With the 12th Plan proposing to provide universal healthcare coverage, the debate of the day is whether the government or PPPs should spearhead this drive
Vishal Bali
Across the globe, more and more countries are realising that neither the government nor the private sector can deliver optimum and universal healthcare services all alone. There is an increasing optimism about PPP in healthcare delivery, particularly in light of the economic crisis and the realisation that the government has many pressing agendas to solve simultaneously. Government will always have purchasing power on its side and can effectively use that to empower the private sector to build, maintain and deliver healthcare along a desired framework.
Even in Hong Kong, where the state has always been the dominant healthcare provider, it?s being realised that they have to encourage private participation for further capacity creation. So, with land being an immensely scarce resource in the Special Administrative Region of China, the government has recently set out to tender four large sites to the private sector to build new hospitals. Singapore is another example where the state balances the public provision of healthcare with provision of services by private players. Vietnam has embarked on a vision to insure 15 million people in the next three years to give them access to private healthcare while in Indonesia public hospitals also provide private healthcare services.
In India, in the last 20 years, capacity-creation measured in terms of beds added and technology upgradation has largely come through private sector initiatives. Now 80% doctors, 78% outpatient services and 60% inpatient services are in the private sector. So, universal healthcare in a country where healthcare expenditure in the next decade will increase by 140% has to be planned in conjunction with the private healthcare delivery system.
The 12th Plan?s proposal to provide universal healthcare coverage would finally have to zero down on a model that is mutually beneficial to the government and the private sector, and overall is in the interest of the citizens of India. Planning Commission deputy chairman Montek Ahluwalia?s attempt to arrive at the right framework should be seen in this context. Any model that is not viable is bound to face a breakdown. It is a self-sustaining model that the Planning Commission is seeking to arrive at and the frowns at such an intent may be misplaced, given the context. Making private players participate in the future agenda seems to a step in the right direction since it would only enrich and strengthen the government?s hand in delivering quality healthcare to the people of India.
India?s GDP spend on healthcare is amongst the lowest in the world but innovations by private providers make it a dominant force in the Asian healthcare delivery arena. Private players have created different models of healthcare in the metros as well as in the tier 2 and 3 cities. The government should make use of these capacities, competence, expertise and experience.
A similar debate was raging on health insurance a few years ago, with different stakeholders having varied views and concerns. We have seen in last half a decade how robustly this sector is growing. There are public sector players, private sector players, central-level intervention, state-level intervention, and different PPP models are flourishing in the health insurance sector, which has had led to a wider coverage of healthcare?even with more than 300 million people now having access, this number is small compared to the overall need within the country. Still, this came about only because the issue came under focus and the sector gained momentum. Today, the issue of universal healthcare is going through a similar debate and this focus should be harnessed to bring in a healthcare revolution. The Planning Commission is one of the most important policy-framing arms of the government and it is very encouraging that this initiative has come about from such a quarter, respected by everyone for impartial, rational policymaking. If universal healthcare is to become a reality, the Planning Commission should be encouraged to firm up a strong, concrete policy roadmap to execute it.
The author is Group CEO, Fortis Healthcare
Arvind Singhal
It is matter of great shame and concern that India has more poor in August 2012 than what its entire population was in August 1947. Likewise, while our political leadership, cutting across party lines, and our planners can hide behind cold statistics by citing the progress made by the nation in the last 65 years on various public-health-oriented human development indicators such as life expectancy at birth, maternal mortality rates, and others, the fact remains that universal access to affordable and accountable healthcare is even more elusive today to a growing majority of Indians than it was on the eve of our independence. In absolute terms, India?s healthcare indices such as the number of doctors, nurses and hospital beds for every 1,000 Indians are shockingly abysmal; they are at levels comparable or worse than many of the sub-Saharan countries. In practice, they are even worse than what the absolute numbers show. Over 45% of the population has to travel as much or more than 100 km to access secondary or tertiary care, over 80% of total spending on healthcare is accounted through a highly fragmented and rarely accountable private sector, the 20 top cities account for almost 70% of the hospital beds in the private sector and 60% of the beds in the public (government) sector, and there is a current shortage of almost 1 million doctors. This highly skewed distribution (in favour of the top 20 cities) has to be balanced in order to provide some kind of healthcare access to the 650+ million Indians who live across the country?s 660,000 odd villages, and even to the 400+ million Indians who live in cities beyond the top 50 or so.
Against this backdrop, it is extremely alarming when the government talks about a further abrogation of its own social responsibility and considers handing over the healthcare mess to the private sector. Indeed, as the data shows, private healthcare providers already account for almost 80% of the entire healthcare delivery in the country, and there are but a few notable good-practice examples that can be seen as role models. In the absence of any transparency in sharing and comparing of clinical outcomes between private and public healthcare delivery providers, it is very difficult to make any definitive statement about the quality and efficiency of the two, but apocryphal and anecdotal evidence would suggest that the cost-quality ratio for delivered healthcare is significantly better in public (government) healthcare facilities.
With India?s population poised to cross 1.30 billion by 2020, and 1.45 billion by 2030, and with medical insurance penetration or third-party payee support still in the low double digits, a majority of Indians will continue to pay for their healthcare needs through their own meagre resources. Private sector participation will justifiably be based on financial viability of whatever business model is suggested to provide universal healthcare access to all Indians. And at this time, it is hard to come up with healthcare delivery models that can provide quality access to rural and small town India and also deliver the requisite financial returns to the investors. PPPs are often touted as a possible solution, but so far, across various sectors in India, such models have not really taken off. And where they do exist, often the outcomes seem to have delivered ?public money? to ?private parties? rather than led to something really good for the public at large.
It is therefore imperative for the central and the state governments to take India?s healthcare challenge with the seriousness and the responsibility that it deserves, putting the best leadership and the best minds together to come up with schemes and solutions that can provide universally accessible, affordable and accountable healthcare to almost all the Indians (and not just the affluent and relatively affluent top 50-100 million who have and will have the option to get the very best either from the government or through private Indian and international healthcare providers), and then get down to the implementation of such schemes and solutions through delivery mechanisms owned and managed by the government.
The author is chairman, Technopak
