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‘Main focus should be on developing a mass-based health insurance system’

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Five years ago, in the same publication, I wrote about what are healthcare matters and what should be the priorities of the then new government. (See link: Mr Prime Minister, healthcare matters! In the last few years, there has been significant improvements in several public health indicators. Life expectancy of Indians has reached nearly 70 years, infant and maternal mortality have decreased though they still continue to be higher than many other countries, polio has been eradicated. Several good public health insurance schemes such as those in Maharashtra have been working quite well with good acceptance and benefits. Both the urban and rural healthcare missions have shown good success. In spite of this, we are far away from what our ultimate goal should be. Indecision and policy paralysis has plagued the country resulting in inordinate delays in healthcare reforms and affecting several aspects of healthcare. I will essentially focus on four aspects.

Accessibility and affordability: Healthcare is becoming more and more expensive. Many rural Indians still have to rush to urban India for even not so serious communicable and nearly all non-communicable diseases. Our distribution channels have only been partially successful in delivering medicines to the end user at the ‘point of contact’. On the accessibility front, the government must develop either alternate channels of supply system or remove the clogs in the current one. On the affordability part, it is high time that we start developing a healthcare insurance system for Indians. In addition to the traditional European model of public, government-funded health insurance and the American model of private health insurance, there are several examples such as that in Singapore who has placed health as a responsibility of the individual and the family but has created a system wherein government helps in whatever way it can in the right way and at the right time. This way, people can self finance to a very great extent. It creates more accountability as well as possible better outcomes. We should now be developing a sustained, mass-based health insurance system. In India itself, there are case studies such as those from Narayana Hrudayalaya where this has been developed and implemented successfully. We must now expand this at an all-India level.

Healthcare delivery: In India, private and public healthcare co-exist. The former is expensive, the latter overcrowded. To keep oneself updated on recent developments in medicine so as to improve quality of delivery and outcomes, healthcare personnel have to find dedicated time. This has to be the next priority. Regular on the job, online or even classroom-based training to all healthcare providers should be made mandatory. The Medical Council in Maharashtra has made this mandatory for all doctors, but this again has to be expanded nationally. Special focus should be made on competency and capability development for physicians, nurses, pharmacists and other allied health professionals. Improving our primary healthcare centres in rural India would incentivise several physicians to visit them on a regular basis and contribute to improvement. Utilising technology to address referral issues would also be a good step.

Research: From being a leader, we have become a laggard in the last few years. It has become extremely difficult to do a single clinical trial project though we have had one of the most evolved regulatory guidelines and processes. Countries like Korea have gone way ahead in terms of number of research projects (including those addressing national needs) with protection to research subjects a top-most priority. There is a need to immediately remove all inefficiencies of the system, delayed approval times and lack of clarity at the highest level. It is necessary to give this a top priority – streamline and speed up all processes, ensure that decision makers are really cognizant of the ground reality and monitor the process by trained and capable personnel. This would also stimulate researchers to develop capabilities for in-house research on diseases of national importance i.e. malaria, multi-drug resistant TB, dengue etc. Unless some concrete radical steps are initiated immediately, we may reach an irreversible stage in the near future.

Public health: The vast improvements in health occur because of good water supply and adequate sanitation. This has to be the focus of the new government. In one of the world’s biggest economies, we should not be having any deaths because of lack of these two basic aspects. The government must focus on these in our overcrowded urban infrastructure as well as deep interiors. For non-communicable diseases, it is important that we protect our citizens from diabetes, cardiovascular diseases and cancer. For this, we require primary prevention strategies-availability of free open spaces, mandatory fortification of foods, availability of free regular check-ups again at ‘point of contact’. It is the government’s role to provide all the required focus on our national health programmes with an objective of removing red tapism and bureaucratic delays.

In short, the main focus should be on developing a mass-based health insurance system, capability development of healthcare delivery personnel and improvements in quality of delivery, prioritising research and stimulating it by removing all inefficiencies and developing an infrastructure to address public health issues.

How do we achieve this?

In a democratic country like India, it is our responsibility to work closely with those in the government to achieve these goals together through measures like:

Public private partnerships (PPPs): Experience in operational excellence is a big advantage of the private sector. The government must set in policies and encourage dedicated private partners to operationalise and run the plans. This would reduce the burden on the government so that they focus more on the pressing challenges and issues.

Professional participation: The government must pro-actively take guidance as well as seek active participation of professionals who are ready to work on selected projects or on a regular basis. For this, they must identify those who are closer to the real world, have the dedication and will to look ‘out of the system’. Several professionals in the industry would be more than willing to participate if there is a genuine effort and clarity.

Use of technology: We need to significantly upscale the use of technology in most of our operating areas. This may include capability development, electronisation of medical records, monitoring of public health programmes etc. Using local co-operative networks could be a way of moving ahead.

To summarise, I am aware that the government has a lot on its plate to do and there are several priorities: economy, infrastructure, labour reforms etc. However, healthcare probably affects each of these. This is a unique opportunity for the new government to put in place several structural changes, far reaching programmes which would affect all of us in the mid-to-long term. For many of these, it requires a strong will and commitment. The new government appears to have both. As stakeholders in healthcare, we must work together in a co-ordinated manner with measurable and performance driven metrices in place to make a firm mark in India’s healthcare story. The choice is entirely ours.

(The author is a pharmaceutical physician who works as Asia Medical Lead in a MNC pharma organisation. All views are entirely personal and do not reflect those of the organisation.)

Dr Viraj Rajadhyaksha, Asia Area Medical Affairs Manager, AstraZeneca

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