Universal Healthcare: Innovations Needed in Regulations
Dr. Sanju Ganju is the founder chairman of Atrimed Pharmaceuticals, a company modernizing Ayurveda. He is the founder of ‘Save a Mother’, a healthcare NGO, which works in over 1200 villages. During his career, he has participated in over a hundred non-profit projects.In the past, he was the CEO of Reliance Health and Technology, executive director of America India Foundation, chairman of Action for India and adviser to Rajiv Gandhi Charitable Trust. He also served in the Indian army. He graduated from the All India Institute of Medical Sciences, Delhi and specializes in gastroenterology and hepatology.
In most other countries, the constitution requires the government to provide some form of healthcare. The implementation, however, suffers from deficit of policy, government or resources even in the countries that consider healthcare as a part of social justice. The Author talks about how India can lead with innovations in legislation, policy, governance and finance to provide health for all.
Adequate healthcare is both, a prerequisite and a consequence, of the growth of a country. A health system can deliver public health and medical services, if its solid foundation includes skilled workforce, information systems, medical products, technology, adequate financing and governance. While technology can provide innovative tools to improve health, it is the regulatory framework whichcan provide the enabling ecosystem. It is important that Innovations not be limited to drugs and devices but also include regulations.Ultimately,it is laws that determine financing and structure of healthcare.
The nations of the world have included healthcare in their legal framework in some form.Almost all countries are signatories to one or more international human rights or health rights declarations.
One third of the countries include healthcare as a constitutional right for individual citizens. Russiaand former countries of the Soviet bloc Italy, Spain, Brazil, Philippines and South Africa have maintained health as human right in their constitution. On the other end of the spectrum are countries like the USA, which have no individual constitutional right to healthcare.
In most other countries, the constitution requires the government to provide some form of healthcare. The implementation,however, suffers from deficit of policy, governance or resources even in the countries that consider healthcare as a part of social justice.
India extrapolates health rights from other parts of the constitution.The right to health in India is outlined the Directive Principles of State Policy- Articles 42 and 47 and the fundamental right to life as stated in article 21.
Article 42 states that the State shall make provision for securing just and humane conditions of work and for maternity relief.
Article 47 states that the State shall regard the raising of level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and of drugs which are injurious to health.
Article 21,“The Fundamental Right to Life” guaranties individual life.
The Indian judiciary has interpreted the “Right to Life’ in many ways. It has held that humane working conditions, health services and medical care are an essential part of Article 21. Public interest litigation, as well as litigation arising out of claims made by individuals,has generated substantial case law showingright to health is an integral part of the Right to Life.
For technological innovations to flourish in its current stage of development, India needs more proactive regulations to progress towards universal healthcare.
Currently the Indian government spends about 1 percent of GDP on healthcare. Compare that to 3 percent in China and 8.3 percent in the USA. Private expenditure on healthcare is in addition to public expenditure; approximately 70% of health expenditure in India is from private sources.
A study done by PGI Chandigarh, suggests that universal health care services for entire 1.2 billion population, the annual cost of providing preventive and curative services will be INR 2415 billion (USD 54 billion). This would amount to increasing the allocation to health sector from current nearly 1% to 3.8% of GDP.
Indian business association, FICCI and consultants EY, estimated in 2012 that universal health cover would require government health spending to increase to 3.7-4.5 percent of GDP.
The current government, under the National Health Assurance Mission, would provide all citizens free drugs and diagnostic treatment and insurance cover to treat serious ailments. It would cost an estimated $11.4 billion annually.
In 2010, a High Level Expert Group on Universal Health Coverage recommended increasing public financing from 1% of the gross domestic product to at least 2.5% to provide essential health care package through tax funding and employer-provided insurance.
The Lancet published an India focused issue on health in Jan 2011. The lead authors (K SrinathReddy, Vikram Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar, Lalit Dandona),summarized the recommendations of various working groups as ‘call to action’ as follows. They propose the following targets to be achieved by 2020 through the creation of the Integrated National Health System with three overarching goals: ensure the reach and quality of health services to all in India; reduce the ﬁnancial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.
• The entire population should be covered by an entitlement package of health care with
ﬁnancing from a combination of public, employer, and private sources. Full range of relevant diseases need to be included in the entitlement package of health services with cost-eﬀective interventions that include health promotion and disease prevention.
• All health practitioners and facilities in the public and private sectors have to be registered with the Integrated National Health System.
• Public spending on health should be increased from 1% to 6% of the gross domestic product, and 15% of tax revenues—including new taxes on tobacco products, alcohol, and food with little nutritional value—should be earmarked for this purpose.
• Reduce the proportion of out-of-pocket spending from 80% to 20% of the total health expenditure.
• Increase spending on health research to 8% of the health budget.
Human resources for health
• Establish the Indian Health Service with guidelines developed through an autonomous National Council for Human Resources in Health.
• An updated training curriculum should be fully in place for medical and allied professions that is relevant to the situation in India.
• Establish suitable incentive structures to retain health providers in underserved areas.
Health information system
• Have in place comprehensive health information and surveillance system that covers all major diseases, health-system issues, and key social determinants, which also facilitates assessment of public health interventions.
• Establish adequate research capacity in India to investigate and report key issues that aﬀect the health system and policy for further improvements.
• Have in place a fully functional autonomous council that compiles and synthesizes relevant information to develop guidelines for evidence-based health care and its assessment.
Drugs and technology
• Implement a national network of pharmacies for generic low-cost drugs for the entire population.
• Establish mechanisms for bulk purchase of patented drugs at low cost.
• Have in place mechanisms to check and control the use of perverse incentives by pharmaceutical and biotechnology companies for health-care providers.
• Have in place mechanisms to make functional the components of the National Health Bill.
• Have a system in place that requires all middle and senior functionaries in public health to have relevant training in public health.
• Ensure devolution of responsibility for health care to district management systems along with accountability mechanisms and explicit community participation (The Lancet, Jan 2011).
India, at current stage of development needs more healthcare in every form and not less. Multiple studies have confirmed the fiscal feasibility and for technological innovations to flourish we needs a progressive enabling ecosystem.
Opposition to right to health emphasizes that it could increase the fiscal deficit;it could create shortage and increase the wait time for medical services, which would lead to rationing and lower the quality. It could also cause people to overuse health care resources. While appreciating valid opposing view, human development is not possible without guaranteed healthcare. Financial burden of a single episode of disease pushes millions of Indians into poverty, which stifles the market for technological progress.
Health and longevity have improved as never before in human history. And with explosive growth in the knowledge of human biology and genetics, it is likely that the life span will increase exponentially. It may even change the very definition of health to include happiness, intelligence and aesthetics as components of a new paradigm. It is imperative that innovations in legislation, policy, governance and finance will have to stay ahead of the burgeoning technologic innovations and not fall behind to irrelevance. It is important to have innovative strategic thinkers in the leadership positions that understand biology, healthcare, governance and finance.