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 Table of Contents  
CONTROVERSIES IN MEDICINE
Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 133-137

Stronger government health sub-system is the way to advance universal health coverage in India


National Professional Officer, Department of Health Systems Development, World Health Organization India Country Office, New Delhi, India

Date of Submission20-Sep-2020
Date of Decision30-Sep-2020
Date of Acceptance03-Oct-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Chandrakant Lahariya
B.7/24/2, First Floor, Safdarjung Enclave Main, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_165_20

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How to cite this article:
Lahariya C. Stronger government health sub-system is the way to advance universal health coverage in India. J Med Evid 2020;1:133-7

How to cite this URL:
Lahariya C. Stronger government health sub-system is the way to advance universal health coverage in India. J Med Evid [serial online] 2020 [cited 2021 Jan 19];1:133-7. Available from: http://www.journaljme.org/text.asp?2020/1/2/133/303560




  Introduction Top


A well-functioning health system strives that health status and outcomes (i.e. morbidity & mortality rates and life expectancy etc.) of all population subgroups are similar (the inequities are removed). Every health system also aims that the decision of the people to access health services is based upon their health needs (and not determined by their paying capacity), and the health services should be either free or affordable to everyone (financial protection). Unless specific attention is given, these conditions are unlikely to be fulfilled in the mixed healthcare systems, which have both public-private providers delivering health services. For example, as the private sector needs to recover the cost, it focuses upon 'maximising the profit' and on the delivery of curative and diagnostic services (very limited preventive and promotive services are provided) and people have to pay to avail the health services. A combination of these aspects results in reduced availability, accessibility and affordability of health services for many, which in turn worsens the health inequities. An example is COVID-19 pandemic in India, when the cost of COVID-19 testing and treatment services in private sector was reported to be very high (later on, regulated by the government through price capping), which made accessibility and affordability difficult. In this article, deriving immediate learnings from COVID-19 pandemic response, the author examines how mixed healthcare system can accelerate progress towards the goal of universal health coverage.


  Mixed Healthcare Systems and Associated Challenges Top


India has a mixed health-care system, comprised of public or government (In India, the terminology of 'public' or 'government' health system is used interchangeably. However, it must be noted that when the term 'public health' is used in context of services, it carries an entirely different meaning. Public health services focuses on prevention, promotion and maintaining the health of the population. Description of 'public health services' conveys only the type of services and not a reference to the type of provider, which delivers these services. The preventive and promotive services, even if provided by private sector, would be called public health services) and private (Many argue that even the private sector is not fully homogenous. It is comprised formal (or qualified) providers as well as of the informal providers. There is another distinction created by the ownership of private sector between the corporate hospitals and chains and those run by an individual or a small group of doctors. Similarly, the non-governmental, not-for-profit and charitable institutes at times are considered as private, not for profit. However, there is merit in keeping these as a third and a separate entity. In this article, the 'not for profit' health sector has not been discussed) health subsystems. (A health system is comprised of the people, institutions and resources, whose primary objective is to promote, restore and/or maintain health. Therefore, while terminology such as public or government health system or private health systems are commonly used, in reality, within defined political and geographical boundary, be it nation, state or district, there is just one health system, which combines everything including government and private health sectors. At best, these can be defined as 'health sub-system', a terminology which author has used throughout this article.) Each of these two health sub-system has their strengths and challenges. Health is a state subject as per the Indian constitution and both the union and state governments have set up health-care facilities. The government has vast network of health facilities across rural and urban parts of the country, which provides health services, mostly for free (except for a small co-payment as user charges in select services and states). However, government facilities are often known for insufficient funding, shortages of human resources and remains underutilised.[1] The private sector is mostly confined to the urban settings and provides, mostly the medical care on the payment basis. The challenges commonly associated with private sector are high treatment cost and the resulting unaffordability for many (unless covered by some form of insurance mechanisms); insufficient regulation and the quality of services are not always known.[2]

One of the most detailed documentation of challenges in the government health subsystem has been in the situation analysis document, released with India's most recent national health policy (NHP) 2017.[1] This arguably is as close as any government can be in acknowledging the weaknesses in health systems. In contrast, the challenges in private health sector are nearly always contested by the private associations and rarely acknowledged.[3]


  COVID-19 Pandemic and Government and Private Health Subsystems Top


The severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) and COVID-19 pandemic in India is being fought with a full range of health services. The preventive measures or the non-pharmacological interventions of face covers, hand washing and physical distancing are being followed by the individuals and communities. The public health interventions of testing for COVID-19, contact tracing and quarantine and isolation are being carried out, mostly by the government agencies (Though COVID-19 testing is also done in the private sector). These two subgroups of interventions are targeted for the entire population. The third subgroup of interventions, treatment, is needed for only those tested COVID-19 positive. Nearly one in every five of those tested positive need admission-based COVID-19 services. These treatment services are being provided by both government and private sectors in India. While the pandemic is being fought by people and health systems together, among the health subsystems, the major responsibility is being shouldered by the government health sub-system.[4]

COVID-19 pandemic and subsequent developments have amplified the already known challenges in Indian health system. Soon after the start of pandemic, while health services across sector were drastically reduced, the private health facilities remained largely closed.[5] Soon health services started to open up, in majority of private facilities, the fees for non-COVID consultation as well as the charges for hospital room and other services were hiked by 20% to 50%.[6] When private sector started providing the COVID-19 treatment services, the cost of intensive care units (ICU) and ventilator beds reportedly went up to Rs 75,000 to Rs 100,000 per night of stay.[7] The total cost of treatment for COVID-19 patients in private hospitals ranged from Rs. 3 to 16 lakh per patient with minimum charge, usually starting at Rs. 3 lakh, irrespective of the duration of stay.[8] The cost of COVID-19 treatment in private facilities was considered so high that even insurance companies were rejecting a large proportion of claims and reimbursing usually half or even less of the cost of treatment for COVID-19 cases.[9] This situation resulted in that both union and state governments in India resorted to price cap on COVID-19 treatment services.[10] The only other COVID-19 service being provided by the private sector has been testing service, which were also capped for price regularly[11] and in some cases, punitive actions were taken against a few laboratories for violating the provisions and government guidelines on COVID-19 testing.[12]

The price regulation done by the government for COVID-19 pandemic period is, arguably, the first explicit recognition of excessive cost and overcharging by the private sector in India. It was also the first time when health regulation were strictly enforced by a number of Indian states, to make health services accessible and affordable and yet, did not meet a widespread protest from the private sector.


  Government and Private Health Subsystems: services and Efficiency Top


It is often argued that private sector provides a majority of health services. The commonly quoted data sources are periodic surveys conducted by the National Sample Survey Organisation (NSSO).[13] 71st round of NSSO reported that in 2014, the private sector provided nearly 75% of outpatient and 58% of hospitalisation and admission-based services.[13] Nearly similar findings were reported in 75th round of NSSO survey for year 2017-18, with marginal improvement in share of government health facilities. It seems to convey that private sector is a major healthcare provider. However, that is correct information but incomplete interpretation. The NSSO data covers mostly the medical care (curative and laboratory services), which are only a part of health services. The health services include the full range of preventive, promotive, curative, diagnostic/testing, rehabilitation and palliative care services. Another approach to define health services is group into the public health (disease prevention and health promotion including services such as antenatal check-ups and vaccination) and medical care (curative including outpatient and admission-based services and the diagnostic services). The primary objective of NSSO surveys is to collect information on health expenditure rather than providing the information on the provision of health services. The NSSO does not fully capture the information on public health services. Therefore, use of the NSSO findings for health services provisions results in an incorrect or incomplete interpretation.

The nationwide demographic and health surveys such as National Family Health Survey (NFHS) and District-Level Household Survey (DLHS) provide more detailed information on health services with additional tracer conditions such as immunisation and antenatal visits.[14] The findings from NFHS and DLHS have regularly reported that a majority (up to 80%–90%) of public health services are delivered by the government health system.[14] In this background, if we look at health as a whole, the government health sub-system does perform far better than the private health subsystem.

Another health discourse, which has nearly occupied the status of 'accepted myth', is that government health sub-system is 'inefficient' and private sector 'highly efficient'. The truth is that every health system, across the world, has inefficiencies which need to be addressed. The World Health Organisation's World Health Report 2010 had identified 10 common causes of inefficiencies in health systems.[15] These inefficiencies are indicated at the health system levels (and present in both government and private sub-systems) and it has been proposed that all countries should try to address the root causes of these inefficiencies.

Going beyond the opinions, if examined on the objective parameters of 'technical' and 'allocative efficiencies', the government health subsystem in India may not be as inefficient as painted, and the private sector may not be doing exceptionally well. In fact, the governments (both union and states together) spend nearly 30% of total health expenditure (THE) in India. In return, the government health subsystem delivers one-third to half of the medical care services and nearly 80%–90% of the public health services.[16],[17]

[TAG:2]Mixed Healthcare Systems Need Strong Regulatory Mechanisms to Work for People[/TAG:2]

In mixed healthcare systems, the private sector is an important contributor in the overall provision of health services. The private sector is good in delivering 'high cost and low volume' services. Top two quintiles of population which can, either afford or are covered by some form of health insurance schemes prefer to use private sector. The private sector, being 'market driven', at times can contribute to fill some of the gaps in medical care services. However, to ensure that health services are available irrespective of paying capacity of the people and to all quintiles of population, strong government-funded health subsystem is equally desirable (In mixed healthcare system, if used to the strength, the private sector can be of real-value addition. In COVID-19 pandemic, private health sector contributed to the expansion of COVID-19 testing and treatment services. It helped in expanding the supply and availability of testing kits, personal protective equipment as well as ventilators. A small proportion of people in need could use COVID-19 treatment services in the private sector, either through the personal health insurance or the Pradhan Mantri Jan Arogya Yojana under broader Ayushman Bharat Program. Similarly, the government and private sectors are collaborating for development of additional testing approaches, in development of drugs and therapies as well as vaccines). The strong government health sub-system is foundation of famed National Health Services in the United Kingdom, in the Organisation of Economic Cooperation and Development (OECD) countries as well as in a number of countries in Asia such as Vietnam and Thailand.[18] On other spectrum, there are countries where majority of services are provided by the private sector, i.e., Japan and the Netherlands. However, in these countries, the health regulatory mechanisms are exceptionally well functioning and enforced effectively.[19]

The implementation of health regulation in most low- and middle-income countries (LMICs), India included, remains suboptimal and often resisted by the private sector on various grounds. Private sector predominance and poor enforcement of health regulation can become a real challenge and may result in health inequities and poor people not getting the desired health services. Therefore, in mixed health systems and LMICs, stronger government health sub-system can work as an important balancing force to address the challenge of a weak health regulation. The approaches of price regulation and strengthening other regulatory mechanism should be continued in the time ahead; however, strengthening government health subsystem could be the best regulatory mechanism in LMICs.


  What we Can Learn from COVID-19 Experience in Health Sector? Top


There is global evidence to support the role of government health sub-system. In COVID-19 pandemic response, Vietnam and Thailand continue to remain the success stories.[20] Till the mid of September 2020, Vietnam with nearly 10 crore population reported around one thousand COVID-19 cases and nearly 40 deaths. Thailand, with nearly 7 crore population, had slightly higher number of infections but <100 deaths. Analysis by experts concluded that it was a combination of a strong and well-functioning government health systems as well as the learning and implementation of the lessons from SARS outbreak in 2002–2004, that these countries have done well in COVID-19 pandemic response. After SARS outbreak, both Thailand and Vietnam invested financial resources in government health sub-system, increased annual allocation to health services by 8%–10% over next few years and strengthened disease surveillance, reporting and contact tracing systems. These countries had established decentralised public health laboratories and recruited and trained health workforce which was needed to make public health services functional.[20]

Another lesson from COVID-19 pandemic experience is that the empowered citizens play very crucial role in preventing diseases and staying healthy. In pandemic, the non-pharmacological interventions of hand washing, face masks and physical distancing were and are to be followed by the individuals. These interventions at Individual levels combined with public health interventions of 'Test, trace, isolate and quarantine' implemented by government health systems have been the foundation to pandemic response.[21]

If the similar 'collaborative approach', where individual and health system fulfil their responsibilities – can be continued for other health initiatives, i.e., for prevention and control of non-communicable diseases (NCDs) such as diabetes and hypertension, it can reduce the burden of these disease rapidly. In this specific case of NCDs, people can contribute to reduce the burden of risk factors and diseases by adopting healthier lifestyle of eating healthy, regular physical activity, no smoking and moderate or no use of alcohol. The government needs to strengthen the provision of testing, counselling, referral and other follow-up services for these conditions, closer to the people, preferably delivered through Primary Health Care (PHC) system. In nearly all countries, the preventive and promotive health services are largely delivered by government health sub-system. There is piling evidence that when governments fulfil their responsibilities, people also start taking responsibilities for their parts. Similarly, the learnings and experience from the 'contact tracing' in COVID-19 can be continued in time ahead and be useful for control of other communicable diseases. More specifically, as India aims for tuberculosis elimination by 2025, strengthened 'contact tracing' approach could be a game changer.

COVID-19 pandemic has also busted another myth that 'the high end technology driven and super specialist based health services are the best for all situations'. The health services in the United States of America (USA) are considered amongst the most technology advanced, the most expensive and highly curative focused. The healthcare system in the USA has focused on specialist care instead of primary care and the dominance of medical care and limited focus on public health services. Many experts have argued that it is this 'medicalized' and curative centric health system that the USA has been the worst affected and struggled in responding to pandemic.

COVID-19 pandemic has once again highlighted that the healthcare is comprised of public health (preventive and promotive services) services as well as medical care (treatment and diagnostic services). Private health sector which mainly focuses on medical care increases access to limited health services; however, to ensure healthy population, we need public health services as well. Even medical care provided by private sector comes with a cost (for most people that is unaffordable) and which deters people from seeking early care. The public health services are nearly exclusively provided by governments health facilities. The stronger provision of public health services would reduce the need for curative and diagnostic services.


  The Ways Forward Top


In 2010, the Universal Health Coverage (UHC) became a global calling. The central goal of UHC is to ensure that 'all people have access to needed promotive, preventive, curative, and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship, when paying for these services'.[22] India had committed to UHC as a part of Sustainable Development Goal Agenda, which has target 3.8 under Goal 3 on health.[23] Subsequently, in 2017, the government of India released the latest NHP, which has the goal to ensure availability, accessibility and affordability of quality healthcare services. The NHP goal is fully aligned with the concept of UHC, which makes NHP 2017, arguably, India's most explicit commitment to achieve UHC.

However, if we look at the current provision of health services in India [[Figure 1]; triangle on the left side], it appears to be an inverted pyramid. A large proportion of health services are delivered and used at secondary and tertiary levels. Many of these services can and should be delivered through PHC facilities. The provision of primary care and public health services is relatively less (representational schematic, not to be quantified). Similarly, private sector is a major provider. The service provision is specialist heavy and general physicians are not given due importance.
Figure 1: Reverse the ‘pyramid of inverse care system' for improved health outcomes in India

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The Indian states, which have responsibility for health as per the constitutional provision, need to consider the strategies to correct the inverted pyramid by both re-organising and strengthening the health services at PHC level (supply side) and supporting the behaviour change in people to use these services at appropriate levels (demand side). A better and efficient health system needs to have public health services and PHC as the foundation of service delivery. India needs to inverse the 'inverted pyramid'. This can become possible only through a strengthened government health sub-system designed to deliver public health, PHC and other health services [[Figure 1]; triangle on the right side]. Ensuring that the pyramid returns to the right shape should be the vision for health service delivery in India.

An increased government investment on health- targeted at identified health needs- can address many challenges in the mixed healthcare systems. Stronger network of well-functioning primary healthcare facilities, enhanced provision of public health (preventive and promotive) services, free medicines and diagnostics services, and effective enforcement of health regulation can make health services available, accessible and affordable for all populations. These are some of the learnings emerged from COVID-19 pandemic response so far and should be used for strengthening health systems in low and middle income countries.


  Conclusion Top


COVID-19 pandemic has sensitised the citizens, the elected representatives and policymakers about the challenges people face in the access to healthcare services. This should be grabbed as an opportunity to strengthen government health sub-system. Even with the challenges, it is the stronger government health subsystems, which assure the equitable and affordable access to health services in India. The UHC by definition has three dimensions of coverage of all populations (rural–urban, young-old, men-women-transgender and rich–poor, amongst other), coverage with broader range of services (public health as well as medical care) and the financial protection coverage (services should be either free or affordable to everyone). Most countries could progress toward UHC with stronger government health sub-systems. India and Indian states will be able to achieve UHC on the same approach – a stronger public or government healthcare sub-system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclaimer

Author is the staff member of the World Health Organization (WHO). The views expressed in this article are personal, and do not necessarily represent the decisions, policy, or views of the WHO.



 
  References Top

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