WHITE PAPER SUBMITTED TO HM
AHPI has been raising various concerns with the government which have been pain points with the Healthcare industry. A white paper (mention below) has been submitted to the Hon’ble Minister. AHPI has succeeded in providing a platform to the industry from where their voices can be heard in forceful manner.
Healthcare Agenda for Government
Though Indian economy has grown at a satisfactory rate of 4-8% in last one decade, but the social sectors i.e., healthcare and education have lagged behind. It is believed that social and human development and environmental sustainability have been neglected in Indian growth story since independence. This is born by the fact that we have yet to achieve the targets set under Millennium Development Goals and our social and health indicators like human development index (HDI), IMR/MMR and life expectancy lag behind BRIC and even neighbouring SAARC nations. The Human Development Report 2013 released by the United Nations Development Programme (UNDP), ranked the country at a low 136 among 186 countries on its Human Development Index (HDI). We as a nation are duty bound to ensure well being of its citizens through framework of good governance built around these sectors i.e. EDUCATION, ENVIRONMENT & HEALTHCARE.
HEALTHCARE as FUNDAMENTAL RIGHT:-
The Supreme Court of India has held that the right to live with human dignity, enshrined in Article 21, derives from the directive principles of state policy and therefore, includes protection of health. Further, it has also held that the right to health is integral to the right to life and the government has a constitutional and moral obligation to provide health care facilities to every individual. Though right to health for every Indian citizen has been well enshrined in the constitution, the Government has not been able to provide adequate, affordable and quality healthcare services for all through the rights approach alone.
ACHIEVING UNIVERSAL HEALTHCARE:-
The High Level Expert Group instituted by Planning Commission of India in Oct 2010 lays out the blueprint and roadmap for achieving universal health coverage for all by 2022. To achieve these goals, the role of the State is to act as a catalyst, provide necessary regulatory framework, and take appropriate policy initiatives and make legislative changes so as to create an enabling environment for overall and speedy growth of healthcare sector in the right direction.
ROLE OF PRIVATE SECTOR:-
At the time of independence, only 8% of modern medical care was provided by the private sector. Limiting the need for private practitioners was one of the recommendations of the seminal 1946-report on the Health Survey & Development Committee (Bhor Committee). Contrary to the recommendations made by Bhor committee, the private sector now dominates (with about 80% share in healthcare expenditure) the provision of personal care except in selected health programs. More than 70% of all outpatient and 55% of all inpatient care is being delivered by private sector. We have not been able to raise healthcare spending (public + private) more than 5% of GDP, as compared to global average of 9.7%. Though the role played by private sector in healthcare is significant, and to an extent fills up the infrastructural gaps in the public sector, the Government cannot absolve itself of providing primary and secondary healthcare services in remote and rural areas, and tertiary healthcare services at an affordable cost.
ROLE OF NATIONAL HEALTH MISSION:-
National Rural Health Mission (NRHM) was launched as one of the major healthcare reforms in the year 2005, with a goal to promote equity, efficiency, quality and accountability of public health services in the rural settings. There has been good impact of the mission but only in parts. We have still long way to go. The mission aimed to achieve an infant mortality rate of 30 per 1000 live births, maternal mortality rate of 100 per 100,000 live births and a total fertility rate of 2.1 by year 2012. We were able to reach 40 per 1000 in IMR and 200 per 100,000 in MMR. Moreover, there is a wide variation among different states as far as these indicators of healthcare are concerned. With simple initiatives like training specialists and involving private sector, we can quickly achieve better outcomes.
PUBLIC FINANCING OF HEALTHCARE:-
The India’s public financing for health care has been less than 1 percent of the world’s total health expenditure, although it is home to over 16 percent of the world’s population. Till year 2008 only a small fraction of total expenses was pre-paid and most were out-of-pocket payments. According to a World Health Organization (WHO) study of 2007-2008, India ranks 171 out of the 175 countries in the world in public health spending which is even less than some of the sub-Saharan African countries and 1/3 rd of BRIC nations. Further, according to the national health account study in year 2009, percentage of private out of pocket expenditure have decreased from 92.2% in year 2000 to 78% in year 2009.Still, this OOP expenditure and debt is responsible for pushing 3% of Indians to BPL every year.
ROLE OF HEALTH INSURANCE SECTOR:-
As the state governments insurance schemes are under launch, it is expected that 50% of population will get covered under some or other insurance scheme by year 2015. While this is welcome step, there have been serious concerns about the manner in which these schemes are being launched and executed. However, the current system of empanelment of lowest bidder and inordinate delays in the reimbursement to the providers by some of these schemes like CGHS and ECHS is unfair to the providers of efficient, safe and quality healthcare.
MEETING SHORTFALL IN MANPOWER:-
Manpower is another big issue. We have 400+ medical colleges which annually produce over 50000 doctors and about 20000 specialists. This number of specialists needs to be enhanced at least by 100% to match the demand in rural as well as in urban areas. Same is the case with nursing staff and paramedical staff. Government needs to ensure adequate numbers and appropriate mix of trained health care providers and technical health care workers at different levels by giving primacy to the provision of primary health care, increasing HRH density to achieve WHO norms of at least 23 health workers per 10,000 populations.
ACHIEVING QUALITY & SAFETY:-
Quality (Patient Safety) and affordability are the two challenges, which need to be addressed simultaneously as we expand the infrastructure. It is reported that whopping 5.2 million medical errors are being observed annually in India. The health being a state subject, 29-states have their own health regulatory framework. In most cases it is far from being effective. In many places, hospitals are registered under Shop and Establishment Act, with no provision to ensure that these hospitals follow minimum guidelines on patient safety and quality assurance.
RATIONALISATION OF TARIFFS:-
There is growing perception that private healthcare is expensive. There has not been any effort to compute the actual cost for delivering of safe healthcare. There is high taxation on healthcare. Cost of land and building in metro towns is beyond limit to set up a sustainable hospital. Over and above hospitals are today bracketed with cinema hall/ shopping malls for fixing electricity/ water tariff. Medical equipment is imported at exorbitant duty of 12%. All these factors contribute to increase in the cost of healthcare. We need to realise that quality (safe) healthcare will cost some definite price, whereas absence may cost LIFE.
KEY ACTION POINTS FOR GOVERMENT
The present contribution by the government and private sector is 1.2% and 3.8%, which makes it 5% of GDP. The global average is 9.7% .We urgently needs to plan increase in government allocation or alternatively incentivise investment from private sector so as to achieve total expenditure of about 7.5% of GDP in next 3-years.
Priority needs to be accorded to establish and augment a robust and credible primary healthcare system. We need to urgently re-invent PPP model and to begin with apply it for the PHCs. We need to formalize the referral system from primary to secondary and to tertiary level hospitals. This will avoid overcrowding of district level hospitals. Government should bring back the into focus public health measures such as population control, immunization (including adult vaccination), vector control and other public health measures like safe drinking water, pollution control, empowering of community on preventive health measures etc.
Review the functioning of MCI to bring transparency and objectivity. Legislations like NCHRH Bill 2012 (awaiting passage in Rajya Sabha) that aim to prescribe, monitor and promote standards of health professional education, need to be speedily implemented after addressing due concerns of all stakeholders. There is urgent need to increase PG seats in Medical Colleges and strengthening of the existing Diplomate of National Board (DNB) stream run by MOHFW to augment PG seats. Without these measures, we will not be able to improve the health indicators including IMR & MMR. Government needs to partner with private players to open 50 seat medical colleges attached to District Hospitals with bed strength of more than 200. These colleges should be opened in states like Chhattisgarh, Jharkhand, UP, MP and Bihar which have lower density of medical colleges. This will remove disparity in the distribution of medical colleges in the country.
There is acute shortage of skilled nurses in the country, yet the seats in nursing schools/ colleges remain un-utilized. We urgently need to revamp nursing curriculum, empower them to take higher responsibilities by introducing career progression, which only will attract good candidates to opt for nursing profession. This may require appropriate legislation. Same needs to be done for paramedical category of health workers.
Healthcare needs regulation, which is transparent and objective. Regulation must ensure that healthcare organizations follow evidence based practices and adopt minimum patient safety protocols. Clinical establishment ACT-2010 has still not been implemented. It should be re-visited and made applicable across the nation, in consultation with all the states. Along with it, there must be strong incentive for HCOs to seek NABH accreditation, which is proven framework for quality governance based on patient safety.
With private sector showing great initiative, it is expected that shortage in healthcare infrastructure would be fast met. Government has to take private sector as partner in letter and spirit as both put together are providers. Government need to simplify procedures for giving single window clearance for numerous regulatory (presently there are as many as 50- legislations) compliances and provide incentives so as to attract larger investment into health sector. Healthcare needs to be given special status to encourage investment. Import duty on medical equipment needs to be abolished as these are necessarily the life saving measures. Likewise there is absolutely no justification to impose electricity tariff on hospitals at par with cinema halls and should be reduced as much as possible.
Healthcare is slowly becoming election agenda. More and more states are introducing government sponsored health schemes. The coverage however remains far from comprehensive as the schemes are focused on in-patient, often surgical care. There is urgent need for increasing health insurance coverage for both out-patient and in-patient care to include all poor and near poor patients and at the same time restructure the schemes by fixing logical rates for different procedures and ensuring timely payment to the providers.
Central government already have few schemes like CGHS, ECHS, and ESI etc. Unfortunately these schemes are not being managed in a professional manner. It is surprising to note that rates for various medical procedures are fixed based on tenders. This has very serious implication for safety of beneficiaries. Over and above the lack of transparency in releasing of payment makes system prone to corrupt practices. CGHS is like mother scheme, pattern of which is followed by other schemes, the government must make sure that it is executed in professional manner by fixing logical rates and with transparent way of releasing payment.
Indian health systems have no data of its own population. We only quote western data in our education system. For example we do not have demographic distribution of population with specific disease pattern. Government need to allocate adequate budget and provide to research institute and also to tertiary level hospitals in public as well in private sector. We need to promote indigenous research & development and manufacture of medical devices and implants and usage of low cost OEM refurbished equipment.
A separate Device Management Regulatory Authority to monitor indigenous medical device development, research and conduct of trials needs to be set up under MOHFW to give boost to this sector, achieve quality assurance and achieve better synergy with other healthcare activities
Government needs to formulate policies to establish a framework for adoption of national accreditation system like; (NABH), Standard Treatment Guidelines, Electronic Medical Records, Tele-Medicine, Mobile Health etc. This will improve operational efficiency, portability, storage of health records and quality of healthcare delivery across the health systems including private and public systems.
Making available drugs at rational prices and achieving synergy with other healthcare activities and Departments of MOHFW, it is proposed that drugs, cosmetics, and medical devices and other pharmaceutically active substances may be brought under the ambit of MOHFW. This will need restructuring of Government Ministries, but will eventually rationalize and synergize their functioning.
This white paper provides only a blue-print and framework that shows how it is indeed feasible for India to establish a UHC system within the next few years. Follow-up work by experts and professional bodies like AHPI, IMA, ICMR, NABH, and MCI, is needed for spelling out the modalities and giving final contours to how best various proposals may be implemented considering concerns of all stakeholders. Private Sector has good presence and government only has to facilitate transparent and objective, regulatory framework, which can propel growth while ensuring quality and safety. Government under the National Health Assurance Mission is expected to introduce reforms which will bring down the cost and make quality healthcare affordable to community and society at large.