Trust in a person, institution or system is built and garnered over time. For centuries, people have trusted their physicians. When hospital-based care evolved at the turn of the last century, people started trusting hospitals. Later, public and social health insurance institutions came into beingand people placed their trust in themfor financial protectionin meeting their healthcare needs. As health systems evolved with increasing complexity,it became challenging for people to navigate these complex systems. As a consequence, the trust gradually started to erode. Unless health systems meet the health needs of people when they need, where they need, and how they need them, the trust will continue to decline.

When public healthcare started faltering in India, private healthcare evolved in response to the growing unmet needs of its people. In the beginning, private healthcare was driven by well-intentioned doctors and philanthropic and faith-based organizations. Healthcare costs started rising rapidly with advances in medical technologies. As the Indian economy opened up for private capital, hospitals started getting corporatized through the flow of private equity funds. While itimproved access to modern medical care across metros and cities, it brought in a fundamental dichotomy between the purpose of medicine and that of business.

Businesses started competing for patients by investing in five-star facilities and latest technologies andeliciting referrals through inducements. With fee-per-service becoming the dominant form of payment system, providers (clinicians, labs, pharmacies, hospitals etc.,) were inherently driven to provide more services and goods, whether needed or not. As disparity between physicians working in private and public systems widened, distribution of limited doctors skewed towards private and urban healthcare systems.

Private healthcare met the healthcare needs of people, as public healthcare continued to languish from the lack of political support and public apathy. With diminishing trust in public healthcare, people had no recourse but to pay for private healthcare out of their pockets. That explains India’s dubious distinction of beingamong countries with thehighest out of pocket health expenditure in the world.

People started distrusting private healthcare for their unethical practices and rising costs. They were able to see the growing dominance of business interests over medicine. Financial protection through public, social, and private health insurance programs may beaddressing the issue of healthcare costs to some extent.But their confidence in getting the right care is not growing. Despite more and more people having some form of financial cover, out of pocket expenses continue to be high.

Health systems, both public and private, can regain the lost trust of its people. Governments, through effective leadership of public health systems and stewardship over private health systems, can rebuild people’s trust in public systems. Policy reforms to achieve ‘Universal Health Coverage (UHC)’, if implemented well, will provide reasonable financial security to people in meeting their healthcare expenses. Parallel efforts in strengthening access to Comprehensive Primary Health Care (CPHC) within the public healthcare system through health & wellness clinics and improving overall access through online public and private healthcare services will generate people’s confidence in the system to meet their health needs when, where, and how they want. Efforts are being made to improve access to comprehensive hospital-based healthcare in tier two and three cities and towns by strengthening public hospitals and by engaging private providers.

While the above developments do improve access to healthcare and financial protection, efforts are needed to ensure that people receive safe, effective, timely, and evidence-guided appropriate care. It is important that people are not discriminated on age, gender, caste, religion, socio-economic status or race. It is also essential that people are treated in a dignified way when they surrender themselves to care givers. The issues of Quality, Equity, and Dignityshould be brought on top of the health policy agenda. Leadership should use levers of finance, regulation, and market forces to steward both public and private health systems to address these three critical issues. The recently notified National Digital Health Mission (NDHM), if implemented effectively, can support all the above efforts in restoring public trust.

Capacity building of both individuals and institutions is needed to strengthez governance. Reforms in health professionals’ education, focus on leadership and management development programs, strengthening national and state level public institutions like the National Health Systems Resource Center, National Institute for Health & Family Welfare, Department of Health Research, National Center for Disease Control, Indian Council for Medical Research, National Accreditation Board for Hospitals & Healthcare Providers&National Accreditation Board for Testing and Calibration Laboratories, National Medical Council, Indian Nursing Council,non-governmental organizations engaged in health systems etc., are urgently needed to enable leadership to effectively transform health systems and regain public confidence.

Governance of any complex system cannot be done by the government alone. All stakeholders representing both public and private systems (people and their representatives, payers, providers, managers etc.,) play an equal and important role in health systems governance. Unless each stakeholder owns the responsibility and accountability, government alone cannot restore people’s trust.The Covid-19 pandemic has shaken up entire health systems. Let’s use the current heightened awareness to rebuild the fractured system and restore people’s confidence and trust.

Dr. Krishna Reddy Nallamalla
Country Director, ACCESS Health India