Where are we on the road to free and high-quality healthcare for all in India?

For any country, the road to universal healthcare (UHC) is a long and difficult one. India and our states are no exception. In this note, I try and take stock of what, in my personal opinion, we know with some certainty about this journey and where we are still somewhat confused.

What do we know?

These are listed in no particular order.

1.??????It is clear that owing to both current (and anticipated) shortages in the availability of MBBS doctors in India, the classic British-style physician-led primary care is infeasible for us in India. However, well-designed 4th stage Community Health Worker led models of the type being followed by Iran (Rahbar et al., 2020) and Alaska (Golnick et al., 2012) are eminently feasible which, among other things, reduce sharply (but not entirely eliminate) our dependence on physicians. We have a new paper that we’re working on which examines this 4th stage more carefully and also explores several Indian models that have sought to implement it.

2.??????We find that Indian medical costs are far lower than most people imagine, and UHC may be within reach, at least financially speaking, merely from current government expenditures in over ten states already (Mor & Shukla, 2023). Worryingly, however, we also find that in several of the other states, in particular Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh, the gap between what is needed and what is being made available is prohibitively large (Mor & Shukla, 2023). It is possible that entities like the Finance Commission may need to intervene to address them through a drastic change in the inter-state allocation algorithm by first defining carefully basic needs and then adjusting the current algorithm to first provide resources for them across the entire country. This needs new thinking.

3.??????Globally effective UHC systems (with no exceptions) have relied on tax-based funding (GHE) to provide 75% plus of Total Health Expenditures (Mor, 2022). However, in addition to the problem of the link between GHE and OOP (discussed below), this is only a necessary condition and not a sufficient one. In this paper (Mor, 2022), 15+ve and 09-ve extreme outliers stand out. In another paper, I am hoping to explore these 24 extreme outliers more carefully to try and understand what, in addition to GHE, drives their performance. Even on the financing front, we have a position paper in which we argue that while tax-based financing is ideal since it is not being made available in adequate amounts and, even when available, requires several other health systems reforms, there is a lot that can be done even without it instead of merely waiting interminably for it to happen.

4.??????There are several modifiable social determinants of public health which can be considered, as it were, a “free lunch” as far as the healthcare sector is concerned.?These could include alternations in building codes to address tuberculosis and lower-respiratory tract infections (Pardeshi et al., 2020), separations between highways and housing to address the noise-related cognitive decline in children (Cohen et al., 1973; Khazan, 2016), improvements in public transport to reduce the numbers of two-wheelers and therefore the associated issues of Road Traffic Injuries (Vasudevan et al., 2021), and adequate funding of programs like MNREGS to help reduce the burden of mental illness (Tsaneva & Balakrishnan, 2019). The need here is for focused research and advocacy around each of these “free lunches” with the relevant parts of the government responsible for them.

5.??????While this is well understood, it bears repeating that without the bedrock of essential public health functions and services (CDC, 2020) in place, it is simply not possible to build good health systems. Unlike social determinants, however, while these are low cost, they are not entirely a “free lunch” as far as the healthcare sector is concerned and will have to be paid for from government health budgets. The deep technological capabilities of India can, however, help reduce these costs to a degree and also open up new ways of providing these services (Mor, 2021).

6.??????In curative healthcare, while there is no doubt that primary care is important, there are several considerations which suggest that governments, even those that must make a choice because of their funds' constraints, must first ensure that there is adequate secondary care infrastructure in all parts of their state, particularly in remote areas. I explore this somewhat controversial issue more carefully in this blog post and in this preliminary health systems design document for the state of Chhattisgarh (Mor, 2023).

7.??????Even in the remotest parts of our country, in terms of sheer numbers, there is no shortage of primary care providers, with, possibly, over 3 million of them against a requirement of 300,000.?Instead of building yet another set of low-performing primary care centres and clinics, the urgent need is to find a way to deliver higher quality in ways that actually impact the disease burden. In addition to working on 4th generation CHWs that I mentioned earlier, we are also working on a new paper exploring the potential of our 1 million pharmacies as a channel for delivering NCD care in our context, learning from the experiences of other countries (FIP, 2019).

8.??????While making primary care continuous, comprehensive, accessible, and coordinated (Starfield, 1998) is very important and a pre-requisite, the idea of Gatekeeping (preventing people from accessing higher levels of care until they have been referred by their primary care provider) is of critical importance as well (Bito et al., 2014; Dumontet et al., 2017). It is possibly one of the features of high-performing health systems that our “extreme outliers” paper (mentioned earlier) will help uncover.

9. Government-financed health insurance (Dubey et al., 2023) does have a very important role to play in India but possibly not for secondary care and for smaller pay-outs to some segments of the population. In this op-ed , I suggest that a better role for it would be to focus on universal coverage of high-cost and rare diseases for the entire population (rich and the poor).

10.??There are multiple very important and urgent reasons for the government to substantially increase its investments in health, not just because good health is intrinsically important but also to preserve the growth momentum of the economy both in the near and medium terms. I explore this issue in this blog post .

What are we confused about?

These are listed in no particular order.

1.??????If we look at the experience of the Indian states, we find, very curiously, that as Government Health Expenditure (GHE) goes up, so does out-of-pocket expenditure both in absolute terms as well as a proportion to total health expenditures. This is a worrying finding, and it is not clear why it is happening. It is vital to figure this out so that our continued advocacy on increasing GHE takes these issues into account. Sri Lanka has found this to be true as well, but, in their case, it is because the rich are choosing to opt out of a high-performing public sector, and it is not the poor who are having to pay – the so-called “progressive OOP” phenomenon. Is this what is happening in India? There are some very important research projects in progress which are hoping to get to the bottom of this.

2.??????As mentioned earlier, we find that there are over 10 Indian state governments, such as Kerala, Delhi, Goa, and Himachal Pradesh which appear to be spending enough money already to deliver fully on the ideal of UHC (Mor & Shukla, 2023). Why are they not able to deliver UHC with this money? ?What do they need to do to get on that path?

3.??????The public-sector-delivered healthcare system is likely to remain an important component of our health system for the foreseeable future. However, it is not clear how to get its performance to improve. Can it deliver primary care in the manner and quality needed (Kumar et al., 2019; Lee et al., 2022; Nadella et al., 2021) like Iran (Rahbar et al., 2020) and Alaska (Golnick et al., 2012) have been able to do? Can it offer good quality and responsive secondary care (Aranha, 2020; Chattopadhyay, 2015; Goli et al., 2019; Sharma et al., 2019)? ?Will “strategic purchasing” (Langenbrunner et al., 2019) help us, or is it a form of “isomorphic mimicry” (Andrews et al., 2017) that can hurt because we just don’t have the institutions in place? Why are we seeing such high C-section rates in the public sector in our richer states (Mor, 2020)? I have new work in progress that is hoping to throw some light on some of these issues, but?a lot more in-depth thinking is needed here.

4.??????There is a new phenomenon of Digital Public Goods (DPGs) that is on the horizon. If we are indeed doomed to live in an environment where more than 80% of our healthcare is being delivered by a highly fragmented provider base, paid essentially on an out-of-pocket basis, can DPGs help shift this "Nash Equilibrium" (Mankiw, 2018) so that even the fragmented system can deliver on superior health outcomes for the consumer? What are the non-cooperative games/prisoner’s dilemmas that DPGs need to disrupt to produce more welfare-enhancing outcomes?

5.??????The aggregate revenues of the large formal corporate sector hospital systems are only about 5% of the total health expenditure. Despite this small base, their growth rates seem modest. What can be done by them to accelerate their growth rate? Is Managed Care the win (consumer)–win (corporate) answer to this conundrum? I am hoping to do some new work on this.

6.??????The health insurance sector seems to be in a similarly difficult position, with very few insurers making much money. I worry that the underlying attempts by the industry to risk-select, consumers to not be entirely transparent, industry to reject claims, high-channel costs for the industry, high switching behaviours of consumers, and high entry barriers for new entrants are resulting in unstable and suboptimal equilibria. I am hoping to do some new work on this using Agent-Based Models.

7.??????Going beyond design issues of healthcare, a broader problem appears to be the state’s continued bias toward the “Commanding Heights” (Yergin & Stanislaw, 1998) frameworks with active interference in well-functioning markets and little interest in spheres in which markets fail. Even where there is a desire to govern, the coercive, low-trust approach appears to dominate.?How do we get our administrators and civil servants more comfortable with the ideas of “governance without ownership” and “regulation without laws”?

8.??????How do we rethink “Healthy Public Policy” (PlanH, 2021), where being healthy is built into the very design of our cities, our schools, and in every other policy?

9.??????What else can we do to improve political engagement in healthcare (Tillin et al., 2022; Venkateswaran et al., 2022)?

10.??One Health issues are very real for us in India with the ever-present possibility of spillover (Paul et al., 2020). Not yet clear what the way forward for us should be on how to organise for it. Efforts at building fully integrated approaches to dealing with it have not proved to be very successful anywhere in the World. ?

11. Almost 80% of primary care is provided by the private sector (La Forgia et al., 2019) and is paid for on an out-of-pocket basis (Baeza et al., 2019; NHSRC, 2022). With such a mechanism of payment, consumers tend to not only avoid preventive care but also derive very little value from the primary care they do seek on account of the quality of care on offer. In response, they tend to “shop” extensively, moving from provider to provider (Kapoor et al., 2012), offering little incentive to providers to invest in improving quality.?This is a classic suboptimal Nash Equilibrium (Mankiw, 2018) which needs to be urgently addressed so that from the millions of primary care providers currently in the market, a high-quality subset emerges even if we are forced to live with out-of-payments in the foreseeable future.

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