Restructuring delivery of health services in India

Ques. “Until we choose to change the way the poor access health care, it is unlikely that we will be able to change their poverty status” critically comment.

India has a universal health care system run by the constituent states and territories of India. The Constitution charges every state with “raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”. Catastrophic health expenses are the biggest reason for pushing individuals and families into poverty. The poor cannot afford to be sick because they cannot afford to get well. Parallel to the public health sector, and indeed more popular than it, is the private medical sector in India. As reflected in surveys, 70 per cent of India’s sick, mostly belonging to the poor or lower middle class, choose to go to the private sector when there is ostensibly free healthcare in the public system.

Both urban and rural Indian households tend to use the private medical sector more frequently than the public sector due to following reasons:

  • Poor quality of care, long waiting lines, patient maltreatment and neglect in the public healthcare sector.
  • Lower-level public healthcare facilities often suffer from a variety of problems, including worker absenteeism and dual public-private practice, low demand for their use, and shortages of supplies and staff.
  • In contrast, private healthcare varies greatly in quality of care, being unregulated and financed largely through out-of-pocket payments. In the private sector, there are a large number of health workers who have only a high-school education or do not have a medical degree.
  • According to the Central Bureau of Health Intelligence report of 2010, India’s government hospitals have one bed for every 2,000 people. The Planning Commission’s report also says that Primary Health Centres across the country have a shortage of 6,148 doctors.

There are two major healthcare programs in India:

  1. National Rural Health Mission (NRHM)- Which is the central government’s attempt to improve delivery of services in public facilities as well as public-health and preventive interventions, led by the Ministry of Health and Family Welfare. NRHM, launched in 2006, has had some success in improving access to certain services, such as maternal healthcare (under the Janani Suraksha Yojana program).
  2. Rashtriya Swasthya Bima Yojana (RSBY)- Which is a health insurance program led by the Ministry of Labour and Employment. In most states RSBY covers people “below the poverty line” for a selected set of tertiary care services.

India needs to improve its vaccination coverage for children, which is one of the most cost-effective health interventions. Government needs to experiment with different tools for reforming its healthcare system, including how the central government pays state governments and the incentives on those payments, as well as how state governments can improve the delivery of healthcare services through changing payment systems, improving regulation and accreditation of facilities, increasing autonomy in public facilities, and using demand-side incentives such as cash transfers or insurance to stimulate the supply of services.

The government needs to engage the private sector in restructuring delivery of health services. The private sector must be innovatively engaged to become part of the solution. The government must ensure that this sector is regulated and monitored effectively. The overuse of diagnostics, over-the-counter sale of drugs and the rising numbers of quacks must be checked immediately. The onus is more on the government to build a mutually beneficial relationship with the private sector.

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