Universal healthcare must be our national goal. India’s public expenditure on health as a percentage of GDP is abysmal — about 2 per cent. This must be raised to 5 per cent in the current financial year. Also, the private sector should be given highest priority, including incentivising its entry into research.
State budgets are grossly inadequate. The risk taken by private sector should be appropriately protected by GoI. Price controls and raids will not attract investment. The hidden capacity of private sector to harness investment needs to be unchained. National policy should clearly commit preference for the private sector in medical education, health infrastructure and medical device manufacturing.
A national scheme should aim to double the number of hospital beds. Incentive schemes to attract investment without any restriction on FDI should also be announced. India also needs predictability of regulation around intellectual property rights (IPRs).
GoI should announce the contours of a national health scheme backed with free insurance coverage to all citizens with an annual income up to Rs 20 lakh. Responses and standard operating procedures (SOPs) need to be vigorously stress-tested to identify gaps for improvement.
States should be free to adopt GoI’s minimalistic agenda. They would qualify for financial assistance on the basis of minimal national programme fulfilment. States can freely go above and beyond this minimum by topping up through their own schemes.
The healthcare framework must be reviewed urgently. There already exists a national programme to set up medical care hospitals covering three parliamentary constituencies. But the implementation of infrastructure and staff placement is tardy and often substandard. We continue to have buildings with no doctors, and rural healthcare, as the Allahabad High Court recently observed, is seen to be left to ‘Ram bharosey’.
GoI should include mobile healthcare, connecting each revenue village to district and primary health centre. The mobile van should have a contingent of two doctors, two nurses and one technician with listed essential medicines. Each revenue village should be visited at least three times a month with a pre-fixed schedule. ASHA (accredited social health activist) workers must be part of this scheme, which can be supplemented with private sector telemedicine initiatives, many of which have already started.
An effective health management framework needs a robust data backbone for two-way passage of information. The mobile health scheme will become the primary unit for such communication.
Human capital must be a prerequisite for an efficient health infrastructure. There is an acute shortage of trained doctors, nurses and technicians. Along with infrastructure expansion, a corresponding supply of human capital to efficiently operate the system has to be there. Instances of emergency equipment remaining unused is rampant. Either the staff has not been sanctioned, or recruitment is pending. Many of those serving have grossly inadequate training to operate equipment.
The admission, syllabus and prerequisites for degree and training should be reviewed to attract more candidates at doctor, nursing and technician levels. The health ministry should come up with a scheme for doubling seats for medical students. There is a strong case to finance medical education at all 500-bed capacity hospitals. Nursing colleges should also be compulsory for 300-bed-plus hospitals.
Quality Time in Villages
Specialists should be motivated for adoption and mentoring programmes. ‘Good’ doctors must be encouraged to commit their professional time in rural areas and district hospitals. Periodic training should be mandatory up to technician level. Digital delivery of training and upskilling will resolve the issue of quality trainers.
The second wave has driven home the point that India remains desperately dependent on other countries for key medicines and raw materials. Mere ‘reverse engineering’ is not enough. A 2019 US congressional testimony, ‘Safeguarding Pharmaceutical Supply Chains in a Global Economy’ (bit.ly/3yA1pTi), highlights the urgency of identifying alternative sources. According to the US Food and Drug Administration (FDA), between 2000 and 2019, the Chinese share in active pharmaceutical ingredient (API)-making facilities more than doubled.
No doubt R&D is capital-intensive. But India’s regulatory institutional framework is a disaster. A few years ago, the Indian Pharmaceutical Association (IPA) listed a plethora of approvals and delays in the Central Drugs Standard Control Organisation (CDSCO) and Indian Council of Medical Research (ICMR). IPA made noises at all levels but the regulatory framework did not budge. Some major companies shifted their R&D work to Europe and even China. India’s regulatory framework has to be overhauled and be welcoming towards R&D.
GoI support is essential in the beginning for setting up research establishments. Higher R&D spending is an insurance premium. It will mitigate future health crises.
Skill sets — experience and understanding health tech — are mandatory in modern public health. We must learn from the pandemic, and ‘fit-for-purpose’ healthcare infrastructure will be the right response.