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Why the Indian railways should provide healthcare, not purchase it

Sample the following headlines – they and many others like them have often hit the headlines in the months since India’s COVID-19 outbreak formally began in early March.

* ‘Railway coaches as COVID care centres’

* Railway to deploy 2,500 doctors and 35,000 paramedical staff to tackle COVID crisis

* Indian railways develops RAIL-BOT robot to assist hospital staff in COVID-19 patient care

The Indian railways’ participation in the country’s pandemic response is neither new nor surprising. India’s first successful cardiac bypass surgery was carried out by the Indian Railway Health Service (IRHS) in 1975 and a corrective transposition of the great arteries in 1979. The world’s first hospital on a train, the ‘Lifeline Express’, was rolled out in July 1991 to provide free healthcare services in remote parts of the country.

The railways are also installing telemedicine and health management information systems. In 2018, beneficiaries of the railway health service were provided ‘smart cards’, and the railways tied up with Microsoft to connect them to doctors via chat.

Besides, the IRHS provides complete promotive, preventive, curative, and rehabilitative care at primary, secondary and tertiary level to all its employees. Jobs of the IRHS include conducting pre-employment and periodic medical examinations and attending to railway casualties, accidents, and sick passengers. Apart from this direct medical care, the IRHS also looks into indirect medical care by regular inspections of the water and food supply at the railway stations, with collection and testing of the food samples.

The railways undertook these tasks because its employees and passengers suffered a large number of serious injuries due to railway-related accidents. Second, the railways had expanded its lines to remote areas, many of which didn’t have adequate medical facilities. In the nascent phase, the railways’ health system wasn’t uniform. Every railway station had its own arrangements that differed in quality and scope. In April 1954, E. Somasekhar, the then chief medical officer of the Southern Railways, introduced a comprehensive plan for the organised expansion of medical services for the railways. Since then, the railway health service has been continuously expanding and improving.

Core competency, neoliberalisation and hospitals

An expert committee chaired by Rakesh Mohan in 2001 called the IRHS an “idling asset”. It discussed the financial crisis in the railways and recommended that the organisation be restructured. The Bibek Debroy committee also suggested in 2015 that the railways should focus on its core sector, as it was facing stiff competition from low-cost airlines for passenger and goods transportation.

The management experts C.K. Prahalad and Gary Hamel, writing in the Harvard Business Review in 1990, noted that organisations should reorient their strategies to form competencies that their competitors would be hard-pressed to imitate. So the Mohan and Debroy committees suggested that the railways stop focusing on non-core activities and instead augment its core services – of passenger traffic and good transport. In the same vein, the committees also recommended switching from a healthcare-providing to a healthcare-purchasing model, by adopting a health insurance system akin to the Central Government Health Scheme.

As such, we infer that the committees strongly argued for neoliberal economic policies in the Indian railways. However, healthcare ought to be part of India’s social policies rather than neoliberal policies.

A case for health by the public sector

The productivity of any organisation depends on the health of its employees. The railways constitute a highly labour-intensive enterprise. The health of its employees and their families is important for the organisation to be in good health as well.

Several studies have elucidated the dismal fates of publicly-funded health insurance schemes in India. For example, according to a systematic review published in 2017, there is no clear evidence that publicly funded insurance plans reduced out-of-pocket expenses on healthcare or provided greater financial protection. In contrast, employees of the railways can avoid such expenses if the railway can protect and attend to the health of its beneficiaries, instead of buying healthcare products and services from private hospitals.

The private sector is ultimately a for-profit service known to often overcharge patients. So strict capping and regulations on prices are required. There are chances of over-diagnosis and over-treatment. Managing employees’ insurance would add to the administrative costs.  Services like inspection of food and water at the station might get excluded. In addition, private sector hospitals are not available at all places in the country; they are disproportionately concentrated in the urban areas. So a large portion of beneficiaries may be denied access to essential health services.

Instead, the railways is in a good position to provide equitable, comprehensive, affordable and good-quality primary, secondary, tertiary and rehabilitative healthcare for all – thus helping India move closer to the ideal of universal health coverage as well.

A little less than perfect

This said, in spite of being several tens of years old, there are still some drawbacks in the IRHS. Human resources are in short supply, the recruitment process is quite lengthy, there aren’t enough specialists and job security is low. As a result, there are few incentives to improve performance, a skewed doctor to patient ratio, and a general paucity of trained hospital administrators, even relative to other public hospitals in the country.

Above all, the percolation and adoption of technology is slower in railway hospitals compared to private hospitals. The red-tapism in the public sector often delays decision-making, which can affect the quality of care. Being part of a large transport organisation, the nuances of hospital management are often ignored. There is a lag in implemented best practices in railway hospitals. All of this is exacerbated by the growing number of referrals to private hospitals from railway units.

But as things stand, all these drawbacks can be remedied. The IRHS is planning to accredit its hospitals to help them regain the trust of their beneficiaries, over private hospitals. Larger hospitals can be converted into medical colleges as solutions to improve the doctor-patient ratio. Mid-career doctors and nurses can be trained in hospital administration to improve the quality of governance at the railways’ facilities.

Railway hospitals have access to India’s rural interiors, and this access can be utilised to improve rural healthcare. As the bed occupancy ratio of the railway hospitals is a little lower compared to that in other public hospitals, hospitals can be utilised under the Ayushman Bharat scheme to cater to the needs of the general population.

In the final analysis, it’s clear that the railways has a strong infrastructure and many opportunities to provide healthcare to its employees, with a comprehensive package and advanced technologies. Buying health services from the private hospitals through public insurance has not worked well for the country, so enhancing the IRHS’s capacity and resources, and professionalising it further, can provide a credible alternative.

Praveen Bhide was formerly with the IRHS and is former senior professor, Academy of Indian Railways. Feroz Ikbal is an assistant professor and Apurva Jain is an MPH candidate, both at the Tata Institute of Social Sciences, Mumbai. – The Wire

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