Private hospitals have been in the news for all the wrong reasons lately. Sujatha Rao, former Union health secretary and author of the book, Do We Care? India’s Health System, tells Rema Nagarajan that the recent exposés underscore the need for greater investment in public healthcare delivery as well as better systems to regulate the private sector
You say in your book that the government has an ambivalent policy towards the overwhelming private sector. Why?
The recent exposes in the media regarding the overpricing of cardiac stents and establishing fake colleges by the private sector show what happens in the absence of regulations. Fraud on such a large scale cannot happen otherwise. As traced in my book, the evolution of public policy in health clearly shows how the private sector in India grew by default and the persistent failure of the political system to articulate a consistent and coherent policy to manage this elephant in the room. This is a serious omission since the health sector has severe market failures making government intervention an imperative, not a choice. Such indifference to develop an appropriate framework of laws, systems, protocols and the institutional architecture to regulate the sector is a failure of governance.
Does the government have any option but to purchase healthcare from the private sector?
As the private sector provides three quarters of outpatient treatment and two thirds of hospitalisation, options to ignore it are limited and the perception that government can provide all health services is impractical. The government still has room to bring in a balance in two ways. One, by creating the fiscal space to step up public investment with at least 1% of GDP only for building the health infrastructure, particularly in areas where government is the sole provider. Two, by keeping its dominance in primary and secondary care markets that address over 95% of medical ailments, prevent disease, promote wellness, and in the long run, reduce costs for government and households. Every country tries to keep control over healthcare expenses, either by controlling primary care so that the push to more expensive hospitalisation is regulated, or by regulating secondary and tertiary care with protocols and price caps so that there are no runaway surgeries and unnecessary care. If the whole chain is privatised and unregulated as it is now, then it can become unaffordable. In any case, government’s first charge is to ensure universal access to public goods like basic healthcare, clean air, water, environmental hygiene and nutrition. In my opinion, this is an obligation the state cannot abdicate. This alone will reduce a substantial burden of disease and out-of-pocket expenditure.
You say public policymaking is trending towards greater reliance on consultants than building institutional capacity. Why?
If you take a historical view, you will see a transition from reliance on classical public health experts to commercial consulting companies like Ernst Young or McKinsey, in helping draft public policy. This is not a stable solution. What is needed, and government does not do adequately enough, is investing in institutionalised research and promoting knowledge to anchor policy on evidence. Our success in reducing the incidence of communicable diseases like malaria, guinea worm, polio or HIV/AIDS is largely on account of good quality evidence that helped guide policy and implementation strategy. Health falls in the realm of behavioural economics and regulating that requires policies to be rooted in our own cultural and behavioural preferences, social realities and political and administrative contexts. Besides, such accounting firms also have conflicts of interest as many are also consultants to private companies in the health sector and carry a bias against government intervention and public health.
Budget 2017 does give a lot more to public healthcare delivery, doesn’t it?
It’s not the 28% increase that should concern us but the quality of spending proposed. More worrying is the absence of a clear vision. In this context I am glad to see the recently released National Health Policy embedding a vision. One may disagree with it and there may be some contradictions, yet at least there is a vision that will now enable bringing in required regulations to mitigate any harm. The challenge today, rather than spelling out schemes, is articulating a vision for the next decade and an implementation plan that has a national consensus to ensure it is placed above partisan politics. Public health goals have been stated but realising them would need huge investments in terms of trained people, and appropriate infrastructure, particularly at the level of primary care. Primary care is not just about polio drops and institutional delivery. It’s about averting diseases that are expensive to treat. For example, there would be no need for too many dialysis centres if we can control hypertension and diabetes. Neglecting primary care means opting for the high-cost, specialist-led and hospital-based US system of care. The US is already paying a heavy price because of their model; in India, it could be catastrophic.