Roadmap for better healthcare

The mandate that the UPA government perceives for itself raises the hope that more attention will be paid to improving public health services in India.

This is urgently needed. Health provisioning in India is lower than even the average for low-income countries. Through the nineties, the decade of reforms, the rate of improvement in basic health indicators has slowed down.

Everybody, including the poorest, is spending more of his income on healthcare, something the latter can least afford. Simultaneously, the rich continue to corner more than their share of public health expenditure.

Simply put, there is crisis on the national health front, which large sections of the middle class and those better-off are unaware of.

This is because the health scene for the better-off is improving.

The number of private health insurance providers is increasing and third party health administrators are getting into place, making private health insurance (at least the reimbursement of large hospital claims) a system that is seen to work.

Simultaneously, speciality care is improving. Leading corporate speciality hospitals are taking delegations abroad canvassing for health tourism business by emphasising how cheap but good the best Indian healthcare providers are.

Improving healthcare for the poor is tricky because straightforward privatisation is not the answer, like it is in, say, hotels or airlines.

The privatisation of healthcare in China has produced negative results. On the other hand, the poor provisioning and quality of healthcare in India seem clearly related to the appalling standards of governance.

So how to create a bigger constituency for more public spending on healthcare, and how to dramatically improve healthcare delivery, that gets greater value for money for every public rupee spent on it?

The national healthcare scene is variegated and similar to the national governance and human development scene. The southern states do the best, the BIMARU states do the worst, and the rest come in between.

Considering that Kerala and Tamil Nadu do the best (both in terms of the volume and quality of spending) and West Bengal and Tripura lag behind, just a bit ahead of the likes of Bihar and Jharkhand, the ideology of the rulers doesn't matter much. What matters is whether a state has a culture and tradition of good governance.

Since the support from the middle and chattering classes for more public spending is closely related to establishing that the spending will be more efficient, the whole future rests on making a better use of public spending.

Relatedly and equally importantly, it is necessary to improve the regulation of private healthcare. Some progress has been made in recent years in this regard through the slow unfolding of private health insurance regulation, arrival of TPAs, and rating of hospitals.

But we are still far away from a minimum regulatory system. Today, it needs only a shops-and-establishments licence to start a nursing home. Quacks proliferate in the countryside and even among the medical practioners accessible for the urban poor.

A better licensing and monitoring of nursing homes and hospitals is a must but going by the way state governments regulate the drug industry, merely laying out a regulatory mechanism will not do.

The best way to reform urban private healthcare is through better competition from the public sector. When the healthcare delivery of selected public hospitals in Madhya Pradesh improved as a result of takeover of management by Rogi Kalyan Samitis, it brought down both the business volumes and prices of private providers in the vicinity.

But what about a village, which must rely solely on its primary health centre? The sub-district level panchayats have to step into the role of public monitoring.

Also a charter of citizens' right vis-a-vis such centres should be posted at them along with details of government spending and provisioning of medicines. The governing principle should be public oversight through empowering.

Next comes the issue of quacks, some of whom even hold legitimate degrees, while others are dispensing chemists masquerading a s doctors. Such is the state of some private and public medical colleges that you do have qualified doctors who are a social risk.

The best way out may be to introduce a minimum, simplified yearly voluntary test (in the format of those for engineering and medical admission) designed for those with MBBS-level education.

Those clearing it will be able to display the attractively designed certificate (recognisable even to illiterates) in their clinics and a public education campaign will advise patients to go only to those who display the certificates.

These will clearly say the year for which they are valid. As this will be voluntary, a confident doctor with a good practice need not bother.

What still needs addressing is the issue of diagnostic clinics, which are incapable or indifferent. The antidote for that is a public health facility doing its job.

How to get public hospitals to give a better account of themselves? One way may be to allow private nursing homes or hospitals to admit poor patients, treat them and get reimbursed by the government. The ESI system can be opened up to private providers.

The TPAs can negotiate bulk rates for standard treatments, keep a check on fraudulent and inflated claims, and disqualify non-performers. This is where there is competition.

Two initiatives have made a dent in the quality of public hospitals. One is the Madhya Pradesh model Rogi Kalyan Samiti, made up of local stakeholders' representatives and officials, which takes over the management of a hospital, allowing it extensive autonomy.

It levies user charges (below market rates) for those willing to pay and keeps the proceeds for hospital improvement. In individual instances the model has made a huge difference, as in Indore, and its originators have been internationally awarded.

The other is the World Bank-funded states health systems development project, which now covers over half the country. It employs the same principles of outsourcing what can be outsourced and decentralisation in administration.

If public health expenditure becomes more efficient, as it has done, through initiatives like these, then the middle class should not mind greater public expenditure, should it?