This section of the Pragati Manifesto outlines the government should approach Public Health. Read the other pieces here.
Health and healthcare have shown the first signs of becoming a national political issue over the past two years. Politics at its best can be a contestation of ideas and solutions. It is essentials that Indians debate, discuss and decide on setting up laws, institutions and policies to ensure good public health of all Indians.
India has about two more decades till its working-age population peaks in size, after which an older Indian society will bear significantly more healthcare costs. This is not something that will just affect the nation at large, but also every family. Studies using new data like that from the Indian Human Development Survey have firmly established that old models of chronic poverty no longer apply to much of India, and poverty is quite dynamic. Shocks from healthcare costs often result in families slipping back into poverty even after having escaped it because of economic growth and better opportunities.
In the last two years, we have seen new announcements by State and Union governments for publicly funded health insurance schemes for large sections of society, focused entirely on covering hospitalisation. These remain largely under-funded, and overall public expenditure on health by State and Union governments remain low, at less than 1.5 percent of GDP. At the same time, India’s noncommunicable disease burden is steadily increasing and communicable diseases like Dengue, Malaria and Tuberculosis remain unresolved challenges. Various parts of India have also seen public outcry against hospitals alleging exploitation and overcharging of patients, and strikes by healthcare workers against draconian government interventions to prevent medical fraud and crime and ostensibly to make private healthcare more affordable.
Here is a set of ideas on health and healthcare that we would like to see in political party manifestos in the upcoming national elections.
One: Put Public Health First
Prevention is less expensive than early treatment, and early treatment is less expensive than hospitalisation.
Health is often confused with healthcare, and public health is often confused with government-provided or government-funded healthcare. While we know that clean air, clean water, good sanitary conditions and hygiene can dramatically improve the health of any population, Indians governments rarely focus on them as health concerns and act in a concerted manner. Public expenditure on “Medical and public health” and “Family welfare” together just about touches 1 per cent of GDP. However, the entire expenditure on providing clean drinking water, sanitation systems, drainage systems and pollution control mechanisms don’t even cross 0.5 per cent of GDP. These are either public goods that need to be provided by the state, or need public enforcement of regulations on polluters. Indian cities have storm water drains acting as sewers, and most Indians spend enormous amounts of money on water purification.
At the same time, India’s Ministry of Health and perhaps other relevant ministries must come together to start a Public Health Focus Group that can track all efforts on public health in a concerted manner, and pivot away from focusing entirely on healthcare schemes of various types. Indian governments also need to invest significantly into epidemiology, and need to build up institutions like the US Centres for Disease Control (CDC). India’s National Vector Borne Disease Control Programme (NVBDCP), the Indian Council of Medical Research (ICMR) and institutions like AIIMS are inadequate.
Two: Liberalise Medical Education
Rapidly increase the healthcare workforce in quantity while improving quality.
India produces barely 60,000 medical doctors every year, and the overall doctor-to-population ratio in India is about 0.5-0.6 doctors for every 1000 people. This is half the WHO norm, and a small fraction of the ratio of doctors available in most advanced countries. The numbers are similarly deficient when it comes to nursing staff, public health workers and other medical workers.
A highly regulated medical education system under the control of the Medical Council of India has resulted in choking the number of medical colleges and seats, while increasing the cost of medical education as well. This further results in most Indian doctors needing to specialise further and/or go abroad in order to recuperate education expenses and make a good living.
While the National Medical Commission Bill introduced by the Modi government had its challenges and ultimately lapsed with the end of the current Lok Sabha, India needs to urgently liberalise and modernise its medical education regulations to double and quadruple the number of healthcare professionals entering the market every year.
Three: Improve the Healthcare Market
Provide Patient Protection Services and reduce information asymmetry in healthcare.
Much of healthcare consists of private goods. The biggest challenge in markets providing healthcare is information asymmetry: patients have to trust healthcare professionals to provide the best solutions for them. Healthcare providers often have perverse incentives to provide expensive and unnecessary treatments, and hold patients to ransom during the time of emergencies.
Governments can address this problem by reducing the information asymmetry in healthcare – by starting Patient Protection Services. Patient Protection Officers and helplines can help patients make better choices, increase access to second opinions on medical diagnoses, allow patients to own their own medical information, and provide a more robust grievance redress system.
Four: Invest in Public Goods Necessary For 21st Century Medicine
Public investment in drug discovery and population genetics is vital.
India needs new vaccines, new drugs, and new diagnostic tools to tackle diseases and health risks that are more prevalent in India. Today, India largely depends on drug development happening elsewhere and we rarely develop medicines in India, for Indians. Most drugs developed and patented by big private pharmaceutical corporations still have a layer of basic science and early drug discovery that is often funded by governments. That layer of public funding for drug discovery is minuscule in India, and even for Indian problems like the widespread Dengue, the rare solutions we see are getting developed in Mexico or elsewhere. India needs to invest much more on drug development and fundamental biosciences to change this.
Further, India is unique in having up to 5000 unique genetic populations of humans due to wide-spread endogamy. This means that different populations in India likely have unique genetic disease burdens. A National Genome Platform with annotated and anonymised genetic information of Indians is a necessary public good based on which precision medicine solutions can be developed. Further, India will need to provide better regulatory clarity for therapies based on gene-editing and other modern technologies to allow for great research and development.
Five: Empower State Governments and Hold Them Accountable
State governments are better placed to attend to the health needs of their residents.
While the Government of India has a large role to play in improving the health of all Indians, the constitutional mandate of health lies with the states, and justifiably so. Any new initiatives must be federal in nature, and must actively include states in designing new public programmes, and allowing greater autonomy in execution. India’s Centrally Sponsored Schemes on health must be radically redesigned for better equity and greater autonomy for States to formulate their own solutions.
Most public attention and scrutiny is on the Union government’s efforts on health and healthcare, but over 70 per cent of public expenditure on health in India is done by state governments. While the total is still far from enough, greater public attention needs to go into state-level policymaking on health – and the Union government can also switch its role from a provider of funds and schemes to one that tracks the progress of State governments at tackling local health challenges and increase public accountability.
