UHC provides the framework in which the issues of access, quality and cost can be integrated
Three recent incidents involving the health-care sector in Delhi have sparked widespread outrage over the alleged mercenary motives and callous conduct of high-profile corporate hospitals. Two cases involved children with dengue who died soon after leaving these hospitals in a serious condition after their families were presented huge hospitalization and treatment bills. The third case involved a live premature baby being “declared dead” and handed over to the parents wrapped in plastic.
Distrust and despair
Questions have been raised, and rightly so, about the lack of professional standards in terms of competence and compassion. The medical bills, running into huge figures, also stoked anger at perceived corporate addiction to profit maximisation. The government, the hospital management and the Indian Medical Association have begun inquiries. Even as these go on, there is deep public distrust and despair over health care in private and public sector hospitals.
Three major issues are involved when we assess health care: access, quality, and cost. Each of these needs to be addressed with clarity, and not in isolation. Solutions have to be those that fit into a common system architecture, or a system best designed and delivered as Universal Health Coverage (UHC), now enshrined in the Sustainable Development Goals.
Access to readily reachable, trustworthy and affordable health care is a major challenge before poorly served rural areas and overcrowded urban areas. Also, the inadequacy of organized primary health services here is compounded by a weakness at the intermediate level of care in many district hospitals and nursing homes. While corporate hospitals boast of high-quality advanced care and compete with each other for a significant share of medical tourism, they are mostly inaccessible to the rural population and the urban poor. Government institutions of advanced care suffer from low budgets and a lack of managerial talent.
Steps to improving access
The pathway to improving access lies in expanding the network of public sector facilities at all levels. This calls for higher levels of public financing, investment in training and incentivized placements of more health personnel and improved management through the creation of a public health management cadre. These measures have been envisaged in the National Health Policy, 2017 and need urgent and earnest implementation. Health-care providers in the private and voluntary sectors should be impanelled to fill the gaps through carefully crafted contracting mechanisms that best serve the public interest.
Quality of care is determined by the extent to which appropriate care is provided in each clinical context. Here there must be an emphasis on the benefit and safety of tests and treatment, and ensuring that satisfaction levels of patients, families, care providers in the nature of institutional processes as well as human interactions are met. This requires ensuring conformity to accepted scientific and ethical standards. Here, the Clinical Establishments Act is a good beginning, in moving health-care facilities towards registration, ensuring compliance with essential standards of equipment and performance, adopting standard management guidelines, grievance redress mechanisms, and respecting encoded patient rights.
Cost of care is a major challenge in a system where patients and families have to bear the burden. High out-of-pocket spending on health care leads to unacceptable levels of impoverishment. With high levels of poverty and a very large segment of the working population in the informal sector, both private insurance and employer-provided insurance can cover only small population segments. With a small risk pool, these schemes can only provide limited cost coverage to subscribers. Government-funded social insurance schemes to increase access to advanced care. But they have not been shown to provide financial protection as they cover only part of the hospitalization cost and none of the expenses of prolonged outpatient care which forms a higher percentage of out-of-pocket spending.
The solution lies in doubling the level of public financing to at least 2.5% of GDP by 2019, rather than 2025, as proposed in the National Health Policy, and by pooling tax funding, all Central and State insurance schemes and employer-provided health insurance into a “single payer system”. That can be managed by an empowered autonomous authority which purchases services from a strengthened public sector and, as necessary, from impanelled private health-care providers. Quality is promoted through audited insistence on implementation of standard management guidelines by all service providers who enter this system, and the cost is controlled by the negotiating power of the single payer. Since the risk pool is very large, there is a high level of cross- subsidization of the sick by the healthy, the poor by the rich and the elderly retired by the young employed. The burden on an individual is greatly minimized.
Implemented piecemeal, these three areas of action will yield only limited results as access alone cannot assure appropriate or affordable care and cost subsidy will be meaningless if there is limited access or undependable quality. The UHC provides the framework in which all three elements can be integrated. The cry for stronger regulation of quality and cost is justified but regulation will fail to deliver needed health care to all if the health system architecture does not adopt UHC. Similarly, the success of UHC depends on effective regulation. Now, there is a disconnect between these two in ongoing health system reforms. It is time to bridge that gap if tragic tales of terrible health care are not to cause recurring lament.