Prioritising healthcare counts, not grandstanding

Grind is the glory in healthcare policy-making. Glitz is not! But one sees flashy and sizzling pronouncements more often. The Covid-19 pandemic has been a wake-up call. Worse still, the position and pathway taken in health is not optimal because it is not critical to political equilibrium. Inevitably, we find policies and actions where rubber does not meet the road and health outcomes end up short. Now, it is beyond doubt that unless there is a political will to reform, no palpable change will be possible. The interregnum is more dangerous where a market without competitive equilibrium will operate even though 80% of society does not get attended to, lacks affordability or faces hardships to access the healthcare offered by the market (Niti Aayog statistics). Resultantly, the government misses out the opportunity on right investment.

Bangladesh invested in healthcare. They pressed the right button, remained substantially undistracted by the glitzy best practices and the improvement in social indicators is there to see. Better social indicators, among others, contributed to better economic outcome. But how do we actualise and trigger the need for change and reform. The reforms required are quite well-known. They are letting go, letting be and doing right. The present resolute leadership gives a lot of hope. But can they do it right? The real leadership hinges on doing the right thing. Once that is done, the right way of doing it will fall in place.

Let’s start in reverse. Having an insurance scheme for secondary and tertiary care at the cost of primary healthcare is not the best way of going forward. It could be a good support scheme for the corporate hospitals, but does not meet the healthcare needs. On the one hand, we see a willful deprioritisation of support to primary healthcare and other public hospitals. We also see an insidious collaboration with private hospitals by leaving the space open to them, even though it is beyond the majority’s affordability, and thereby access. They also conveniently sidestep their systemic challenges in consolidating the existing government hospitals and continue to under-invest in money and manpower. There is a shortage of 20% doctors in PHCs and 33% specialists in CHCs. Even if the budget is enhanced significantly, it may be wasted on unwise new-fangled ideas.

Letting be requires putting your attention where the nous of the matter lies. When 80% of the people go to rural medical practitioners (RMPs), the political economy doesn’t allow the BSc nursing graduates to become a nursing practitioner who are more amenable to work in rural areas. Instead, the emphasis is on creating more doctors knowing full well that they would be reluctant to go to the villages to serve. Curiously, what we see in a country with 50 crore poor and another 50 crore non-poor who can easily slide below the poverty line is naïve to repose faith in private and corporate healthcare with an insurance scheme. The result can range between the sub-optimality to calamitous outcome. Nowhere was the inevitable mismatch clearly discernible as during Covid-19, when revenue gouging and reluctance of private players came to the fore. Underinvestment in primary healthcare and negligible investment in the government’s hospitals exacerbate deep problems in the health sector. Can the politico-bureaucratic structure be forced to correct its course?

Letting go is an important aspect of health management where science and judgement of the professional can prevail. The pandemic showed disconnect between policies and scientific judgement. An association of political actors should be at the board level of these health institutions, instead of direct intervention, which topples the apple cart. To be fair, politicians here are clueless and they must be guided by the enlightened policy actors. Instead, what we see is a widely believed crony plan to corporatise them with private capital. If it is true, it is driven by pure greed of the real estate of public health institutions. The ecosystem of public hospitals can change without giving them on a platter to the private sector which does not hold solutions to the health problem of most Indians.

For the right policies to be enforced and right emphasis in terms of priority and budget to be given to the sector, political will is a must. But in most countries, until the time the political establishment is threatened, health does not get the priority and importance it deserves. Be they the National Health Service (NHS) of the UK or elsewhere, until the time the ruling elite is pushed to the corner, it has not happened.

Politicians and political parties are vote maximisers and they artfully bundle issues to their benefit. Though there is a tendency to move towards the median need even in an electoral promise, it is surprising that something on which 80% of the voters depend has not been flagged as the real issue. In the process, the political establishment can change the distribution of benefits. It can support the corporate hospital while starving off the public health institutions. It can go for an insurance scheme where private sector institutions get their custom and consequently, public institutions, particularly primary healthcare, suffer. Emphasis can continue to be on increasing the number of institutions without consolidating the existing ones despite a shortfall in trained manpower, giving full play to smoke and mirrors.

How do people become demanders of affordable and accessible healthcare? Community-based organisations, NGOs and the panchayat system should create a demand among the people. Once it is created and figures in the election as an issue, politicians are bound to respond to this new development. Only then will priority funding, proper sequencing and recognition of issues involved take place. There will be recognition that there is no escape from direct production and allocation at the primary level and certain secondary and tertiary hospitals.

But here, grind is the glory. To force the government to recognise the inescapability of the critical issues and the responsibility involved, the people and the NGOs will have to package it as an electoral issue. This will compel the political actors to respond to it as an electoral trade-off. Politicians cannot escape the onus by organising glitzy schemes with questionable outcomes. Both sides will have to put their act together and it is not without grind. Next time a pandemic happens, the country will not hopefully grapple with half truths and ‘ad hocism’ then.

Satya Mohanty, Former Secretary, Govt of India. The Tribune India