By Dr Shyam Ashtekar (MD)
India needs to develop a humane, affordable, scientific and equitable health care network. Important preconditions include a freedom to choose and optimal client say. Content of care is as important as access. The health sector agenda will include pooling of resources, primary care, promoting economy hospitals in public and PPP sectors, health information sources, health laws and regulation, promoting AYUSH, control of important diseases, Health Human Resources (HHR), rational use of drugs and technology, healthy demographic change and a better role for states and local governments.
As a national framework, Social Health Insurance (SHI) is preferable to both statist or market driven models. The critical issues are health finance and Human Resources (HHR). The Srinath Reddy committee recommended 2.5% of GDP (about 1.2% till last FY) for providing a free Universal Health Care (UHC) package supported through tax source.
However this ambitious plan requires above 5% of GDP. This is achievable only through pooling of private and public health-spending.
Good SHI systems are functioning in Germany, South Korea and China etc. SHI can negotiate our diversity and provide some space for control/ participation by users including middle classes. The current private spending (about 2500/ Rs PCPI) needs to be harnessed as pre-payment for SHI.
The SHI requires small co- payments at the point of service. BPL families can get free UHC from Govt support. The SHI model is way different from the miserable US care based on private insurance, not to mention its high costs (at 16% of US GDP).
HHR is another complex front. About 60% of basic specialist positions in rural hospitals are vacant, negating the quality concerns in referral care. We failed to get enough doctors even in urban public hospitals that are already scant. This is due to gaps in training infrastructure, poor working conditions and employment terms. It is time to end the chronic neglect of AYUSH and paramedic HHR. About 7 lakh ASHAs get below Rs 1000 a month. No UHC is possible without good HHR management.
Here are some easier things. The first is taking primary care deeper in rural and urban units. Trained paramedics can handle some 50 common health problems. Through this we can upgrade SHAs, informal providers and create a million jobs. The ambulance network is a good development, and we need paramedics here too. AYUSH doctors can manage the existing subcenters. The rural doctor course (BRMS) is a lesser alternative. Handing over the nearly one lakh subcenters to panchayats will also open a new front for local action in primary care.
A wide primary care network will ensure preventive programs and reduce hospital-workloads and hence total costs. No UHC is possible unless we have this gate-keeper system. The small family and spacing of births should again be an important primary care concern. It is both a cause and effect of underdevelopment, among other factors. But let us do it without coercion or bribes. Also, primary care calls for a national open source on health in all languages.
On the disease control and prevention front …continued »