Monday, December 21, 2015

The broad outlines of a health care system for India

Lancet last week released a comprehensive study of India's health care system which reinforces the belief that it needs serious repair. Its headline findings,
We make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022.
The conventional wisdom is that health insurance is the holy grail in health care. I have written here about why this is a fiscally unsustainable slippery slope that could potentially ruin even that small part of the country's health care system that functions. In this context, here is a set of possible prescriptions about translating this vision into action.

1. India's healthcare priority should be to dramatically improve preventive and primary care standards. Its facilities should be strengthened with more personnel, increased capacity building, and rigorous monitoring, all complemented with greater demand-side pressures. The primary health center (PHC) and its subcenters should be trained to act as a single-stop for all preventive and primary care services, and a gatekeeper for all referral services. While this is notionally their mandate even today, its compliance remains weak and these institutions have been reduced to being maternal and child health centers. All the existing national programs, including the village public health activities, should be closely integrated into the PHC and brought under the control of its medical officer. These facilities should be provided resources to equip themselves with all the basic infrastructure and equipments and maintain them in a clean and hospitable manner. Wherever the medical officer is not appointed, a senior staff nurse should be entrusted the supervisory responsibility.

2. The PHC would act as a nodal agency co-ordinating all preventive and primary care activities - maternal and child health interventions, basic OP services, normal deliveries, administration of national programs, and coordination of village public health activities. This functional profile demands the services of a public health manager, more than a trained medical practitioner, much less one trained rigorously for more than five years. A three-year course with a curriculum designed to accordingly may be one way to also overcome the acute shortage of MBBS doctors that leaves a large proportion of PHCs without any doctor. 

3. Given that less than fully qualified (LTFQ) providers, commonly called quacks, are the point of first contact in nearly 80% of cases in rural areas, no meaningful reform is complete without integrating them into the mainstream. Their capacity building should involve continuous trainings and a gradually phased pathway to formality. One approach may be to offer a very basic preventive and primary care-focused course curriculum as a certificate in primary care, to be acquired over a 4-6 month duration of distance learning. The entire coursework can be provided on-line and through mobile phone apps, with the final examinations too conducted online under strict monitoring. Once they acquire the certification, these providers can be empanelled and used for various preventive and primary care services offered by the government in return for a fee.

4. The secondary care institutions like the 30-100-bed community health centers (CHCs) should be strengthened with all basic facilities and kept very clean. Currently, they are the weakest part of India's health care system. These hospitals should contain round-the-clock doctors and be equipped to handle basic surgeries including C-section deliveries. Wherever resources are extremely scarce, staff from two CHCs can be temporarily redeployed to run at least one full-fledged CHC. A mobile team of anesthetists can be made available if required.

5. All tertiary care admissions, except in cases of emergencies, should happen only through the primary care center and preferably the first referral unit in the CHC. While this may be difficult to enforce, a variety of different approaches may have to be adopted to gradually internalize this approach among all the public and private stakeholders.

6. It may be difficult to put the insurance genie back in the bottle. The next best option is to consolidate all the public insurance schemes offered to different categories of people under one umbrella, with a basic insurance plan and different types of top-ups, including those which provide premium care. Like in the continental Europe, the basic plan should be community-rated, cover a very basic set of high-incidence catastrophic medical conditions and no more, and have the same premium across insurers within a region. Private insurers should also offer this basic plan and at the same terms. They would be allowed to differentiate based on the top-ups and the quality of their services. 

7. The government, jointly with the private insurance agencies, should negotiate the annual price schedules of care providers and diagnostic services on a regional basis. This price schedule would be applicable for all government and private insurance and for any other contracting of services (like with CGHS). It would be a matter of debate as to whether the fee schedule should become the price standard for all categories of consumers as would be the case in a completely regulated market. 

8. The public tertiary care facilities should be strengthened with more facilities, greater cleanliness and responsiveness, and better management. Since such institutions are only a handful in each state, the state governments should take it up as a mission to bring them up to the standards of the best private hospital in the region. Patients under public insurance or being subsidized for their health care should be discouraged from visiting tertiary care facilities for simple secondary care treatments. Apart from providing affordable and accessible care for the poor, strong public tertiary care facilities are essential to keep private providers honest. 

9. In an environment where government hospitals are badly managed and discourage even those who cannot afford private hospitals, allowing insured citizens to choose their hospital is certain to further enfeeble public facilities. In the circumstances, there may be only two options. One, public insurance schemes can mandate that patients go to private facilities only in case the same treatment is not available at the public facility and on referral by the tertiary care facility (or on pre-authorization by the TPA). Two, the personnel delivering the care in the public facility should be incentivized with a share of the payments. It is not clear as to which of the two alternatives may work and a light-touch mix of both may be necessary. 

10. Finally, districts should be allowed to innovate to implement the components of this plan. The Government of India should offer a menu of interventions to improve health care service delivery - electronic medical records of all medical transactions in public facilities, strengthening of the rogi kalyan samitis at the PHC level, initiatives to make public facilities more attractive for patients, integration of the LTFQ care providers, rating of private providers and so on. The district may commit to the implementation of a clearly defined action plan consisting of some of these interventions and corresponding outcomes and enter into a 3-5 year MoU with the state National Health Mission Society. In return, the district should be encouraged with an incremental share of the NHM allocations. This strategy should not be forced upon all districts. In fact, only a handful of self-selected districts in each state should experiment with it, and based on their learnings, the strategy should be gradually expanded to cover others. Apart from closely monitoring and refining the programs, the state and central governments should encourage competition among those districts in the achievement of their action plans.

Now, it would be impossible to implement all these components in a one-size-fits-all mode across the country on a mission mode. It is just too complex. For sure, many of these reforms would struggle to pass the test of political acceptability and seriously strain the administrative bandwidth for effective implementation. Greater program flexibility would certainly lead to failures and scams. Dfferent parts of the country, even parts of the state, will progress at different pace in implementation. But given the enormity of the challenge, this may be the only way to initiate a process which could, potentially, over a long time frame, atleast stand a reasonable chance of getting us to the destination. 

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