Healthcare just like security or defence is one of the primary duties as well as the responsibility of the state as it should be. However over the years that responsibility has sought to be accomplished through partnerships with the private sector with investments going lesser and substituted for other imperatives like the defence. India is no exception in that thinking and budgets have consistently lowered investments both in the Infrastructure as well as the service part of healthcare. It is presently 3.6% of the GDP which is woefully inadequate for a country having the size and population of India. The state over the years has retreated in the sector while encouraging the private sector to invest through providing in many cases prime parcels of land for the infrastructure. Whatever may have been the rationale, the current COVID 19 pandemic has clearly enunciated the woeful state of the healthcare sector and reinforced the point that both people, as well as infrastructure in healthcare, is a key deterrent capability against pandemics such as the one we are witnessing. It requires investment in infrastructure, human expertise, innovation all at a cost which is sustainable for a country like India. It needs to be a developmental objective and the State needs to claim a significant investment as well as organisational role. How is it going to happen and where do we start??
Health is wealth is an old adage and as true today as it was in times gone and probably will be true forever. As this pandemic subsides, each of the Governments specially for countries like India would like to start thinking about this adage and how they can ensure a healthy population for the future. In my mind, there are four areas one needs to study and come up with options for a new policy as well as investment, these being-
the key healthcare needs and the infrastructure relevant for those needs
Availability of skilled human resource at every level
Financing and money for the expansion: and
Regulatory oversight of the institutions and the medical profession
The healthcare needs are different at various stages of health issues and therefore the need for infrastructure is also different. The bottom of the pyramid needs is what we call as Primary healthcare. These needs are satisfied by doctor clinics, diagnostic chains, diagnostic centres which are and should be across the length and breadth of India like a neighbourhood medical facility as well as your first port of call. This is your primary connect with the patient, your key diagnostic action point and in times of pandemics your primary distribution for vaccines as well as medicines. They also double up as education centres and key prevention centres.It is the most important link in the chain and the analogy you can draw is with a beat cop who is your eyes and ears to the street. A lot of the infrastructure already exists but some may have to be built. The Delhi mohalla clinics are a similar and a good initiative but they need to be more broad-based. The key is to provide a policy guideline to monitor this layer and define a protocol. The local doctor and private practitioner need to be part of this chain. The bulk of state attention needs to be given to this layer and the use of digital needs to increase manifold as we have seen it is possible.
The next layer is the Secondary care which is capable of a few specialist procedures and hospitalisation. A key capability for advanced diagnostics and to be a holding place for people requiring specialist procedures or procedures requiring greater care as well as specialist interventions. These could be typically 50 to 200 bedded facilities having operating capabilities and critical care facilities. The requirement could be one for many villages or more than one for towns and districts. The investment value here is higher and State needs to play a key role as investor and operator.
The next layer is the Tertiary care. These are typically large hospitals with world-class critical care as well as specialist care verticals. This would be typically AIIMS kind of institution which is Government-owned or Medanta or Max which are privately owned. The present has not seen much investment from the State in such facilities and that needs to be a key area to be looked at. We need many more AIIMS type of facilities. More than the investment it’s the management of these institutes which is likely to be a key challenge for the state.
Human Resource and Skills
India has provided more healthcare professionals to the world than any other country, whether it’s the Doctors, paramedics, nurses, skilled machine technologists and continues to do so. Unfortunately, we need more such human resource for the country rather than have them go for better prospects outside. We have trained them and we need to keep them. Medical education is heavily subsidised in India and state, therefore, is losing a substantial amount on every Doctor that we give to the world. One way is to pay them more as skills are costly and in high demand. The other way is to depoliticise the education where the seats are artificially frozen to get high capitation fees. We need more doctors, more nurses, more technicians and need to invest in those educational facilities and take away the unfair practices. The Regulator of the medical profession is a key arbiter for the development of the medical profession where the action has not been satisfactory. We need to change that. The numbers and quality of the human resource need to improve to make a difference.
There is a lot more to discuss but the key issue is infrastructure, human resources and of course governance. If one has these then the financing and investments can be found. Healthcare should rank right after food, security and housing and I’m sure if the state can subsidise some of the other must-haves it will find a way for this too. Affordability of health care ranks very high on the population mindset and that’s why State must take a greater role than the Private sector whose primary motive is profit and not to forget the furthering of medical insurance sector which is key to affordability. Having a large population is a benefit only if it is healthy and working. This message along with the COVID disruption should embolden the State to act. Hopefully in our lifetime! – Business World