“Health has to become political”: Shamika Ravi

This World Health Day, HealthLEADSs Asia spoke to Prof. Shamika Ravi, Non Resident Senior Fellow at Brookings Institution and former member of the PM’s Economic Advisory Council under Narendra Modi, on India’s healthcare system, its opportunities and challenges.

On the occasion of 72nd World Health Day, as COVID-19 rejuvenates discussions on equitable healthcare, HealthLEADS spoke to Prof. Shamika Ravi. An economist with experience in public policy design, Prof. Ravi spoke on India’s efforts on improving its grassroots healthcare, including the country’s flagship Ayushman Bharat scheme. The country faces significant challenges in delivering affordable healthcare to its 1.4 billion population – the biggest of which, Prof. Ravi says, is “gender bias”.

The pandemic teacheth

“It has taken a pandemic to lay bare the reality,” says Prof. Ravi, on the inequities in healthcare that COVID-19 has brought to fore. “Many of us who have been studying (the) healthcare sector globally, we are well aware of that iniquity except now it is very immediate and the impacts are being felt globally.”

Among the lessons of this pandemic was the evolution of public health knowledge itself. “If you recall in the beginning, a lot of how the pandemic was going to go, it was very difficult for anyone to predict. As you know a lot of the predictions were also subsequently junked.”

Highlighting the importance of research in healthcare, she says that the pandemic serves as an opportunity which hasn’t been fully utilized yet. “Healthcare infrastructure is not just the service of healthcare in terms of hospital and human resources doctors nurses medication but also knowledge.” “We don’t talk much about it … I think we should seize the opportunity to highlight that shortage and the less we know the less we are likely to make precise policy interventions.”

India’s healthcare – Accessibility, Quality and Affordability

“When you start ranking it (India’s healthcare) based on international parameters then we stay limited to some indicators,” says Prof. Ravi, “it will be beds per million, hospitals per million (and) number of doctors and nurses per million”. 

India indeed does not fare well on these parameters. World Bank data indicates that India, in 2017, had a meagre 530 beds and 778 physicians per million population. China’s numbers, in comparison, were 4310 beds and 1980 physicians.

“But I think we really need to take the conversation below that level.” Critiquing on healthcare access, Prof. Ravi comments that 30 percent of India’s villages do not have any health infrastructure within five kilometers.

“But access has to do with more than physical availability.” Referring to a study conducted in 2019, she points out the ‘hindrances’ at the society level. “Inequities emerge even if people have physical access.”

On India’s quality of healthcare, Prof. Ravi opines that it is “something we have just started looking at.” Quality of care has to be measured through different indicators such as readmission rate and average length of stay. Prof. Ravi remarks, “We are yet to imbibe these basic indicators and quality measures in day-to-day decision making of not just public healthcare, but also governance and running the management of hospitals.”

Prof. Ravi believes that India is doing well in making its healthcare more affordable, and being a producer of generic drugs plays to the country’s advantage. While medicines remain the top component in health expenses, she acknowledges that, “Health care affordability goes beyond medicines,” and that, “health care costs are rising for urban areas much more than rural areas.” “These broad iniquities within the country,” she says, “will require for us to constantly keep working on the policy interventions.”

“You need people and that is our biggest constraint right now.”

Prof. Ravi asserts that all the media attention remains on only one of two components of Ayushman Bharat – the publicly financed health insurance scheme. “But Ayushman Bharat had a second component which had to do with the wellness centers,” adds the professor, “if you can take care of the early preventive and primary care then subsequent need for hospitalization and the burden therefore of hospitalization can be reduced.”

India’s primary healthcare centers, the country’s first line of defense, have seen a shortfall of doctors. Says Prof. Ravi, “You need enough well-trained nurses and healthcare practitioners to be able to man those wellness centers.” Government data from March 2018 indicated a shortage of over 3600 doctors across these centers, nearly 62 per cent of which was from Uttar Pradesh alone, while 22 states indicated a surplus. “Different states are reporting very different experiences, and they are tied with the old traditional problems of governance,” says Prof. Ravi. “You need people and that is our biggest constraint right now.”

Jan Aushadhi stores are an acceptable livelihood model

India ranks among the highest in out-of-pocket healthcare expenses – over 62 per cent – of which medicines account for a major portion. The government’s Pradhan Mantri Janaushadhi Pariyojana, launched in 2008, aims to provide quality medicines at affordable prices to the masses through the Jan Aushadhi stores that can be registered and opened by anyone who meets requirements.

“The understanding that you know people are entrepreneurial, and if you basically give them a simple business idea and the incentive to set up these stores, then there are people who will come forward and use this opportunity,” Prof. Ravi explained.

The scheme, however, faces obstacles. “It (the Jan Aushadhi store) has become (an acceptable livelihood model) in areas where the revenue is decent. But the remote areas’ connectivity problems remain, (the) market is small so those places are underserved.”

When asked if this model can be extended to deliver affordable diagnostics as well, Prof. Ravi notes that diagnostics is not as standardized as drugs. “Diagnostics also require a longer logistic support,” she says, “all of that, right now, become(s) an impeding factor. But it will definitely work in the big cities. It might still not be a sustainable model in the villages but definitely worth experimenting.”

Is PPP the way to address the manpower shortfall then?

In January 2020, the Indian government’s policy think tank NITI Aayog unveiled a scheme “to link new and/or existing Private Medical Colleges with functional District Hospitals through PPP”, in an attempt to address the “dire shortage of qualified doctors”. When asked about the feasibility of implementing this model across India’s districts, Prof. Ravi says, “Manpower is our biggest constraint, yeah, we will have to produce more human resources for the care sector.” She also points out that the shortage is not restricted to doctors and nurses but “a whole range of specialists which also includes health IT.”

“I think it (the PPP model) will work in those district hospitals which have the capability which have the scale.” Prof. Ravi speculates this approach to eventually turn into a “cluster model” with trainings “across district hospitals”. She asserts the importance of incentivizing training, “Doctors who are joining private hospitals are doing as practitioners…getting a salary to see patients or they get a percentage of whatever the incentive schemes might be. They’re definitely not being incentivized to train people.” The NITI Aayog’s PPP model, she says, “does have merit, and we must try and bolster that.”

Gender bias India’s biggest problem

In the 2021 edition of the World Economic Forum’s Gender Gap Report, India slipped 21 places, and ranks a paltry 140th, among 156 countries. Calling out the issue of gender bias in the country, Prof. Ravi says, “It is one of our single biggest problem, not just from the healthcare perspective, but the broader gender perspective.” One of the reasons India doesn’t fare well on gender indices, according to Prof. Ravi, is access to healthcare, “Even when care is cheap, affordable, and close by the society discriminates very strongly.” Quoting alarming numbers from her 2019 study conducted at Delhi’s All India Institute of Medical Sciences, she says, “More than 40 per cent of (female) patients are missing. AIIMS should have ideally had almost twice the number of women patients that what it’s currently having.”

“As a society we tend to take very few young girls and older women to hospital. In fact women’s access to hospital is best during the reproductive age, so women at young age and older age are very strongly discriminated against.” She therefore considers policy intervention not enough. “The government has a limited role,” she says, “if the household, the family, the community discriminate in such deep ways.”

“Deeper societal inequities that needs to be addressed”

Over 15 per cent of India’s reported suicides from 2019 were by housewives – one of the largest demographics. Prof. Ravi, underlining the compelling data, raised concerns about access to mental health for housewives, and women in general.”Mental health is a very big problem,” reminds Prof. Ravi, “because suicides are directly linked to mental health.”

Women’s constrained access to healthcare does not end there. “If you look at people who report being sick then women generally tend to under report health issues.” Prof. Ravi, quoting her work with people around the poverty line, reflects on the critical issues of empowering women with financial literacy and social decision making. “Having health insurance and still not filing claims, and systematically it being the case for women who are spouses rather than borrowers of loans is an indication of lack of empowerment.”

“Health analytics can help us make more precise policies”

An economist, Prof. Ravi has been closely analyzing the numbers behind COVID globally. On the importance of data and tech, she says, ” Data analytics becomes particularly relevant for low income and middle income countries,” says Prof. Ravi, “and the reason is because resources are scarce.”

Explaining how the pandemic has not been uniformly bad everywhere. “We can say now in hindsight that this is largely a urban phenomenon,” she elaborates, “if you look at the mortality numbers then it seems to be you know much more skewed on the western part of the country.” But India’s policies remained uniform. “We have national level policies. Health is a state subject.”

“Health analytics can help us make more precise policies,” she argues, “data and analytics can help you fine tune policy interventions, particularly for a resource poor country like ours.”

What’s in store for a post pandemic India?

Nearly seven per cent of the Indian population is pushed below the poverty line on account of health expenses. “Health burden is quite debilitating for people,” explained Prof. Ravi.

Prof. Ravi considers health to be one of the two driving forces of the Indian economy. “We have lost a lot and we continue to do that with the second resurgence. And that’s because our healthcare is not prepared for this.”

“Health has to become political. People have to demand better health care,” emphasizes Prof. Ravi, “we have to make healthcare more equitable and affordable, and available to all. It is a basic right.”

As India battles a second, even bigger wave of COVID infections, its public health system and infrastructure is set to be stretched to its limits, again. The country’s health challenge, as pointed out by Prof. Ravi too, extends beyond COVID. Whether or not policymakers build on lessons from this pandemic, remains unknown. And whether these lessons will guide the society towards a more inclusive, equitable future with quality healthcare for all, too remains unknown.