By strengthening health systems, India can better prepare for the next health emergency
The Covid-19 pandemic has exposed weaknesses in every society and health system around the world and continues to disrupt economies globally. Covid-19 seems to be evolving into an endemic disease, much like influenza, that returns regularly and occasionally with large epidemics and pandemics. Additionally, there are always other emerging infectious diseases that remind us to continue strengthening our health systems to prepare against the next health emergency.
Although India’s response to the Covid-19 pandemic witnessed several positive outcomes, the country’s health system remains highly vulnerable to health crises. Its people are highly affected by both communicable and non-communicable diseases, and its large and diverse population creates challenges in responding to the very large scale or scope of problems. However, the response to Covid-19 underscores India’s commitment, potential and capability to strengthen its health systems. The pertinent question is: What should India do to strengthen its health system?
Strengthening Health Systems: Building on recent initiatives
In the recent years India has launched multiple initiatives that attempt to address significant challenges within its health systems. This includes Ayushman Bharat with its two legs of strengthening primary health care and providing financial protection against health expenditure to the poor, introducing digital health in mainstream patient care models, promoting alternative medicines, recognising allied health and healthcare professionals, and enhancing public private partnerships (PPPs), amongst others. However, some critical and systemic problems persist, that impede the development of a robust health systems. Strategic measures can help accelerate development in the field.
Pursue universal healthcare coverage (UHC) in a more integrated way. The 2018 launch of the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (PMJAY) was indeed a significant step towards achieving UHC. While this health assurance scheme promises to cover the most vulnerable citizens from much of the costs of hospitalisation, constituting the poorest 40% of the country’s population, there is immense scope to do more and have a greater impact. Better coordination and seamless integration between Health and Wellness Centres (HWCs) being developed under the first leg of Ayushman Bharat and PMJAY will help in expanding access and ensuring follow-up care for the poor. Greater focus on prevention and management of several health conditions at HWCs will also reduce cost for PMJAY. In addition, much work is needed to expand communication with the public about how to benefit from the schemes, as well as to ensure that public and private providers will be able to use the scheme to cover their costs and provide quality and responsive care. But as a whole, the health coverage schemes in India are fragmented, leaving out important populations, having inconsistent benefits packages, not efficiently and fairly paying providers, and are not oriented towards prevention and integrated person-centred care models.
Unfortunately 30% of the population which forms the middle class are largely without health coverage. While the population has a significant capacity to pay for health insurance, the insurance products generally cater to higher-income groups. There remains a need to expand financing of health services coherently, probably by leveraging PPPs to provide better quality and range of services at affordable price point. Today, outpatient care contributes substantially more to out-of-pocket expenditure that impoverishes people and creates a barrier to needed care. UHC financing and delivery programs need to integrate and be inclusive of both inpatient and outpatient care. It is important that health financing models are reviewed and designed to support access to quality healthcare by all across the range of services that people need.
Integrated care models. Like most healthcare systems, Indian healthcare largely has a vertical model of care delivery and reacts to problems as they emerge. There is a need to trigger a shift to person-centred integrated care which caters to the needs of an individual, their family, and the community. This approach should seek to add value across prevention, promotion, curative and rehabilitative and palliative services. In addition to linking the financing of out-patient and inpatient care, another step in this direction would be to link health and wellness centres with hospital care and other health services. Some important aspects of patient centred care include respecting patient’s will and dignity, delivering coordinated and personalised support and care, and helping patients develop their independent abilities.
Build an inter-professional public health cadre. The current Indian health professional education does not focus on developing competencies for public health and management. Physicians are trained in individual clinical care, but not provided the appropriate learning opportunities to fulfil roles in population health functions or managing health facilities and programs. A wide range of competencies are needed to support community health engagement, disease surveillance and response systems, health promotion and prevention program management, monitoring and evaluation, as well as leadership, and management of teams, finances, and other resources. A public health cadre should not be solely focused on physicians whose primary training is around individual clinical services, but should be developed as an inter-professional cadre that also includes nurses, social workers, epidemiologists, policy and management experts, social scientists and engineers, and be equipped to work in inter-professional teams that can address the full range of population health needs within India’s complex health system.
Increase and better allocate health spending. Despite multiple health initiatives implemented in the recent years, the current spending on health in the country is very low. For the year 2017-2018 India’s total health expense was a dismal 3.3% of its GDP. Other BRIC nations (notably Brazil, Russia, and China) ranged between 5% to 9.5%. India’s current public spending on health is only 1.3% of GDP. More than 50% of health expenditure is incurred directly through out-of-pocket by people. This is both inefficient and inequitable as it often delays and discourages appropriate treatment and disproportionately penalises the poor. For the programs to drive the desired and long-term impact, it is essential that the programs and initiatives have sufficient and sustainable funding mechanisms. Significantly more funding will be needed to transform the health sector. Specifically public funding is needed to support the goals of providing universal financial protection from the costs of healthcare, and to implement purchasing arrangements that promote high quality and integrated health care. And of course there is even greater need to invest in public health systems that address the population needs for prevention, promotion, disease surveillance and response and other common goods for health.
Appropriate policy reforms will help improve the existing health ecosystem in the country and open avenues to effectively cater to most pressing health issues in a systematic and well-thought strategy. The Indian health system is undeniably complex, largely fragmented, inadequate and most importantly, it is recovering from the pandemic onslaught while braving these challenges. The Covid-19 experience highlighted an increased availability and awareness of digital healthcare technologies such as telemedicine, as well as some initial strengthening of health data surveillance capabilities. It has also heightened attention on developing a public health cadre, and on the value of increasing collaboration across national agencies (ICMR, National Institute of Virology, National Communicable Disease Centre, National Health Authority etc.), and with state and local authorities, as well as with private providers and others in the private sector, notably vaccine and medical supply manufacturers. We know that the country has the intent and capability to make the transformations needed to creating a robust, high-quality health system. Following through on its intentions will enable India to create a story of positive change and sustainable impact, and be able to share it across the country and with an increasingly interconnected and interdependent world.
The Covid-19 pandemic has exposed weaknesses in every society and health system around the world and continues to disrupt economies globally. Covid-19 seems to be evolving into an endemic disease, much like influenza, that returns regularly and occasionally with large epidemics and pandemics. Additionally, there are always other emerging infectious diseases that remind us to continue strengthening our health systems to prepare against the next health emergency.
Although India’s response to the Covid-19 pandemic witnessed several positive outcomes, the country’s health system remains highly vulnerable to health crises. Its people are highly affected by both communicable and non-communicable diseases, and its large and diverse population creates challenges in responding to the very large scale or scope of problems. However, the response to Covid-19 underscores India’s commitment, potential and capability to strengthen its health systems. The pertinent question is: What should India do to strengthen its health system?
Strengthening Health Systems: Building on recent initiatives
In the recent years India has launched multiple initiatives that attempt to address significant challenges within its health systems. This includes Ayushman Bharat with its two legs of strengthening primary health care and providing financial protection against health expenditure to the poor, introducing digital health in mainstream patient care models, promoting alternative medicines, recognising allied health and healthcare professionals, and enhancing public private partnerships (PPPs), amongst others. However, some critical and systemic problems persist, that impede the development of a robust health systems. Strategic measures can help accelerate development in the field.
Pursue universal healthcare coverage (UHC) in a more integrated way. The 2018 launch of the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (PMJAY) was indeed a significant step towards achieving UHC. While this health assurance scheme promises to cover the most vulnerable citizens from much of the costs of hospitalisation, constituting the poorest 40% of the country’s population, there is immense scope to do more and have a greater impact. Better coordination and seamless integration between Health and Wellness Centres (HWCs) being developed under the first leg of Ayushman Bharat and PMJAY will help in expanding access and ensuring follow-up care for the poor. Greater focus on prevention and management of several health conditions at HWCs will also reduce cost for PMJAY. In addition, much work is needed to expand communication with the public about how to benefit from the schemes, as well as to ensure that public and private providers will be able to use the scheme to cover their costs and provide quality and responsive care. But as a whole, the health coverage schemes in India are fragmented, leaving out important populations, having inconsistent benefits packages, not efficiently and fairly paying providers, and are not oriented towards prevention and integrated person-centred care models.
Unfortunately 30% of the population which forms the middle class are largely without health coverage. While the population has a significant capacity to pay for health insurance, the insurance products generally cater to higher-income groups. There remains a need to expand financing of health services coherently, probably by leveraging PPPs to provide better quality and range of services at affordable price point. Today, outpatient care contributes substantially more to out-of-pocket expenditure that impoverishes people and creates a barrier to needed care. UHC financing and delivery programs need to integrate and be inclusive of both inpatient and outpatient care. It is important that health financing models are reviewed and designed to support access to quality healthcare by all across the range of services that people need.
Integrated care models. Like most healthcare systems, Indian healthcare largely has a vertical model of care delivery and reacts to problems as they emerge. There is a need to trigger a shift to person-centred integrated care which caters to the needs of an individual, their family, and the community. This approach should seek to add value across prevention, promotion, curative and rehabilitative and palliative services. In addition to linking the financing of out-patient and inpatient care, another step in this direction would be to link health and wellness centres with hospital care and other health services. Some important aspects of patient centred care include respecting patient’s will and dignity, delivering coordinated and personalised support and care, and helping patients develop their independent abilities.
Build an inter-professional public health cadre. The current Indian health professional education does not focus on developing competencies for public health and management. Physicians are trained in individual clinical care, but not provided the appropriate learning opportunities to fulfil roles in population health functions or managing health facilities and programs. A wide range of competencies are needed to support community health engagement, disease surveillance and response systems, health promotion and prevention program management, monitoring and evaluation, as well as leadership, and management of teams, finances, and other resources. A public health cadre should not be solely focused on physicians whose primary training is around individual clinical services, but should be developed as an inter-professional cadre that also includes nurses, social workers, epidemiologists, policy and management experts, social scientists and engineers, and be equipped to work in inter-professional teams that can address the full range of population health needs within India’s complex health system.
Increase and better allocate health spending. Despite multiple health initiatives implemented in the recent years, the current spending on health in the country is very low. For the year 2017-2018 India’s total health expense was a dismal 3.3% of its GDP. Other BRIC nations (notably Brazil, Russia, and China) ranged between 5% to 9.5%. India’s current public spending on health is only 1.3% of GDP. More than 50% of health expenditure is incurred directly through out-of-pocket by people. This is both inefficient and inequitable as it often delays and discourages appropriate treatment and disproportionately penalises the poor. For the programs to drive the desired and long-term impact, it is essential that the programs and initiatives have sufficient and sustainable funding mechanisms. Significantly more funding will be needed to transform the health sector. Specifically public funding is needed to support the goals of providing universal financial protection from the costs of healthcare, and to implement purchasing arrangements that promote high quality and integrated health care. And of course there is even greater need to invest in public health systems that address the population needs for prevention, promotion, disease surveillance and response and other common goods for health.
Appropriate policy reforms will help improve the existing health ecosystem in the country and open avenues to effectively cater to most pressing health issues in a systematic and well-thought strategy. The Indian health system is undeniably complex, largely fragmented, inadequate and most importantly, it is recovering from the pandemic onslaught while braving these challenges. The Covid-19 experience highlighted an increased availability and awareness of digital healthcare technologies such as telemedicine, as well as some initial strengthening of health data surveillance capabilities. It has also heightened attention on developing a public health cadre, and on the value of increasing collaboration across national agencies (ICMR, National Institute of Virology, National Communicable Disease Centre, National Health Authority etc.), and with state and local authorities, as well as with private providers and others in the private sector, notably vaccine and medical supply manufacturers. We know that the country has the intent and capability to make the transformations needed to creating a robust, high-quality health system. Following through on its intentions will enable India to create a story of positive change and sustainable impact, and be able to share it across the country and with an increasingly interconnected and interdependent world.
