No Indian citizen should be forced to choose between illness and financial hardship due to out of pocket payments to his or his family’s healthcare.

Has anything changed since 2014, and does Narendra Modi as Prime Minister indicate a change in approach towards public healthcare?

Yes and no.

Yes because, after Modi took up the job we could see a distinct shift in approach towards the health of the nation. Personally for me, two of his standout programmes in healthcare are:

Swachh Bharat Abhiyan Promotion of Yoga

Swatch Bharat (Clean India) is the best antidote for communicable, infectious and vector-borne diseases put together. Not only does it make our country clean, tidy and appealing; Swatch Bharat if implemented in totality will result in far-reaching results with, vanishing communicable, infectious and vector-borne diseases. The contribution to gross domestic product (GDP) through savings on health expenditure and increased economic productivity will be enormous. United Nations Development Programme's (UNDP's) goals with regards to malaria, tuberculosis and other vector-borne diseases will be met easily and we may actually surpass them. The drawback I see: bureaucracy, it is not as enthused about this programme as the ruling polity is; there is an implementation failure as volunteers/amateurs cannot carry this burden beyond their time and capacity limitations, therefore slowly this is a case of diminishing returns developing overtime post the initial euphoria.

Promotion of Yoga is synonymous with fight against advent of non-communicable diseases (NCDs). NCDs today are the leading cause of death, surpassing 50 per cent as cause of death in our population. Like Swatch Bharat, in this programme too, a case of diminishing returns is developing. Both the programmes need to be professionally managed with targets to achieve, for better outcome and influence on public healthcare to be realised.

No: because, despite the above two programmes which caught the imagination of people, there is no change in the continued, curative bias (in healthcare bureaucracy), which consumes huge amount of money with insignificant results in overall improvement of health of nation.

I have expressed in my earlier articles that the National Health Policy 2017, despite its limitations, is the best vision document on our healthcare, post the recommendations of Bhore Committee in 1946. But what is the benefit of a good document if nothing gets accomplished on the ground? Modi has to take up the cudgels himself, finish the job under his direct supervision and not leave it to even his Cabinet colleagues (like a captain batting through the innings, playing captain’s knock).

Here are five purposeful interventions:

First Strategic Intervention – Comments And Suggestion Of The Author: India is today a $2.3 trillion economy and growing, it is the right time for the government to go big, allocate 3 per cent or more of GDP for health, “declare health as a fundamental right” and provide – Universal Health Coverage (UHC). It is time to take charge and go for big audacious goals. Strong governments can pull through the impossible and achieve results beyond the bounds of human imagination due to collective efforts and the goodwill of people. This is actually Modi’s moment in history to seize and leave an indelible mark, more importantly; it is the right thing to do.

UHC, in its simplest definition means, access to quality, effective and affordable health services for all, without imposing financial burden. This can be achieved through various methods using government and private sector expertise and the costs borne by insurance premium paid by the government on behalf of citizens and other methods feasible. All citizens should be entitled to a comprehensive package of healthcare services, and have access to public health and accredited private facilities for attaining services such as diagnostics, medicine, vaccines or surgeries as an entitlement, without having to pay at the point of use.

Caution: A large body of evidence suggests that up to 25 per cent of “quality” care may be unnecessary and inappropriate and higher utilisation of resources is not associated with improved health status/outcome or quality of care. The push, therefore, should be for appropriate care and not quality care as part of UHC. Replacing quality care with appropriate care will make UHC in the changed Indian context defined thus: Access to appropriate, effective and affordable health services for all without imposing financial burden.

Let me explain this with an example: In 99 per cent of patients requiring CT scan, findings can be assessed with a low cost-low end, 4 slice or 16 slice CT scan machine, only 1 to 2 per cent of patients will require CT scan machines of higher capability and cost, therefore it does not make sense to subject all patients requiring CT scan to a 128/256 slice machine in the name of quality healthcare. Only those who will benefit from such quality improvement must be provided with it. SOPs and management regimes developed should opt for lower-cost approach unless value is demonstrated in higher-cost alternative. This pragmatic approach of appropriate care will bring down the cost of UHC by minimum of 20-25 per cent.

Second Strategic Intervention – Establishment Of National Drug Procurement Policy: The “Jinx of 70”, it is well established that 70 per cent of healthcare expenses are due to cost of medicines. Right to health and universal health coverage cannot be achieved without access to affordable essential drugs on a regular and viable basis. Millions of Indians could access better care, if government decides to procure generic medicines in bulk and distribute them free of cost at public health facilities. The government should establish a national drug procurement and disbursal policy with mandate to procure and provide generic medicine, surgical implants, stents, devices, suture goods etc..., to all public and private institutions participating in UHC across the country. Distribution of free medicines and treatment accessories through public healthcare systems helps increase citizens trust in our public healthcare system and in the government of the day.

A centralised public procurement and decentralised distribution of essential medicine (drugs only) model has been successfully implemented in Tamil Nadu and Rajasthan. This initiative has been shown to lower the cost of medicines and allow free access to generics. India is called the pharmacy of the world due to the huge concentration of companies manufacturing generic drugs and exporting them to developed countries including the US; it is time to ask those companies to manufacture for India thereby promoting Make in India too.

Third Strategic Intervention – Universal Standard Operating Protocols: A body of practising clinicians with peer acceptance, must be set up to formulate universal SOPs, standardisation of treatment regimes, prescription standardisation, treatment audit methodology and treatment audit, quality/value assurance methods to improve performance, efficiency and accountability of the UHC. With standardisation of treatment, outcome across the country can be assessed, audited and monitored in a better way. Data obtained through such a system is of immense value and can be used in various ways including disease outcome prediction and development of artificial intelligence (AI) and its implementation in medical device technology increasing their efficiency and overall medical device intelligence.

Fourth Strategic Intervention – Focus On Impact Areas In Healthcare: Availability and accessibility of primary care in the time and place of need especially rural areas leaves an impact, it also allows the person to suffer minimum in terms of illness and also economic losses. The other area of impact is “Care in Critical illness”. Here more than the economic losses, it is about saving patient’s life which leaves a lasting impact with the whole family and society. UHC should look at these two areas as priority areas on focus. The rest of healthcare services patients have time on hand, can wait and schedule them as per their convenience. All India Institute of Medical Science (AIIMS) and the enormous expenditure on it can wait, right now government should go after primary care and critical care as they are high impact areas and will produce quick results.

Fifth Strategic Intervention – Research and Development: After Ronald Ross discovered malaria parasite in female anopheles mosquito on 20 August 1897, there has been no touchstone moment in the history of medical research and development (R&D) in India. The number of national research institutes on TB, tropical medicine, malaria, vector borne diseases, VDs and now NCDs should have made us a powerhouse in global healthcare but we are not.

India is nowhere in the map of R&D in healthcare, countries like South Korea have taken a giant leap as they allocate substantial percentage of their GDP towards R&D in healthcare, linked to performance ensuring results from their scientists. India needs to start allocating serious money to develop newer methodologies of disease treatment, develop more efficient drugs, develop low cost efficient equipment, develop methods to reduce burden of disease, increase disability-free living in geriatrics and develop database of traditional medicines and their APIs. Our scientists are not pushed enough from the healthcare administration to deliver results, it is time now to do it, Modi must take personal interest in this similar to what he has done with Indian Space Research Organisation (ISRO). R&D can encompass much more than what is written here and must be developed as an important adjuvant to UHC.

A note of caution and advice to be vigilant: The task of integrating plural systems of medicine, which was not attempted till now, has been attempted in NHP 2017; however, it needs to be closely monitored. This may lead to lot of heart burn among allopathic practitioners; Prime Minister and Health Minister may have to intervene here if required to assuage the ego of healthcare practitioners and reassure them. Government should work hard to reach common ground and goals with private healthcare providers too, assign practical roles to the private sector and ensure public duties from private professionals for greater impact on our public health.

Finally, it is not all about sickness – wellness is the key to a healthy life. Clean water, clean air, cleaner environment (core principles of Swachh Bharat), adequate nutrition, lifestyle modification (core principles of Yoga), grooming of good healthcare assistants, good doctors, and also sex education of adolescents are all equally important to achieve our commitment to sustainable development.

This article is the intellectual property of Dr Jagadish Hiremut and will appear on his personal blog; those wanting to quote from it should do so with permission and due credits.

Also read: India’s Public Healthcare System Needs Urgent Overhaul: Are Those In Authority Listening?