In India, we have less than three per cent people paying taxes for 1.3 billion people. Can we afford free health care for all?
As I write this today, I feel naïve thinking about how excited I was when I started my medical career in 1980. The World Health Organization (WHO) slogan “Health for all by 2000” was actively promoted back then. It took us a while to realise that the goal was unrealistic.
Today, as India celebrates ‘Azadi Ka Amrit Mahotsav’, an initiative by the Government of India to commemorate 75 years of independence and the glorious history of its people, culture, and achievements, it is important to ask: Has Indian healthcare progressed enough in the last 75 years?
In my view, from launching national-level and ambitious initiatives to reducing and controlling some of the deadly diseases, India has come a long way. Our country has made substantial improvements in many health indicators, such as maternal and infant mortality, but progress in other areas have lagged behind, although huge variations exist between and within states.
The cost of healthcare
Universal health coverage (UHC) means that all people have access to the health services they need, when and where they need them, without financial hardship. In India, we have less than three per cent people paying taxes for 1.3 billion people. Can we afford free healthcare for all?
Till date, we have wide disparities between states, between genders, between rural and urban people, between castes, between the educated and the uneducated, and between formal and informal labour. We still account for close to 15 per cent of global maternal deaths and 27 per cent of global tuberculosis cases; 43 per cent of our children continue to be undernourished and 20 per cent continue to be vulnerable to diseases because of no or incomplete vaccination. Our sex ratio is at 935 females to 1,000 males, placing us at 192nd position in global rankings.
India’s public health expenditure at 1.2 per cent of GDP is one of the lowest in the world. Though out-of-pocket expenditure as a percentage of total health expenditure has declined from 62.4 per cent in 2014 to 48.8 per cent as per a recent study, it continues to cause financial hardships to many low- and middle-income families.
Despite India’s progress, the health workforce and health infrastructure are grossly inadequate to meet the healthcare needs of people as per the growing disease burden. COVID-19 exposed many of India’s strengths and weaknesses, as one of the world’s worst-affected countries. The healthcare system was completely unprepared and ill-equipped to manage a pandemic of this magnitude.
Over the last couple of years, central and state governments have committed to address these gaps in India’s healthcare system. The system needs to be reconfigured if these commitments are to provide optimum benefits to the people. The most effective way is to improve primary and public healthcare facilities, and focus on preventive health.
Secondary and tertiary healthcare needs of the population can be achieved on a mass scale by joining hands with private healthcare and regionalising it with a hub-and-spoke model that subsidises the costs, instead of penalising the private healthcare providers. Also, public healthcare needs to become more transparent and accountable.
For India to become truly self-reliant, we need to create a robust health policy platform and scale up public spending on health. Similarly, the adoption of an integrated primary health approach is expected to result in a gradual, but significant reduction in overall disease burden across the country.
Greater emphasis on the use of information technology to link healthcare networks can improve health surveillance in the country with the establishment of a health information system that generates valuable data on various health and disease trends and outcomes.
The way forward
UHC for India calls for a flexible architecture to deal with inequities in health outcomes, regional and sociocultural diversity, and the differential healthcare needs of populations in different locations. We need to take into account the challenges of rapid urbanisation, simultaneous demographic, epidemiological and nutritional transitions underway, as well as social and political changes occurring in the country.
In other words, UHC can be achieved only when sufficient and simultaneous attention is paid to at least the following health-related areas: nutrition and food security, water and sanitation, social inclusion to address concerns of gender, caste, religious and tribal minorities, decent housing, a clean environment, employment and work security, occupational safety and disaster management.
The government needs to set clear goals, with actionable items to improve primary health, public health and preventive health across the country. The secondary and tertiary health needs of a large and diverse country like India can best be achieved through Public-Private Partnerships.
Prime Minister Narendra Modi’s vision for India to play a larger role in the global economy, and for it to become more efficient, competitive, and resilient has seen the light of the day with several health schemes such as PM Jan Arogya Yojana (PM-JAY), Ayushman Bharat Digital Mission (ABDM), and PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM).
This is a golden opportunity, especially post pandemic – as the focus is on health. India needs to create an efficient and equitable health system urgently. The task is so urgent that it cannot be deferred any longer. We must rise to this challenge and use the next decade to usher in UHC, which the Indian people deserve, desire and demand.
(The author is the Founder Chairman & Neonatologist, Cloudnine Group of Hospitals, Bengaluru. He is also a healthcare delivery graduate from Harvard Business School.)