Should the focus be on improving public health systems or should we instead strengthen and support the development of the private health systems?
Two contrasting media images haunt me as this year comes to an end. First, of the health minister of Uttar Pradesh explaining away mounting children deaths at a government-run Gorakhpur hospital as a normal annual phenomenon. Second, a private hospital near Delhi terming the nearly Rs 16 lakh in charges for two weeks of care of a child suffering from dengue as not being unusually high. Do we have to choose between private exploitation and public sector callousness? Or is there a way out?
As individuals living in any part of India, we remain vociferous critics of our public health systems for their inability to deliver, especially on quality. Our criticism is justified inasmuch as we desire that our own public systems should do better. At the same time, we are forced to access healthcare in the private system, not because we find them to be inherently better or desirable, but because we don’t have a choice.
In the year gone by, the state of healthcare provision in the country has been debated upon fiercely in the context of various issues, which include newborn and children deaths, private sector regulation, the re-emergence of diphtheria, the lack of life saving medicines, privatisation of health services and Aadhaar. The confidence in the private sector too that it can deliver has been shaken. Concerns about blatant profiteering, ‘cut practice‘ and bad conduct of hospitals in the private sector has rocked the country and made us think about healthcare systems in place. This is not to say that there is any return in faith or trust in the public health systems.
Private vs public healthcare
In such a situation, should our focus be to remedy the imbalance and improve the public health systems to become the quality-assured, free and predominant healthcare provider? Or should we instead strengthen and support the development of private health systems?
This year, the National Health Policy (NHP) was released, which brought out the tensions of this polarised debate and yet had prescriptions for strengthening universal health coverage through a strengthened public health system where ‘strategic purchasing of secondary and tertiary services’ from the existing private systems has been proposed without mentioning the specifics of implementation. But the question that we need to ask is: do these initiatives in any way impact current situation of health and healthcare in the country?
Since a large number of people in our country are still under abject poverty with no financial reserves for sickness, we need the provision of free healthcare for them. And the quality of this care can only be assured if all people, especially the middle class, accesses it. Or else, any programme that provides care only to the poor runs the risk of becoming poor in quality. Even now, we know that in the states of Mizoram, Sikkim and Goa, the bulk of care – which includes primary care – is provided by the public system since the private one is not strong or overbearing. Can other states learn from these examples?
This year, we saw the sad spectacle that is our public hospital system, with the district hospitals in central India reporting an unacceptably high proportion of newborn and children deaths among those who sought secondary-level care, with proportions of dead to those admitted sometimes reaching 25%. These included large hospitals like in Gorakhpur, Ranchi, Jamshedpur, Nashik and Banswara. While much of this could be attributed to poor primary preventive care, these tragedies largely reflect the neglect of our institutions that provide curative care. These deaths were avoidable, but were also in a certain sense waiting to happen. These tragedies brought out the problems plaguing our public systems – financial corruption and incompetence. This situation cannot be remedied by more private care providers in these areas.
Re-emergence of diphtheria
This year, several states also reported the re-emergence of a deadly disease – diphtheria. Diphtheria is an uncommon illness these days and when such uncommon illnesses re-occur, their management becomes neglected as the health systems are not ready for it, and due to the non-availability of life saving drugs for rare diseases, as the market dynamics ensure their poor production, sale and distribution.
Due to this, not just diphtheria, but other conditions such as rabid animal bites, snake bites, scorpion stings, rheumatic heart disease have also been neglected. Orphan drugs like antidiphtheritic serum, crystalline penicillin for its treatment, anti rabies antiserum, anti-snake venom, benzathine penicillin are either not available or are frequently out of stock in the most marginalised areas. This highlights the need for production of and access to life saving drugs for neglected diseases, where the responsibility of the state is paramount.
Universal health coverage
The NHP suggests that universal health coverage (UHC) should be attempted through comprehensive primary healthcare, where we aim to provide care for the triple burden of communicable diseases such as tuberculosis, malaria and HIV, maternal and child health problems as well as the non-communicable diseases (NCD) such as hypertension, diabetes and heart diseases.
The policy recommends development of health and wellness centres serving the population in groups of 3,000-5,000, as well as supporting a cadre of mid-level care providers to man these centres supported by good use of information technology. And all this is supposed to be supported by referral hospitals such as community health centres and district hospitals. The NHP advocates an “assurance-based approach” which abandons the idea proposed in the draft policy of 2015 – that of a National Health Rights Act aimed at making health a right.
There is good evidence that mere hospital-based care for NCDs leads to only half of people continuing their treatment with the others dropping out. This can be remedied only through community-based programmes for these chronic illnesses. The private healthcare systems would be structurally incompetent to do this. Here it is disconcerting to see this NITI Aayog’s proposal for sub-contracting part of the district hospitals in tier two and three cities to private providers to provide care for selected NCDs on their own terms without any financial risk taking. This is clearly a regressive step for UHC. One is not sure whether the private sector would find this arrangement lucrative enough to consider this idea.
The biggest charge against the private healthcare systems is the humongous profiteering that it does at the cost of people’s pockets. And we know it very well, that private health systems don’t like to be regulated by anyone, even if they don’t show any self-regulation. The recent Karnataka private medical establishment regulations amendments debate were construed as a draconian measure by the protesting private providers, though the major objection was regarding price caps of medical procedures. We also saw a huge protest to the government’s capping of prices for cardiac stents and for knee implants, all of which was unjustified.
A valid objection course, that was voiced by some of the private providers against those supporting their regulation was their moralistic position of the public systems being their regulators despite being poorly-regulated themselves, and their posturing as predominant care providers to people at large. I think this objection regarding the moral position of a regulator is a strong reason in itself for the development of a strengthened public health system. How can a public health system regulate others without itself becoming an example of a provider of good healthcare?
Similar debate also emerged in the recent failures of the private providers in and around Delhi either providing care of unacceptable quality, or indulging in extreme profiteering or being patently inhuman. There is no getting away from the need to regulate the large private sector. And it can be only be done effectively only if we have a strong public health system.
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Another axis of debate, at least in the public system, that threatens access to social support programmes including healthcare has been making Aadhaar seeding and biometric verification mandatory for accessing its services. While this is being contested in the highest court of the country, insistence of this in the first place is a worrisome development and makes one question the seriousness of the intent of ensuring access to healthcare, especially in the public systems. At present, the mandatory linking to Aadhaar seems to be depriving people of social schemes in the garb of limiting corruption of a minuscule amount.
What is the amount of funding needed for universal health coverage? While WHO has recommended a minimum of 5% of GDP allocation to healthcare by the government, it has been argued that in light of our cheap drug prices and good manpower, we can arguably get UHC with even 3%. The NHP has recommended 2.5 % of GDP allocation for health, but only by 2025. Not only will that be too little too late, it will also prevent any serious allocation for strengthening public systems, which is a crying urgent need. Especially if the audacious declaration by the government that we will eliminate tuberculosis (prevalence of less than one in a million) by 2025 has to be taken seriously at all from a present rate of 220 per 100,000 people now and almost a million people not being started on correct anti-tubercular treatment after being diagnosed each year. The fact that budgets of the National Rural Health Mission have been sized down by 20% on grounds of fiscal discipline and poor absorption capacity does not enthuse anyone of the political commitment towards a welfare state.
Are we defending the undefendable when we make the case for the public health systems? It is not from past performance by the public systems that one gets strength to defend this. But from a moral stand, as well as from the fact there is no alternative situation to having strong public systems, do we claim that this is the only way. Will 2018 be the year we settle this question and implement the NHP in the right earnest?
Yogesh Jain is a public health physician at Jan Swasthya Sahyog, Chhattisgarh.