Even as the word reservation in India has become much debatable in today’s context of different ideologies define it in their respective interests, the fact remains that it has helped bring some sort of social equity in the fields of education, employment and administration over the years. However, the globally much-touted health equity seems a goal unachievable in India in the near future as the country lags several steps behind the path. However, here is a thought that might sound like a reservation but could help achieve the unachievable.
India’s healthcare services industry has recently suggested incentivising people for their health-seeking behaviour. Although the industry has its interest in the proposal, it makes sense in a country like India, where the disease burden is high, but healthcare access is dismally low; medical talent is high, but facilitation is poor; the public sector owns the largest healthcare infrastructure, but the private sector provides the lion share of services; and the insurance system is robust, but out-of- pocket-expenditure is far too high.
Considering this peculiar nature of the healthcare scenario in the country, it is obvious that access to the best healthcare is largely limited to the class that can afford it in private care settings and the rest are some or other way deprived of it.
How to incentivise?
Incentivising people for seeking healthcare was one of the recommendations submitted by the healthcare services industry as part of its representation to the Ministry of Finance for its consideration while drafting the upcoming Annual Budget for the financial year 2023-2024.
The recommendations include the introduction of mandatory health insurance to ensure true Universal Healthcare access; enhancement of Health Insurance Premium Exemption; increase in tax exemption on Preventive Health Check-ups; and expansion of the Pradhan Mantri National Dialysis Program to all the districts.
But, these financial measures alone won't serve the purpose. You need better clarity in the existing programmes like Ayushman Bharat (AB) and an overhaul in the existing healthcare distribution system across the country.
This is the first time 'incentivising the health-seeker' proposal is being strongly pushed forward by the industry. Though it sounds unviable in the typical Indian mindset, it could prove a milestone move in the journey towards health equity, just like the various reservation policies that pushed social equality in the country. Such an incentive could also find solutions to many practical issues that India is currently facing in its healthcare access programmes. However, the modality needs to be decided with better clarity, and identifying the genuine beneficiaries, going by their health-seeking behaviour, would be key.
Ailing Healthcare
The first and most critical issue India faces in its healthcare services arena is the grossly unequal distribution. Even though the government has the largest healthcare network, ranging from premier institutions like the Indian Institutes of Medical Sciences to State level medical colleges to civic hospitals and primary health centres. The country’s actual healthcare needs and the disease burden are much larger than the total capacity of all these settings put together. More critically, the capacity, skill sets and competency of all these settings are widely varied. It varies from setting to setting and from location to location, and there exists a wide urban-rural divide as well that is much beyond those disparities that remain in the same geographies.
All these together lead to a huge demand-supply gap, despite the public large public health network. Therefore, a large section of the population across States, social status and income levels cannot utilise the service at the government centres. This has triggered the growth of the private healthcare system, which currently caters to almost 80 percent of India’s healthcare need, though private hospitals charge much higher than the government settings for the same ailment, even if it doesn't assure better treatment outcomes.
Still, access to these facilities is limited to a fraction of the population, mainly due to affordability and logistics issues. A significantly large portion of India’s private healthcare settings is located in metros and tier-1 and tier-2 cities.
Out-of-Pocket-Expenditure
Out-of-pocket expenditure is the major impediment that leaves a very large portion of people across cities, semi-urban and rural populations deprived of modern medical care. According to the latest Economic Survey, India has one of the highest levels of out-of-pocket expenditure (OOPE) in healthcare, which leads people even to extreme poverty. The Survey shows that the current level of OOPE in India is at 65 percent of the country's total health expenditure.
While the concept of free treatment, mainly anticipated out-of-state spending, is being largely affected by unequal distribution and other infrastructural issues, private healthcare is inaccessible to a vast majority. Contradictory to the presence of several public and private insurance schemes that provides medical cover to patients, out-of-pocket spending is still the overarching problem in Indian healthcare. Very low penetration of health insurance cover has been a key lacuna here.
Since the government can no longer be the provider of the entire spectrum of healthcare, it is always advisable to have a combination of public and private participation in healthcare services. But, access to healthcare will remain an issue unless affordability is ensured. Minimising the out-of-pocket expenditure is the only solution, and the government can be the best enabler for the same.
Awareness and Facilitation
Awareness of people about healthcare options, including where to go and what to do to access the right treatment, is the second leg that can enable better care for patients and thereby lessen the disease burden. Similarly, increased awareness about the preventive health and wellness options that can keep the country healthy. For instance, along with health and wellness behaviour, people should be equally aware of predictive and preventive health screening to ensure even rare and genetic causes could affect their health in future.
Awareness without facilities won’t make any impact. Better utilisation of the already built public health infrastructure and a guided approach to creating new capacities could help build an equitable healthcare distribution system. India, as a country of medical as well as clinical talent and a young resource base, actually does not have any real issues manning the facilities. India is also the hub of cheap and quality generic medicines. So equipping these facilities with better human resources, medicine, and other infrastructure is not an impossible task for India. While the nationwide public healthcare network can be better utilised for primary care, a combination of public and private infrastructure can be utilised for secondary and tertiary care.
Both these measures will have a positive impact on the economy as well as government spending on healthcare in the long run. However, the issue there is the Centre-States divide in the healthcare administration. Health has been traditionally a state subject in India, while most national-level policies drafted and formulated by the Centre are often faced with either conflicts or non-cooperation. This needs to be eliminated as part of tweaking the healthcare distribution system.
Aches in AB
Although a well-intended move by the Centre, Ayushman Bharat (AB) is still not out of its infancy in terms of clarity and modalities, even after five years of its launch. The initiative has two important components — the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which provides health insurance cover of Rs 5 lakhs per year to over 10 crore poor and vulnerable families for seeking secondary and tertiary care; and secondly, a programme to deliver a comprehensive health service ranging from preventive, promotive, curative, rehabilitative and palliative care. While the insurance cover under the programme can potentially enlist all secondary and tertiary care hospitals (both public and private), comprehensive care (mainly primary care) is being provided free of cost at the newly proposed 1.5 lahk Health and Wellness Centres in the public sector across the country.
Even as the latest government data claims that the PM-JAY has issued close to 1.3 crore insurance cards and spent about Rs 50,000 crore as claims across the country as of now, the scheme is yet to pick up steam in the absence of clarity in the modalities, lack of people awareness and also with resistance from many state governments in the name of overlaps with the respective state insurance programmes. In addition, many standard hospitals in the private sector haven’t opted for enlistment, citing that the rates permitted in the scheme for most surgeries and clinical procedures are not at par with the standard prices and, therefore, not feasible. The hospitals also allege that many modern and sophisticated medical protocols are not included in the cover.
Since the country has already initiated a model for universal healthcare with Ayushman Bharat, bringing more clarity into it along with a little tweak in the current healthcare distribution can easily take us close to the goal of health equity.
—The author, C H Unnikrishnan, is Consulting Editor at CNBC TV-18.com. The views expressed are personal
First Published: Dec 30, 2022 11:19 AM IST
