Dr Harsh Vardhan, a physician by training, coming on a bicycle for his first day to work at Nirman Bhavan, the headquarters of the Union health ministry, on June 3 may have impressed legions of supporters in the capital’s Chandni Chowk constituency he represents in the Lok Sabha.
But those who have known him better, including health-sector policymakers and professionals who have observed him during his earlier stint in the ministry are clear his medical education background helps appreciate issues better and not necessarily infuse changes faster.
The country’s health system is far from transforming into one that assures a reasonable level of access, affordability, quality and effectiveness. Both health care as well as health insurance weighed down by poor governance and poorer regulation, with 86 per cent of the rural population and 82 per cent of the urban population still not covered, are in dire need of rapid reforms.
But it is slow in coming.
What began as the National Rural Health Mission,(NRHM) initiated by the United Progressive Alliance (UPA) government in 2005, strengthened health infrastructure and boosted failing health indicators in rural areas.
Its impact led to the launch of the National Urban Health Mission (NUHM) in 2013 and now both are sub-missions of the National Health Mission (NHM). To complement NRHM, the UPA government then launched the Rashtriya Swasthya Beema Yojana (RSBY), in 2008, to reduce out of pocket expense at the time of hospitalisation.
This is the forerunner of Ayushman Bharat — and Pradhan Mantri Jan Arogya Yojana which falls under its ambit — launched by the National Democratic Alliance (NDA) as ‘ Modicare’, which can possibly accelerate the process and reform both in health care and health insurance.
Health activists have sought a policy on this line for long. What is critical for this is the flow of funds. India currently spends 1.2-1.3 per cent of its GDP on health care. Public expenditure on health is rising but is very low compared to the increasing population.
“Ayushman Bharat needs to be redesigned for greater emphasis on primary health care and to seamlessly integrate it with advanced levels of care while reducing the need for costly secondary and tertiary care. Alongside, public health-care infrastructure needs to be strengthened,” says Dr K Srinath Reddy, president, Public Health Foundation of India.
The absence of a holistic view on the national health policy has also crippled implementation of health programmes that suffer for the want of a priority mix. The potential prescription of priorities and strategies to achieve it, recommended by domain experts, are:
Increase public financing
A programme of Universal Health Coverage (UHC) needs a higher level of public financing to succeed. The current state spend is among the lowest in the world. The out of pocket expenditure is 63 per cent, which is among the highest in the world.
A higher level of public financing is needed to improve infrastructure, expand the health workforce, provide access to drugs and diagnostics and fund different levels of care.
Strengthen primary health care
Primary health care is the foundational basis of a well-functioning health system and acts as an efficient gatekeeper for referral to advanced care. By improving prevention, early detection and effective care at the primary level, the need for hospitalised care is greatly reduced. How to do this?
Scale up capacity for delivering comprehensive primary health care. A study by the Indian Institute of Public Health, Gurugram reveals that although the overall size of the health worker population in India is smaller than that of many development countries, these numbers, at 20.8, are close to the World Health Organization’s (WHO) threshold of 22.8 doctors and nurses for every 10,000 persons.
But their distribution is skewed. “Most doctors and nurses are in the big cities leaving a wide gap in rural areas and in poor states,” says the IIPH research team leader Dr Anup Karan. Only 34 per cent of doctors and 33 per cent of nurses are in rural areas. And four of every five doctors and seven of ten paramedics work in the private sector.
Ensure free/cheap drugs/services
Expenditure on medicines is a major contributor to high out-of-pocket expenditure. Of the 55 million people who became poor because of high health-care expenditure in 2014, 38 million attributed it to cost of medicines.
Providing essential medicines and diagnostics at public facilities will have an early and substantial impact on reducing out-of-pocket expenditure.
Expand the health workforce
Primary as well as advanced care cannot be delivered if there is a paucity of care providers. The health workforce will also provide an opportunity for skilled employment to many young persons.
To achieve this: Augment district hospitals and link them to existing and new medical and nursing colleges; make the upgraded district hospitals training centres for undergraduate and postgraduate training; establish 10 institutions of allied health professional training, to train a large number of youth; allocate central funding to support the creation of public health cadres.
“Pursue the unfinished agenda on child health by increasing immunisation coverage, effectively use revenue-neutral taxes on sugar-sweetened beverages, tobacco, alcohol and pollution and unclean fuels, include subsidies on fruits, vegetables and dairy as part of food subsidy programmes while lowering direct and indirect subsidies on sugar,” suggests Ramananan Laxminarayan, director, Center for Disease Dynamics, Economics and Policy, Washington.
Health Minister Harsh Vardhan is also aiming at time-bound completion of 21 All India Institutes of Medical Sciences to expand and improve the quality of medical education. For this he has to focus on the promised disbanding of the Medical Council of India and setting up of the National Medical Commission to administer a much needed remedial measure.
Like any politician, well versed in passing the buck, he has offered all Indians some free medical advice on his first day in office. “Everyone has to ensure that they undertake some form of physical activity each day and followed a disciplined lifestyle which is supplemented by the intake of balanced food,” declared Dr Harsh Vardhan.
Maybe that will work, to some extent, if his ministry keeps the promise of building 150,000 health and wellness centres across the country.- India Today