Almost every health indicator in India points to a dysfunctional health system. Though many indicators have improved significantly since our independence, we still lag many other low to middle income countries in this regard. The Indian parliament passed the National Health Policy in 2017 with the primary aim of strengthening government’s stewardship in shaping health systems. In the recent years, the government launched major reforms. Among this is the ambitious Ayushman Bharat Program that comprises two major components. One is the strengthening of comprehensive primary health care by commissioning 150,000 health & wellness clinics (HWC) by upgrading existing subcenters and primary health centres. The other component is the Pradhan Mantri Jan Arogya yojana (PMJAY) designed to provide financial protection for hospital based care for nearly 500 million poor people. Other major reforms include the National Medical Council (NMC) replacing the dysfunctional Medical Council of India (MCI) to improve medical education and the National Digital Health Mission (NDHM) to enable standards-based interoperable health records. While the policy intent is in the right direction, the past performance of public health systems casts doubts on how successful these reforms will be in making our health system functional. Below is an outline of strategies to strengthen our health system to improve people’s health status, provide fair financial protection, be responsive to people’s health needs, and be more resilient to face present and future crises, thereby securing people’s health.
Organizing healthcare services as per people’s health needs
Every Indian should have access to high quality care whenever and wherever he or she needs it. People need access to doctors, drugs, diagnostics, ambulances and hospitals round the clock since acute illness does not respect time. People are agnostic about whether these services are provided by public or private players. Fortunately, access to healthcare services has been rapidly improving over the years with the growth of private sector. Growth of online services and at home services in the recent years, accelerated by the ongoing Covid pandemic, has further improved the overall access to services. Digital health is set to further empower people to care for themselves.
While access has been improving rapidly, people continue to need help in navigating the complex healthcare system. They need guidance in accessing the right doctor, the right hospital, the right ambulance, the right lab and the right pharmacy. People with health insurance (public, private or social) need guidance in accessing the right empaneled hospital. Governments can easily help citizens navigate the system round the clock through helplines. They can invest in developing an application to guide people based on their initial medical presentation. Frontline workers like ASHAs, ANMs, Anganwadi workers etc., can help people who cannot handle information and communication technology.
It is estimated that nearly two-thirds of avoidable deaths are caused by poor quality of healthcare services. People are usually not in a position to assess the quality of services before availing them. Hence, the onus of ensuring good quality of care from both public and private providers is on the government. Government can undertake this as a regulator and as the largest purchaser of healthcare services through various public health insurance schemes. Governments should improve their own provider systems to offer market competition to the private sector. It can notify autonomous bodies that rate hospitals and diagnostic labs based on the quality of care. Online rating systems are proving to be highly effective in guiding people in their choice of a provider.
Public healthcare system is the single largest provider. However, it is plagued with chronic shortages of people and supplies with poor management of the facilities. With the age-old system of supply-side line item budgeting, multiple lines of financing from various central missions and state budgets, and underspending of limited budgets, public healthcare systems continued to suffer and eventually lost the trust and confidence of a majority of the people, including those from weaker socio-economic strata. A shift from supply-side financing to demand-side financing, pooling of multiple budgets lines, granting sufficient autonomy to district level health officials while requiring accountability in output and outcomes, and adapting modern financial management systems have the power to improve public healthcare without extra investments.
District public health officials should assess the health needs of people residing in their district as per the population demographics and disease burden, through robust disease surveillance systems. They should have a standard register of doctors, nurses, community health workers, volunteers, hospitals along with the number of oxygen beds, intensive care beds, ventilator beds in each, ambulances, rehab centers, palliative centers, diagnostic laboratories, and pharmacies. They can be geo-tagged so that the search and navigation become easier. Based on existing disease burden and emerging illnesses, public health officials can estimate the need for specific healthcare services and compare them with the available supply across the entire health system, including public and private. Public health officials should engage the private sector in both planning and emergency response so that the available resources can be put to optimal use.
Financing healthcare needs of people
While access to healthcare is rapidly improving, it is being curtailed by the ability of people to pay for it. Many people from middle and upper class are avoiding tax-funded free public healthcare services due to an increasing trust deficit. Informal laborers who accounts for more than 80 percent of India’s labor workforce, have no protection of social health insurance that formal laborers do. Even those formal labor who have social health insurance (ESI) are not optimally utilizing the services available to them due to lack of awareness and poor quality of services provided by ESI hospitals and dispensaries. On account of poor design of health benefit packages and long waiting periods for realizing claims, many good quality private hospitals are not participating in state and central public health insurance schemes. On the other hand, private health insurance, which prices its products as per individual risk profiles, are not gaining enough traction and its clients account for less than 5 percent of the population.
As outlined above, a major structural reform in how public healthcare system is financed and managed is needed to make it more efficient and effective. With improved performance of public healthcare system, it will slowly regain the trust and confidence of people in accessing free or subsidized public healthcare services and goods. The National Health Authority (NHA) that manages PMJAY has a singular responsibility to make the scheme efficient and effective by adopting robust digital health insurance management systems to seamlessly process millions of claims in time and to minimize fraud. It should build capacity in health technology assessment (HTA) to design cost-effective health benefit packages (HBP). It should invest in building win-win relationships with empaneled hospitals. It can provide support to other large social health insurance programs (ESI, CGHS, ECHS etc.,) in the country in improving their efficiency.
The Insurance Regulatory Development Authority of India (IRDAI) should mandate private health insurers to offer essential health benefit packages not linked to individual risk. This will enable people with no form of health cover (such as informal labor, self-employed entrepreneurs running small and medium sized businesses, unemployed middle-class people) to purchase prepaid health insurance. It should commission an app to guide people in choosing the right product, right empaneled hospital, and in sharing their grievances.
Digital financial technologies (FinTech) are revolutionizing entire financial systems. They have simplified consumer financing. Consumption of healthcare services is growing faster than many other services. Banking and non-banking financial institutions should seriously consider financing healthcare consumers. They can help people pay their health insurance premia at more convenient intervals. They can fund hospitals while they are waiting for the claims processing so that hospitals do not struggle with working capital issues. That will encourage them to service more public and social health insurance beneficiaries. FinTech is also enabling innovations like crowd sourcing of funds from donors and mutual aids where people contribute periodically to avail of health loans when they need them unexpectedly.
A majority of private healthcare is owned and managed by medical professionals. They finance the capital needed for these facilities either from their own revenues or through borrowings from family, friends, and relatives. As health insurance claims increase, they are struggling to manage their working capital needs due to long delays in receiving their payments. The entry of private equity capital in healthcare has significantly altered the contours of healthcare services. While it enabled the creation of high-end hospitals, business ethics of private equity are found to be incompatible with medical ethics. There is a need for alternate funding mechanisms to support the creation of the required infrastructure in underserved areas. Blended financing, where a donor or the government provides the risk cover, is emerging as a viable alternative to private equity financing. It is too early to comment on its impact.
Hence, a critical element of strengthening our health systems is to address the issue of health financing for people to meet their health needs, for providers to create the needed infrastructure and run services, and for public health to undertake robust disease surveillance and control.
Governing health systems
Poor governance is an underlying reasons for dysfunctional health systems. Leading and managing the most complex health systems requires an understanding of health systems and its function, the ability to monitor its performance, allocating finances and other resources as per needs, regulating the private sector, building relationships with various actors involved in global, national, and subnational health systems, other social systems and ministries, investigating the underlying issues for its poor performance, developing policies, strategies, skills to implement these, and evaluating the impact of implementation. However, those currently entrusted with governance responsibilities may not have the required competencies to govern efficiently and effectively. In addition, there is continuous inter departmental transfers of these people, with no institutional mechanisms to ensure the continuity of various policies and strategies. Hence, it is critical to have leadership and management development programs that build specific capacities to govern health systems.
Managing health information
Each element in a complex system is interconnected and interdependent. A smooth flow of information across the system is essential for its effective functioning. For the information to be operable across each element and the entire system, it has to be based on agreed upon and uniform global or national standards. Just as grammar is essential for a language for it to be understood by the communities, standards are essential for information to be understood by all communities of a health system. There has to be an identification system to identify where the information has originated from. That means every citizen, every doctor, every nurse, every hospital, every clinic, every pharmacy, and every diagnostic laboratory shall have a unique identification. The information that is generated should be captured, processed, stored, shared, analyzed, and responded. Rapid advances in information and communication technologies are enabling the above requirements to manage continuous information being generated across health systems. The National Digital Health Mission, if implemented well across the country, has the power to strengthen and transform health systems.
Managing people’s health
While health systems address the direct health needs of the people in terms of healthcare provision and financing, there are many other social determinants that have bearing on people’s health status. These include socio-economic status, literacy, gender, access to safe drinking water, exposure to environmental pollution and indoor cooking gas pollution, nutrition, habits like smoking and alcohol intake, road safety, pesticide usage, hygiene, spaces for physical exercise etc. In addition, the gross inequity in our society has a direct implication on the health of marginalized people. Health systems leadership has a responsibility to interact with all others systems responsible for the social determinants health.
Understanding people’s health needs is the first step. These can be assessed as per the demographics and disease burden of the given population. Well-developed health information and surveillance systems will help public health professionals to get a clearer picture of changing disease patterns and emerging new diseases. Population level interventions in terms of public education, preventive screening and treatment, vaccination strategies, disease control measures are based on health needs assessment. The information thus generated can also guide the provider system in terms of demand-supply gaps in a given geography and for a given population cohort.
Engaging communities and local government units is important to managing population health. Community health volunteers (Accredited Social Health Activists or popularly known as ASHAs) and frontline health workers (Auxiliary Nurse Mid-wives or ANMs, Multipurpose health workers, sanitation inspectors etc.,) have emerged as a vital link between people, communities and health systems. Various self-help groups (SHGs) are increasingly playing an important role in population health. They are highly useful for dissemination of health information and education to their members, and for providing financial security net for their healthcare needs.
A systems approach is essential to strengthen the health systems
Every complex system, when understood for its anatomy, physiology, and pathology, becomes easily manageable. Just as a physician manages a person’s health with his/ her understanding of complex human biology and pathology, a health-systems professional needs to have the requisite knowledge, skills, and professionalism to manage complex health systems. Given the complexity, professionals will have to specialize in the various sub-systems and their further divisions and work in teams. A health system professional must not only be proficient in medical sciences but also in various other social and behavioral sciences.
In summary, the following strategies may be adopted to strengthen health systems:
- Health systems leadership development
- Capacity building of health professionals and institutions
- Migration to standards-based, interoperable health information systems
- A systems approach to improving quality of healthcare services
- Innovative approaches to meeting health financing needs of unprotected or partially protected people
- Investing in improving various social determinants of health like safe drinking water, clean cooking gas, clean surroundings, subsidizing healthy foods and taxing unhealthy foods etc.
- Robust surveillance systems to enable rapid responses during unexpected crises
- Constructive engagement of the private sector to generate the needed resources and to create healthcare infrastructure
- Active community participation in various public health interventions
Dr Krishna Reddy Nallamalla
Country Director, ACCESS Health International