India’s healthcare vision expansionary, must be inclusive too

By Soham D Bhaduri

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The NITI Aayog’s recently released report entitled “Investment Opportunities in India’s Healthcare Sector” shortly preceded the World Health Day 2021, the theme for which was “Building a fairer, healthier world”. The latter acknowledges that large, unfair, and preventable inequities in health persist across the globe. A global push for universal health coverage (UHC) over the past decade has inspired a renewed government focus on the health care sector in India. However, this renewed focus has been largely expansionary in character, with equity playing the second fiddle. Certain aspects of India’s expansionary journey to UHC merit discussion.

Rapid expansion
Being a signatory to the Sustainable Development Goals creates an implicit pressure to reorient and buttress the health sector for achieving UHC by 2030. Global experience shows that fair, equitable UHC is built upon years of progressive strengthening of the public health system, from health manpower to hospital beds. However, India’s long legacy of healthcare underinvestment militates against this, and, therefore, a quick-fix has progressively been envisaged in the past couple of decades—through rapid expansion of private sector involvement.

One deprecable consequence of this ‘pressure to expand’ is that while the current global order rallies behind free or near-free healthcare at the point of service, some of India’s official pronouncements have subliminally regressed to the principles of the early neoliberal era—where the large majority of the population (barring the poorest) self-pays for their healthcare. The NITI Aayog’s report is a case in point. It posits the growing per-capita income and rising paying capacity in tier 2 and 3 cities as attractive propositions for private hospital and health insurance investment. While a rapid private sector expansion may help achieve favourable bed-population and insurance coverage ratios on paper, our veritably poor track record of increasing public health spending entails that it would inequitably benefit the well-off. Similarly, the recent measure to turn certain district hospitals into medical colleges by handing them over to private players is aimed at rapidly increasing the number of doctors. In this attempt, not only has the question of alignment of such doctors to national health priorities been dismissed, but the last bastions of subsidised care in district hospitals now stand to be commercialised.

A pressing concern is that a rapid expansion of the private sector does not go hand-in-hand with growth of regulatory capacity and frameworks. While a battery of measures to attract private investment have appeared in the last few years, the only landmark regulatory development is the National Medical Commission, which anyway is of minor consequence in overall healthcare regulation. Important cogs like the Clinical Establishments Act continue to gather dust in quiescence. The possible perils of such mismatch are self-explanatory.

The problem with targeting
Targeting subsidies to the needy and poor is one of the measures directed at upholding equity. However, evidence indicates that in the absence of strong implementation and monitoring mechanisms, targeting is replete with inclusion and exclusion errors and is, thus, inefficient and inequitable. It particularly ceases to make sense for countries like India where healthcare access remains restricted across the board, barring the affluent few. However, the policy of targeting has been gathering steam since the last few years, despite copious evidence and examples against it.

Targeting in the healthcare space must be limited to situations where it is rendered indispensable by overriding fiscal constraints. In others, such as targeting poor patients for subsidies in hitherto universal public hospitals, it would only introduce newer inequities and inefficiencies.

Need for caution with health technology
The technology boost, as shown by the Covid-19 pandemic, can be a boon for Indian healthcare. However, technology is also one of the foremost causes of healthcare inflation worldwide, as has historically been witnessed in advanced nations. While health technology assessment has indeed gained some traction in recent years, the larger discourse on healthcare technology has remained rather directionless. Unaltered, this could create major inequities and inefficiencies. Balance is the key.

The NITI Aayog report mentions that far fewer mammograms or radiation therapies happen in India compared to the West, and the proposal to enhance diagnostic technology in public-private partnership mode should therefore be acknowledged with caution. An excess of such interventions in the West has formed an intractable cause of healthcare inflation, and the boundary between an Indian ‘shortage’ and the Western ‘excess’ could be deceptively thin. The health-economic rationale also says that as health insurance gets more generous, there is a greater incentive for cost-increasing technological innovations over cost-reducing ones. This would be imperative for the government to consider as it embarks on universalising public health insurance.

Amid pressures for growth, India should re-examine and re-articulate its health strategy such that an ambitious campaign for expansion doesn’t chip away at equity and fairness. Apart from keeping intact the real spirit of UHC, this would also help to keep at bay many systemic perils for the health sector.

The author is Physician, public health researcher & commentator