In a post-Covid world that has re-defined multilateralism in health, India is getting increasingly recognised as a significant global player. About five decades ago, with the ascendant wave of neoliberalism, global health started getting multipolar, with behemoths such as the World Bank carving out a dominant niche in the field, overshadowing a lumbering and highly bureaucratic World Health Organization (WHO). But today’s multilateralism aims to be more diversified, coordinated and inclusive, with the WHO retaining its central coordinating role amid aspirations to modernise it. This modernisation entails appreciating the multifaceted nature of modern health challenges, requiring multilateral and synergistic coalitions involving both the public and private sectors. The reality is no different at the national and sub-national levels.
Earlier this year, the chief executive of an English hospital said that the UK National Health Service (NHS) was “locked in a death spiral”. Many Western and Central Asian nations today are staring at acute shortages of manpower in healthcare. Traditionally heralded social democratic models such as the NHS are floundering not necessarily due to inherent design defects, but due to inadequate investments. At the same time, liberal and conservative systems are forced to reconcile their own challenges and embrace inexorable transitions.
How do these transitions occur in reality? As a 2023 report on the NHS notes, radical transformations of health systems are rarely realised despite high-minded ideas. Rather, countries need to build on their existing systems, overlaying reforms and best practices incrementally. The result is a ‘messy’ health system comprising a multitude of players and policies operating together. This approach shines a light on India’s road ahead to universal health coverage (UHC). And it will pivot on one important element—data and digital technology.
It is safe to assume that it would be rather utopian for India today to have a UHC predominantly run by the public sector. The radical increase in public investments, shrugging off of a mammoth private sector, and cross-cutting political and social consensus that such a system would entail are likely to become more elusive with passing time. At the same time, a rejig of Indian healthcare looks to be on the cards. This can be seen to comprise roughly two parts: reorganisation of service provisions and influx of new players, policies and care arrangements, each playing its part in putting together the UHC puzzle.
Currently, India aims to attain UHC through the expansion of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the flagship publicly financed health insurance (PFHI) scheme of the Union government. Expanding PFHIs would entail bringing a large chunk of the private sector under the public fold. Today’s fragmented provider landscape would consolidate into bigger integrated networks like the accountable care organisations in the US. Outpatient care, which so far has remained a conspicuous omission under PFHIs, would steadily insinuate itself into the purview of insurance.
With efficiency considerations reigning supreme, current redundancies, particularly in private care, will need to be increasingly dispensed with, resulting in greater regionalisation of care. Greater attention to task shifting, particularly in primary care and home- and community-based models of care delivery is likely. This will compound the work of state- and district-level agencies whose capacity to administer public-private coalitions will need to be buttressed.
The AB-PMJAY itself would see a dichotomous financing pattern, with contributory insurance for the non-poor even as the government continues to finance the premiums for poorer segments. A major chunk of the middle and upper classes are likely to stick to private health insurance, which will warrant its own set of reforms to alleviate market imperfections and make it more attractive, affordable and accessible. As imperfect as the resultant picture looks, practically speaking such a muddling through would be the practical way forward if India is to attain UHC in the foreseeable future. This proves that health systems are complex and healthcare challenges can’t be solved with elegant, universal and fixed solutions.
It is here that India’s leadership in digital health becomes significant. Under India’s G20 presidency, the WHO has launched a Global Initiative on Digital Health aiming to marshal investments into digital health and facilitate regional and international exchange and reporting on health. India’s own indigenous digital health movement, the Ayushman Bharat Digital Mission, preceded this initiative and is steadily gathering steam. At this juncture, it is crucial to enunciate a renewed philosophy of digital health and health data which looks beyond just its commonly understood advantages.
Digital health must be seen as a tool for effectively managing the inevitably complex nature of UHC expansion. It is obvious that the messier the health system gets, the stronger will be the need for better data and a seamless digital infrastructure. Here, it will have a wide-ranging role to play, right from helping administer diverse contracts to implementing terms for value-based provider reimbursement and incentives. A recent audit report of AB-PMJAY from the auditor general shows how the PFHIs’ challenges need not entail an outright dismissal of the insurance model. A robust digital and data infrastructure can address most of the challenges. Meanwhile, a shift towards a public sector-dominant model would remain as laborious and improbable as ever.
There are some caveats to consider here. India is not alone in this journey. Many low- and middle-income countries are also looking to build on their existing systems to expand UHC for their citizens. The Indian example could be instructive for them in terms of policy lessons. Pervasive staff shortages in the West and initiatives such as ‘Heal in India’ could accelerate the medical brain drain even as we suffer major staff shortages of our own. It will be imperative that national interests don’t lose ground to international ambitions and that digital technologies are leveraged to create non-competing solutions that are mindful of the Global South.
Dr Soham D Bhaduri
Health policy specialist and chief editor of The Indian Practitioner