Question

Describe the Healthcare financial systems in the country of India, and answer the following statements.

• Financing (is it sustaining or are there "fiscal issues" that must be dealt with)
• Service provision (how do they serve the population; what are the political issues)
• Access and equity (more or less of a problem - usually more of a problem)

Answer 1

Healthcare financing deals with generation, allocation and use of financial resources in the health system. Globally it has become increasingly recognized as an area of major policy relevance to achieve Universal Health Coverage (UHC). Understanding the country's healthcare financing system allows to recognize current finances available for health, ways to raise more funds for health, mechanisms to efficiently and equitably allocate, purchase and spend finances to improve access to health services and reduce out of pocket expenditures that lead to catastrophe and impoverishment.

In India several Union and State level policy interventions in the recent past were designed and implemented to address gaps/challenges in healthcare financing. The National Health Mission, Rashtriya Swasthya Bima Yojana, State financed health insurance schemes, Public Private Partnerships in operating ambulances etc. were all interventions in this direction. Further the National Health Policy 2017, gives impetus to increasing government finances to health, better utilization of existing resources to achieve better health outcomes, improving financial protection and strategically purchasing from the not for profit and private sector.

Health Accounts: This division is the National Health Accounts Technical Secretariat (NHATS) with a mandate to institutionalize Health Accounts in India.NHATS conducts periodic National and State Health Accounts using a global standard framework System of Health Accounts 2011(SHA 2011) contextualized to Indian/ State Health Systems. This allows to track the total health sector expenditures in the country by source, schemes, providers and functions. NHATS builds capacity at the national and state level for generating NHA by training individuals and institutions.It developed a strong network of institutions and organizations at state level across the country.

What this policy appears to be lacking is a cohesive, tangible action plan to address problems pertaining to any of the As (access, affordability and accountability) – especially given the challenges faced by the existing public healthcare machinery because of poor governance and deficient funding. The agency-capability critique applies well to the policy due to the restricted capability of public institutions to deliver on the identified objectives. The 2017 NHP policy identifies everything that needs to be done, without clearly illustrating who needs to do what and, more importantly, how it needs to be achieved.

Also, the feasibility of the policy is brought into question because of the limitations arising out of the funds allocated to the various schemes. The policy calls for major reforms in financing public healthcare facilities. But there is lack of clarity around how these financing reforms will be brought about and who will manage them, or how the need for a per capita medical insurance scheme will interplay with this. The proposal to increase public healthcare expenditure from 1.15 percent to 2.5 percent of GDP by 2025 seems inadequate to meet the ambitious goals laid out in the policy (Mohan, 2017).

While the initiatives of the government sound extremely ambitious, it seems more like a “repackaged” version of the social security scheme of 2016. The major reasons why most of the healthcare policy commitments of the Indian Government have failed to translate into results have been inadequate budgetary allocation as well as lack of coordination between the center and the states in the planning process, leading to inefficient spending. The budgetary allocation of Rs 52,800 Crores for healthcare in 2018-19 was only 5 percent higher than the revised estimate of Rs 50,079.6 Crores in 2017-18. This falls way short of a year-on-year increase of 20 percent needed to meet the target of government health spend at 2.5 percent of the GDP by the year 2025 (Matthew, 2018). In particular, Rs 2,000 Crore allocated for the RSBY scheme is woefully short of the required funds of at least Rs 10,000 Crores as per Dr Ravi Wankhedkar, President, Indian Medical Association (Anuj Gupta, 2018).

In India, there is one government allopathic doctor for every 10,189 people, one government hospital bed for every 2,046 people and one state-run hospital for every 90,343 people.

You don’t need an epidemic, however predictable, for the public health system to collapse. It is a matter of routine that patients share beds and doctors are overworked.

India has a little over one million modern medicine (allopathy) doctors to treat its population of 1.3 billion people. Of these, only around 10% work in the public health sector, shows data from the National Health Profile 2017.

The shortage of health providers and infrastructure is the most acute in rural areas, where catastrophic health expenses push populations the size of United Kingdom into poverty each year.

In the absence of doctors, the sick make do with whoever is available, irrespective of their qualifications.

Only one in five doctors in rural India are qualified to practice medicine, found a World Health Organization (WHO) report on India’s healthcare workforce, highlighting the widespread problem of quackery. The WHO report, published in 2016, said 31.4% of those calling themselves allopathic doctors were educated only up to Class 12 and 57.3% doctors did not have a medical qualification.

Training informal healthcare workers who had little-to-no training for nine months increased their ability to correctly manage cases, found a J-PAL 2016 study on The Impact of Training Informal Healthcare Providers in India. Trained informal workers provided correct case management in 60% cases compared to 52% of the comparison group, and 67% doctors at public health centers