Sunday, May 21, 2017

History of Privatization of Health in India: Adapted from "Do We Care"

This is an excerpt taken from the book titled, “Do We Care”, by K. Sujatha Rao. It talks about various aspects of India’s health system through the eyes of the former Union Health Secretary. In the first such article in the series, which is really undertaken for my own learning, I try to portray from the book the history of privatization of healthcare in India. I believe it is extremely important for budding health policy researchers and scientists to be aware of the series of incidences and forces that led to the current unfortunate situation of the Indian Healthcare System. Such awareness will propel our minds to debate, a luxury in India when it comes to public health.

In 1946, India was spending 4 per cent of its expenditure budget on health against 20 per cent by the UK and 13 per cent by the US. There was a substantial disease burden and reducing this burden required strong implementation of public health measures. But before leaving India, the British abolished the public health infrastructure consisting of Public Health Commissionerate and the Indian Medical Service that provided the cadre of trained doctors and the licentiates who numbered at 29,870 as compared to a mere 17,654 trained allopathic doctors. Instead, what was left behind was a co-opted elite consisting of the Western-educated, upwardly mobile middle classes, which believed that traditional medicine was quackery and allopathy a symbol of modern scientific temper. India’s health structure was thus built upon a system of medicine that was contrary to the present-day realities and the levels of development prevailing in the country at that time.

Clearly, the seeds for the conditions that exist today were sown then- a neglected and weak public health policy of a diffident state, a dominance of a Western-oriented medical system, fiscal conservatism with low priority and funding for health, an asymmetry that made states fiscally dependent on the centre for discharging their constitutional obligations, a huge burden of infectious diseases, and an ideal of ensuring health for all that was soon forgotten. Over the years, with meagre resources in hand, India sought to build the foundations of a health system.
During the time when India got independence, the country was juggling between the urgency to spur economic development, to ensure food-sufficiency, and to protect the country’s unity from internal and external dissensions, its health policy focused on the immediate challenges-reducing the toll of infectious diseases, particularly deaths and morbidity on account of malaria that affected over three-quarters of its population, and ensuring maternal and child health. 

India was helped with expertise from various international agencies to build capacity to cope with the situation. Over the years, such help resulted in a tendency towards adopting a techno-managerial approach to disease control rather than undertaking  the more difficult but sustainable policy of tackling the causative factors and linking disease with the social conditions that produce it-an understanding that continues to elude us to this day. Besides, dependence on external help also meant a reduced ability to reflect on what is best for us in our context. The more damaging impact of this early approach, however, was seen in the neglect in building the foundation of the health system in accordance with the recommendations of the Bhore Committee. Yet, the thinking that rural areas can do with a few public health and disease control interventions while urban areas would need medical care took root at this time, resulting in the fragmented approach to the building of the health system.

As India settled down, populations and incomes grew, and so did the demand for health services and people’s expectations. Demand outpaced supply resulting in the establishment of public and private hospitals in cities with large towns bursting at the seams with patients. Quality fell. Instead of addressing this growing demand, public policy shifted its attention to population control through expanding access to contraceptives. It would not be inappropriate to state that due to limited resources and weak prioritization, investments required for building a sound foundation of primary care were patchy and grossly inadequate. Rather than basing the development of the health system on principles or a vision, the tendency to appoint expert committees with specialists and clinicians to deliberate upon issues that were largely of public health significance. The inadequate attention accorded to the provisioning of medical treatment and hospital care led to the mushrooming of a range of stand-alone diagnostic clinics, nursing homes, and hospitals in private sector, particularly in urban and semi-urban areas, catering to different socio-economic strata of society. In this din of swanky hospitals, modern technology, shifting aspirations backed by the willingness to pay, the concepts laid by Bhore committee were lost and it was a slow birth of privatization of health in India.

In 1983, the first National Health Policy (NHP) was released. Critical of the curative-oriented Western model of health care, the NHP of 1983 emphasized the need for a preventive, promotive, and rehabilitative primary health care approach, based on the foundation of community participation. Notwithstanding this articulation, the NHP did not lead to any fundamental changes in the policy or architecture of the health system: the budgets for health continued to be low and the approach to adopting selective health care delivery remained the same. The private sector that existed alongside was invisible and fragmented, treating sickness on a fee-for-service basis. As per a study in 1963-4 private sector accounted for 61 per cent of the doctors-of whom only 11.4 per cent were working in a private hospital establishment-21.5 per cent of beds, and 16 per cent of hospitals. The liberalization process of the 1980s and 1990s changed the paradigm and the fundamental premises: over the following decades service became a commodity, hospitals became lucrative commercial enterprises, medical education became investment destinations, and patients became clients. In the face of technological innovation in medical devices, discovery of new drugs, rapid changes in disease profile towards non-communicable diseases that required better diagnostic tools, more sophisticated laboratory facilities, and institutional treatment, health care became specialist-dependent, organizationally structured, and resource-intensive. Facing a high fiscal deficit, the government had no option but to rely on the market to bring in the required investment to establish hospitals that could meet the demands of a rapidly growing, aspirational middle class. By 1990, private players accounted for 58 per cent of hospitals and 29 per cent of beds. The government struggled to build the primary healthcare infrastructure in rural areas as the principal strategic tool to achieve the global goal of Health for All by 2000. 

Health under minimum needs programme of the central government proved to be inadequate forcing people to resort to quacks or private facilities in accordance with their ability to pay, thereby  fostering the entrepreneurial spirit of the private sector.  It was no accident that Apollo, the first corporate hospital in India, established in 1984, was greeted with curiosity and measured relief by the rising middle classes since it brought in a new definition of quality with its corporate management and modern diagnostics. From then on, the growth of the private sector has been unstoppable; starting with tertiary hospitals, it seamlessly expanded to secondary care, medical and nursing education and diagnostic centres and laboratories. By 2004 the private sector accounted for three quarters of outpatient department, 60 per cent of in patients and three quarters of the specialists and technology. By the mid-1990s , the economic collapse, the International Monetary Fund’s (IMF) conditionalities to cut back on public expenditures to contain the fiscal deficit ,and the ideological thrust towards the private sector impelled the government to introduce a two-pronged approach: the first was a further reduction of what was an already low government budget, and the second was to promote the private sector through fiscal incentives. In terms of GDP, public spending increased from 0.98 per cent in 1975 to 1.36 per cent in 1986, only to fall to 1.28 per cent by 1991- this contracted further to 0.9 per cent by 2000, resulting in marginalization of the state as the primary player in health service delivery. In India, during 1993, the World Bank pushed the private-sector agenda, introducing the concept of PPPs. justified on the grounds of improving organizational efficiencies, the concepts of ‘outsourcing’ and contracting services such as sanitation, laundry, diet, and the delivery of allied services took root, gradually expanding to co-opt NGOs and private-sector care providers as partners. USer fees, based on a large number of ‘willingness-to-pay’ studies, was promoted as a means of mobilizing resources for the cash-strapped hospitals struggling to meet their very modest recurring costs. This argument did not impress many who commented: ‘USer fees are a mere mirage, for no one who can afford anything uses a government hospital; bribes notwithstanding, they are the only sources of surgical and even minimally advanced medical care for the poor.

Starving the public health sector of funds resulted in the collapse of the slender social security nets the poor had, particularly in rural areas, forcing them to go to private clinics for every blood test or treatment of fevers. By 2005, India was a sick country with huge morbidity and mortality and a dysfunctional health system. Eventually, NRHM was launched in April, 2005; its main objective was to revitalize the rural primary healthcare system though that was only a partial response to the crisis. Meanwhile, there were reports that argued that health policies were resorting to technological solutions while ignoring the social dimensions of disease causation and neglecting the importance of social determinants. In confining the NRHM’s focus to revitalizing primary care consisting of a few essential services, the issues left to addressing rural impoverishment on account of medical expenses were left unaddressed. The launch of a variety of tax-funded insurance schemes contributed to the further strengthening of the private sector that was also in a crisis of sorts for want of an effective market and the slow growth of voluntary, commercial insurance. Thus, during the years 2007-2014, India witnessed the strange playing out of a zero-sum game. On the one hand, the government, by deliberate policy, injected into the private sector over 200 billion per year(public as well as private out-of-pocket expenditure that was tax-exempted) as premium for health insurance, thus helping it expand and consolidate its market presence in the secondary and tertiary care markets; on the other hand, it invested an equal amount of money under the NRHM for strengthening the public sector delivery system, largely in the primary healthcare segment. While states initiated tax-based tertiary insurance schemes in active collaboration with the private sector, they did not strengthen primary health care, promote prevention, and establish a referral system. Nor was there adequate investment in expanding the services and quality of public sector hospitals to enlarge access to affordable or free care. Money was available to conduct a heart surgery, a cochlear implant, or a C-section but not for essential medicines and basic diagnostics, preventive education, rehabilitative care, home nursing for the elderly, school health, and adolescent care, or for addressing the direct causal factors of communicable and non-communicable diseases, or treatment of injuries, fever, snake bites- conditions that were critically important for the poor.

The burgeoning private sector estimated at USD 230 billion (or Rs 15 trillion by 2020 and growing at 15 per cnt per year) dominates every aspect of health policy formulation and implementation. Promoters of the corporate sector mobilize resources by sale of their own assets or borrowings from financial institutions such as banks, equity firms, venture capitalists, and share markets. In their pursuit of profits, they exploit the vulnerability of patients and auction medical seats to the highest bidders. It is this increasing trend towards the ‘financialization’ of the health sector that is disturbing. The commitment, then, is not to the health outcomes of patients but to declaring dividends and safeguarding shareholders’ interests. The world over, a growing body of opinion considers such profiteering from the sick as unethical.

In India’s health history, the emergence of privatization of the health sector appears to have been accepted without much contest. There was no explicit outrage when medical education was being privatized in India, except for one incident in 1984 in Mumbai. Even as late as in 2016 when the circular of the MCI, issued in February, permitted promoters to take 300-bed district hospitals on a long term lease of 33 or 99 years for establishing medical colleges, there has been only deafening silence from the academics, civil society, or bureaucracy. The public and private sectors have coexisted in a seamless manner from the village quack to government doctors who run private nursing homes or pursue private practice in private hospitals. Academic institutions, too, were not funded or incentivized to undertake high quality operational research providing credible data on the nature and character of the private sector, comparing it to the public sector in terms of outcomes or unnecessary or exploitative behavior to guide policy. Good research does prevent public policy from causing unintended harm.

Asymmetrical information endows providers with power and authority over the patients who have incomplete information about what ails them. Providers often take advantage of such moments of vulnerability by ordering a battery of tests, unnecessary surgeries, or prescribing high-cost medicines, thus contributing to price inflation. What is, therefore, required are e a set of strong regulations to reduce discretion in fixing prices, treatment protocols, computerization of medical records and monitoring of deviations, supervising for quality through patient-satisfaction surveys, and instituting grievance redressal mechanisms and a revamp of the existing systems of judicial redressal to make them less cumbersome and more accountable.  There are no regulations, accountability, and transparency regarding the functioning of private hospitals and diagnostic centres per se, though they provide major share of care. Apart from illiteracy and absence of grievance redressal systems, information campaigns on unhealthy habits or behavior have been severely compromised for want of funding and attention. The biggest challenge India faces today is solving this riddle called public-private mix in health care.

Sunday, February 12, 2017

NCDs and poverty

First of all, you must be wondering what NCD stands for. Well, NCD stands for non-communicable diseases, diseases such as cancer, diabetes, chronic respiratory diseases, chronic obstructive pulmonary disease (COPD). These diseases are essentially chronic in nature. NCDs are becoming a major public health burden globally, which can be explained by the fact that of the 57 million global deaths in 2008, 36 million or 63% were due to NCDs, a figure which now stands at 68%.

Just like any other person who has not read much about the dynamics of NCDs , I also used to believe, quite ignorantly,  that NCDs are diseases of affluence, ailments which afflict rich people, those living in urban areas until I stumbled resource after resource, report after report upon the premise of chronic diseases in poverty. The fact that poor people can also be affected by diseases such as these seemed implausible to me. I used to wonder that sedentary lifestyle, over-weight, obesity, unhealthy eating habits all contribute to NCDs, and that was right but somewhere I was missing another important point, a point which would later contribute towards more clarity on the risk of poor people  developing chronic diseases. The point was that poor socio-economic conditions were a big determinant of chronic diseases. 

According to WHO report titled, "Global status report on non-communicable diseases 2010", NCDs are the leading global cause of death causing more deaths than all the other causes combined, and they strike hardest at the world's low and middle-income populations. Over 80% of cardiovascular and diabetes death, and almost 90% of deaths from COPD occur in LMIC (low and middle-income countries). More than two-thirds of all cancer deaths occur in LMIC.  In LMIC, a higher proportion (48%) of all NCD deaths are estimated to occur in people under the age of 70 (premature deaths) compared with high-income countries (26%). In LMIC, 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries (HIC).

 The NCD epidemic strikes disproportionately among people of lower social positions. NCDs and poverty create a vicious cycle whereby poverty exposes people to behavioral risk factors. You might be wondering how poverty is related to NCDs. Let us understand. The four major behavioral risk factors for NCD epidemic are tobacco, insufficient physical activity, unhealthy diet and harmful use of alcohol. Now, poor people are more prone to bad behavioral habits such as chewing tobacco and drinking. Further, since they are not able to afford nutritious food, they usually eat energy dense food, for example a soda or even deep fried chips, high oil, high salt and high sugary foods. Uneducated as they are, these people are not aware about the good eating habits, and even if they are, their health is not the first priority, their first priority, you guessed it right, is to have two square meals a day, an employment. Chronic exposure to tobacco and unchecked drinking traps them into an addictive cycle, which is very difficult to break and this further translates into social vices like domestic violence.

 Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs creates significant strain on household budgets, particularly for low and middle-income families. Treatment for diabetes, cancer, cardio-vascular diseases (CVD) and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment. Household spending on NCDs, and on the behavioral risk factors (tobacco, alcohol) translates into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty - education. Each year an estimated 100 million people are pushed into poverty because they have to pay directly for health services. One of the findings of a study titled, "Increasing expenditure on health care incurred by diabetic subjects in a developing country" was that subjects with the lowest income spend as much as 25% of their annual income on diabetes. The economic burden on urban families in developing countries is rising and the total direct cost has doubled from 1998 to 2005. 

Thus, it is clear that the danger is very real. India being an upper-middle income country, faces a significant challenge in managing NCDs, more so because of lack of health information systems, surveillance and monitoring facilities of various data related to health outcomes such as morbidity and mortality. India is also accelerating in economy, and with rapid unplanned urbanization people are further prone to developing the NCDs. Our health ministry has not yet woken up to the needs of the health reform in India and maintains an eerie silence despite the deluge of public health interns who come from abroad to India to learn lessons while observing the health challenges of those in destitution and perpetual neglected state. Health seems to have taken a back seat in this headlong rush for increasing GDP. TB is still not out of India and India is already the diabetic capital of the world. This double whammy is going to cost a lot to the health economy of the nation of 1.2 billion. 

The least we can do is to maintain a healthy lifestyle ourselves so that our families are healthier. If all of us begin to think like that we can control the current situation, while ensuring that the future burden is not as big as today's.

Saturday, February 4, 2017

Disaggregated Data : Urgent Need for Public Health in India

MDGs (2000-2015)
Sustainable Development Goals are out  and the target is well set. With most goals related to the premise of Universal Health Coverage (UHC), health for all and all ages forms one of the most important agendas of the SDGs, as they are called. A comprehensive reading of the WHO report titled, World Health Statistics 2016, provides comprehensive, detailed and tangible account of the role of SDGs in the dream of UHC by listing the vital statistics the organization could gather and estimate on health for the 194 member countries. SDGs are the successor of Millennium Development Goals (MDGs). The Millennium Development Goals (MDGs) were the eight international development goals for the year 2015 that had been established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. 

There are 17 SDGs for the year 2015-2030. Most of them are related to health in one way or the other. Ending poverty and hunger, good health and well-being, quality education, gender equality, clean water and sanitation, decent work and economic growth, reduced inequalities, responsible consumption and production, life on land, life below water, climate action, affordable and clean energy : all these according to my ken form a very close and interdependent relationship with the status of the population health in any country. 

Research after research has proved, verified and concluded that socio-economic status of a family is one of the biggest determinants of the health of the family. A poor family is more likely to fall sick, remain sick and die sick due to inadequate money, accessibility and affordability of health care as compared to those who are comparatively well-off. A poor family is more likely to live in unclean environments in high-density areas where environmental hygiene is compromised, children earning money in early ages is far more important than their education,  especially in urban slums. Lack of appropriate nutrition to pregnant women translates to wasting and stunting in children which further increases their risk of developing chronic diseases as they age; chronic hunger then becomes a big detriment towards the dream of UHC. It is time that gender is also included as one of the social determinants of health because the prejudice and discrimination that girls face in some families manifests in their poor health in growing years despite inherent genetic trait to be healthier than boys. 

A woman's health considerably impacts the health of the nation. Babies born to emaciated and weak mothers are more at risk towards developing early infections after birth. Weak mothers, anaemic mothers, and under-age mothers are more prone to maternity related complications and carry a huge risk of mortality and disability during delivery. According to the WHO report 2016, in India 94% of proportion of population is using improved drinking water sources while only 40% using the improved sanitation. This clearly shows that India has to improve a lot in the sector of improved sanitation facilities to be able to prevent gastro-intestinal diseases, diarrhoea and other ailments that spread due to inadequate sanitation. World Hunger is a phenomenon that can be attributed to shabby distribution, neglecting the needs of those in destitution. While recently there is an announcement of a  program for distribution of eggs to children in aanganwaadis, it remains to be seen how honestly and strictly the program is implemented. The problem hardly lies in spineless strategies, but what really eats away their impact is the nonchalance of those who implement them, their conspicuous apathy towards the cause of UHC partly explainable by their ignorance and lack of understanding of the personal stake that they have which will directly affect Indian posterity. Climate change is also an important part of Ecological Public Health, Earth is warmer by one degree Celsius and that has led to a lot of imbalance in our ecology. With a warmer earth, glaciers are melting, under-water ecology is under a grave threat of extinction, there is an increased risk of forest/bush fires, floods, drought- everything that poses peril to the sustainable development. Clean energy is also related to health with air pollution becoming increasingly a public health burden with increased urbanization. 

In brief we have understood that SDGs are health oriented and in these 15 years time, it is indispensable that the progress is regularly monitored, evaluated and reforms made based on the findings. And this calls for a very potent tool: DATA. 

Imagine a location where there is a disease which affects a particular section of society, and even in that a particular gender and then a particular age, how would you understand the population that needs intervention or garner the subjects of an impending epidemiological study? Since diabetes epidemiology forms my area of interest, let me explain it using its example. In India, we do not have a comprehensive and complete data on the people who have been diagnosed with diabetes disaggregated by age, gender, income-levels and locality. Lack of such data leads to fragmentation in health care and leads to un-organized planning towards programs that focus on prevention and health promotion. But diabetes is an ambitious example, some would quote, when we do not even have a proper CRVS system to log the mortality data and it causes. Morality data is more amenable to proper measures as compared to morbidity and disability. But if India has to perform with regard to SDGs it must be equipped professionally with an expertise to inculcate data gathering and collection as per international standard to avoid any ambiguity. That calls for technically robust health workforce, health systems and somewhere also,  a radical change. 

In many countries, statistical and health information systems are weak and the underlying empirical data may not be available or may be of poor quality. Only 70 countries currently provide WHO with regular data on mortality by age, sex, and cause of death which are required for more than a dozen indicators in SDGs. The most extensive standardized disaggregated data are available for indicators in the category of reproductive, maternal, newborn and child health. Health is not an isolated department, health of a population depends to a large extent to domains outside of health such as agriculture, transportation, human rights, education etc. Closer collaboration, thus, between health and other sectors is required to ensure that health monitoring takes into account data on determinants and risk factors for health and that other sectors give due attention to the health statistics. There is a need for much greater disaggregation of data, including statistics disaggregated by sex, age, income wealth, education, race, ethnicity, migratory status, disability and geographic location or other characteristics in order to track and identify disadvantaged population within countries. Household surveys are primary source of disaggregated health data on demographic and socio-economic characteristics and can be used to identify disadvantaged populations. 

Strengthening health information system of a country is a priority. In future, overall data picture may improve as a result of innovative approaches based on Information and Communication technologies and the trend towards, "open data", that is the release of data by government agencies, businesses, non-profit organizations, researchers and other private entities. Given the large data gaps, and the lack of timely data for many indicators, it is often necessary to use statistical models to obtain a picture of regional and global situation, including comparable statistics for use by countries. Most countries still lack adequate death registration capacity. An estimated 53% of deaths go unregistered world-wide, and progress in improving death registration in developing countries has been slow. Cyclical process of monitoring, review and remedial action will be critically important in ensuring progress towards UHC. 

Disaggregated data enable policy-makers to identify vulnerable populations in the context of reform towards UHC and to direct resources accordingly. Data can also be used to hold governments to account. Investments are thus needed in regular household surveys and electronic facility reporting systems. Whenever possible, data collection should include small area markers (such as postal codes) or individual identifier such as personal identification numbers) that permit cross linkages between different data sources. Countries should move towards implementing standardized electronic record keeping systems while ensuring that personal data are protected and used appropriately. In particular, more data are often needed on direct program performance using coverage indicators and related quality-of-care measures. 

And for all this disaggregated data story to come to fruition health systems strengthening forms a vital part. It calls for strengthening a country's capacity to collect, compile, share, disaggregate, analyze, disseminate and use data at all levels of health systems. Data has emerged as a very potent weapon in these times, extreme meticulousness must be exercised while collecting data, especially when it comes to public health for a mere mistake can lead to horrendous consequences. Disaggregated data and health systems thus go hand in hand and India must train its public health workforce keeping these two in mind and also the approach towards regular monitoring of the SDGs. While at one hand we have Professor Reddy of PHFI advocating need for increased attention to the face of public health in India, the budge allocation towards health remains grim. Seems like our politicians have not yet woken up to the cause of better health and well-being of its citizens and the increasing menace of non-communicable diseases (NCDs). 

India still needs to have a revolution in health and that can only happen when we have a team of people involved in health and health care realize the stake in their work and not merely discharge them as means to earn an emolument.