When you start lending the importance of the first-order criticality to things that at best are of second order, you run the risk of dallying with dangerous unreality. This unreality can tempt you into seductive ideas and take your attention away from the pressing must-dos. When we address the faux questions and if action follows the ideation, the welfare of the common man is the first casualty.
When the thought process of planners is around fragmented delivery of healthcare services, multiplicity of purchasing platforms, non-pooling of the risk equilibrium and interoperability of health records, it misses the basic points. That 90% of rural people go to untrained Rural Medical Practitioner (RMP) doctors, the broken primary healthcare system does not even have nurses at the stipulated standard, and there are many vacancies of doctors at the Primary Health Centre (PHC) level and specialists at the Community Health Centre (CHC) level.
In India, there is a negative Pearson correlation between nurses and doctors. The states routinely have vacancies and are reluctant to appoint doctors and nurses, and the budget for primary healthcare remains abysmally low. This is at variance from the experience in other places where public healthcare accounts for 50% of the total health expenditure.
The public health system is broken with years of underinvestment, non-positioning of personnel, poor supervision, poor medical infrastructure and rent-seeking behaviour. There is a skewed distribution of medical personnel too with the 70% of the population in our rural areas getting poor coverage.With such scarcity of trained manpower, that an intermediate degree for practising a limited range of healthcare has not been introduced will surprise us all. Before Independence, we had Licensed Medical Practitioners (LMPs) with three-year diplomas and when many other countries adopted that, we abandoned it.
The LMPs with intermediate qualification in public health and medicine will be appropriate for sub-centres. And why are trained nurses not entitled to practise independently though they really manage our understaffed primary health with absentee doctors? Trained nurses are more amenable to work in rural areas but they do not get appointed. And the distribution of nurses is most skewed in north India where health outcomes are the worst.
When doctors are reluctant to work in rural areas, why are they blessed with a protective ring that helps in driving up their wages in the absence of supply side response? Instead of stabilising and augmenting public healthcare, the governments plan and work around corporate hospitals. In accepting the impossibility of boot-strapping public healthcare institutions, we are choosing the wrong pathway. Covid has proved that private corporate hospitals are not the right approach for India, where nearly 80% of the households are poor and financially stretched.
First of all, augmenting resources for public healthcare is not impossible. Is it so difficult to find an extra 1% of GDP for health if Rs 1.5 lakh crore of corporate tax can be foregone in the blink of an eye? Surely between the states and Centre, it is possible if conviction and willingness to prioritise it are there. Only 18.8% of rural doctors have a medical qualification. We need to expand the number of MBBS doctors and trained nurses for the system, particularly in PHCs and CHCs. The shortfall in trained nurses in the “high focus states” ranges between 65% to 95%.
Incidentally, these states also do not have an adequate number of nursing training colleges. Moreover, we are losing graduates from public medical colleges to the private sector. The number of seats can be ramped up without much expansion of the already existing infra. Students of the public system should say if they will be opting for service in the public system for 15 years at the time of joining. In that event, the fees should be zero, otherwise it should be comparable to the average of the private system, which is Rs 50 lakh per student. During the 15 years they serve in the public system, they should be allowed two years of study leave at government cost to do specialisation.
This incentive will be a great differentiator. The intermediate level health practitioners should be offered a hospital management course of one year after 10 years to be upgraded to hospitals at higher levels.
Finally, the ecosystem in public hospitals is terrible to say the least. The burgeoning population has exacerbated the problem. But the ecosystem in the government is such that the lower down you are, the more likely it is to get political power. A doctor does not control the support staff in the hospital and everyone is a power centre in that ecosystem. It could be because of their poor HR skills as well as the enveloping political system.
They are dependent on the government budget as a lifeline and politicians have disproportionate control, both formal and informal, over the system. Hospitals above the PHC level should be cost and responsibility centres where the director and the personnel should be responsible for everything they do. Oversight will be done by a board of governors consisting of representatives from the government health department and local users. Politicians should only participate at the board level. Even the usable costs can be collected from the patients. But the flow of the budget should be non-obstructive.
These are the answers the country should be seeking rather than reposing faith in the private sector entirely or privatising or corporatising healthcare facilities by questionable carpet bombing. For an improved healthcare, we need not work with free market orthodoxy or with yesterday’s logic. Nor should we consider the improvement of our public health system as an impossibility. As Nelson Mandela said, the only impossible journey is the one we never took.
Satya Mohanty (Views are personal) (satya_mohanty@rediffmail.com)
Former Secretary, Government of India