areas as it can provide the people of such areas access to a wide range of crucial medical services.
Enforcing Health care as a Basic Right: Concerns and Challenges
For ensuring universal health care coverage, it is of prime importance that health care is made a basic right and the issue related to loss of faith between doctors and patients is addressed. The shortage of doctors and para-medical staff in hospitals is compunded by negligence of doctors and the fact that medical staff is often under-trained. This scenario is very problematic as it defeats the very purpose for which medical profession as a whole stands—timely and appropriate patient care for saving lives.
Online doctor training has been suggested in this regard. Encouraging them to work in rural areas can be done by giving them monetary benefits and improving work conditions there. Importantly, lack of sufficient health-related infrastructure at PHCs will always hamper the government programmes.
After the tragic incident of the death of 150 young children in Bihar, the Supreme Court upheld health care as a basic right. In another judgement, the Supreme Court held that the failure of a government hospital to provide timely medical treatement is a violation of the patient’s right to life.
The judgement is a welcome move. delayed medical care puts the life of a patient in danger, and the hospital and staff responsible should be held accountable for this lapse. In the same way, medical personnel should be safeguarded from the wrath of aggrieved patients and their families, the patients too should have right to recourse in case of wrongful conduct by medical staff.
Tackling Corruption
Another important concern is regarding the prevalence of corruption in healthcare sector which reflects in low-quality healthcare facilities, lack of access to medicines or provision of sub-standard medicines, shortage of other basic healthcare facilities for poor, huge medical bills, etc. The eroding faith on medical personnel is an outcome of these cumulative factors. The National Health Authority (NHA) has warned of claims made for hysterectomies in at least 6 states, in a study commissioned by it. This was reported in July 2019. It called for tighter scrutiny of such claims as these have traditionally been a source of misuse by the private sector.
Corruption in healthcare sector is a very serious issue as it is a sort of crime against humanity. So, there should be no room for complacency as far as malpractices in medical care are concerned. There have been reports of widespread misuse of the scheme by unscrupulous private hospitals through submission of fake medical bills. Within a few months, some 697 fake cases were registered in Uttarakhand alone. A fine of ` 1 crore has been imposed on hospitals for fraud. Though the scheme involves info- tech infrastructure overseeing transactions that can help locate suspicious activities, the risk of unscrupulous private players profiteering is real.
There should be a zero tolerance policy towards fraud and corruption in healthcare sector.
In its attempt to deal with fraud and corruption in the healthcare sector, the government has decided to ‘name and scheme’ hospitals involved in malpractices. According to a report in September 2019, some 1200 cases of fraud were confirmed and more than 376 cases are under NHA investigation. NHA has also de-empanelled 97 hospitals. Over the last year (2019–20), while action has been taken against 338 hospitals over the months, the measures include issuance of warning and show-cause notice. Names of hospitals engaged in corrupt practices are to be made public (put up on the website).
Criticism and Concerns
With the schemes like Ayushman Bharat in place, Universal Health Coverage has just started to emerge in India. There is long road ahead for achieving the goal in a true sense. The vital aspects for realising UHC range from promoting budgetary outlay, creating new public health resources, the application of ICT, addressing issues of corruption and malpractices in the health sector.
Apart from emphasising on financial and managerial aspects of public health, development paradigm of health services must also be taken into account.
NITI Aayog Report for India’s Future Health Policy
NITI Aayog on November 18, 2018 released the report on ‘Health Systems for a New India: Building Blocks-Potential Pathway to Reforms’.
The report puts the health at the centre of the policy making and showed the path towards overall transformation of India’s health system so as to achieve policy objectives.
The report focuses on five areas of a future health system: (i) to deliver on unfinished public health agenda, (ii) change health financing away from out of pocket expenditure into large insurers, (iii) integrate service delivery vertically and horizontally, (iv) empower citizens to become better buyers of health, and (v) harness the power of digital health.
The report criticises multiplicity of health schemes citing the reason that such multiplicity is detrimental to standardisation of purchasing procedures and it also leads to a high level of compliance burden on the providers.
The report recommends that the financing structure of the health system should undergo a change so that there is considerable reduction in out-of-pocket expenditure and spending is channelised towards larger risk-pools with strong strategic purchasing capabilities. It cites the examples of Arogya Suraksha Trust of Karnataka and of Meghalaya as instances of best practices in this regard.