Conversations with Vikram Patel: On the challenges and importance of providing healthcare in India, the world’s most populous country.

India’s population surpassing that of China to become the most populous country in the world, as estimated by the United Nations at the end of April 2023, marks a significant demographic milestone with a population of approximately 1.43 billion people​. This development holds substantial implications on multiple fronts. Economically, the burgeoning population of India could translate into a vast consumer market and an abundant labor force, which, if effectively harnessed, could fuel India’s economic growth and development, potentially elevating its position as an influential player in the global economy​. Moreover, the shift in global population dynamics could potentially enhance India’s influence on the international stage, with the world’s gaze possibly shifting more persistently towards the Asian subcontinent, recognizing its growing significance in global dialogues​.

Additionally, this demographic shift underscores the urgent necessity for effective family planning and social policies to manage the population surge, alongside comprehensive strategies to address challenges related to healthcare, infrastructure, resources, and employment opportunities​. On a geopolitical front, the population shift from China to India could also herald a new era of geopolitical dynamics, reshaping power equations and international relations​. Furthermore, the contrasting population trends between India and China, with the latter experiencing a population decline, highlight the different demographic trajectories of the two nations and their potential implications on global dynamics, as India’s population is projected to continue growing, surpassing 1.5 billion people by the end of this decade​. Hence, as India stands on the brink of this significant demographic milestone, the global community watches with recognition of the immense potential and complex challenges associated with this title.

The importance of healthcare in India’s potential future success is underscored by its direct link to economic health, highlighted during the COVID-19 pandemic, where the health crisis precipitated an economic downturn​. Aspirations for universal healthcare aim to alleviate financial burdens on individuals and contribute to economic equity, with efforts underway to integrate technological advancements and digitization to enhance healthcare delivery and accessibility​. Upskilling the healthcare workforce and fostering educational infrastructure are crucial for improving health outcomes and delivering quality care​.

Moreover, recent policy initiatives such as the Ayushman Bharat (AB)and its component Pradhan Mantri Jan Arogya Yojana (PM-JAY) advocate for an increase in government health expenditure, reflecting a step towards prioritizing healthcare in national agendas. Engaging diverse stakeholders in collaborative efforts to overhaul the healthcare system, coupled with an aspiration for global health leadership, underscores healthcare’s pivotal role in India’s trajectory towards economic growth, social equity, and global health prominence.

Vikram Patel is a notable figure in the field of mental health, hailing from India and recognized for his pioneering work on child development and mental health issues, particularly in low-resource settings​. He holds a prestigious position as the Paul Farmer Professor and Chair of Global Health and Social Medicine at the Blavatnik Institute’s Department of Global Health and Social Medicine within Harvard Medical School. Besides, he co-leads the Mental Health for All lab and the GlobalMentalHealth@Harvard initiative, emphasizing the importance of accessible mental health resources​.

Dr. Vikram Patel. (CREDIT: The Asian Awards)

Over the past few months, there has been a considerable amount of media buzz regarding India’s trajectory towards becoming the most populous country. This narrative often leads to discussions about potential success stories within this demographic expansion. A critical factor that resonated with me is the imperative of having a healthy population to truly harness the potential benefits of this demographic shift. It prompted me to reflect on India’s healthcare infrastructure. For those unfamiliar with the Indian healthcare landscape, could you provide an overview to set the context?

That’s a complex question. Here are a few key points readers should understand:

India operates under a federal system. While health is constitutionally a shared subject between the center and each state, the primary resources for healthcare delivery lie at the state level. Just as in the U.S., every state in India interprets national guidelines and policies in ways specific to their region, largely because most healthcare funding is state-based. The system is considerably decentralized in this aspect.

Discussing the burden of health-related suffering and disability, it’s vital to note that the healthcare system itself only accounts for a small part of this overall burden. The broad population-level health issues differ from the care one receives when ill. Major determinants of health are influenced by upstream social factors outside the healthcare sector. Nutrition, early-life experiences, and education, often overlooked, are powerful health determinants.

To illustrate, in the Western world, the significant decline in TB incidence and mortality took place even before the availability of tuberculosis drugs. This decline was primarily attributed to social policies related to housing and nutrition.

When discussing PM-JAY and Ayushman Bharat, the focus should be on healthcare quality and other essential aspects of health coverage, especially financial risk protection. The Ayushman Bharat isn’t designed to reduce the population’s illness burden. Instead, its primary goal is to ensure access to quality care with optimal financial risk protection for individuals already facing health challenges.

What are the official objectives of the program?

Universal health coverage doesn’t primarily address the reduction of illness burden in a population. Some estimates suggest that healthcare delivery explains less than a quarter of the illness burden. The emphasis should be on prevention. While healthcare delivery indicates an existing disease, you cannot solely rely on treatment to decrease the overall illness burden. Although some preventive measures like vaccinations are within the healthcare system, a significant portion of prevention takes place outside of it.

Charles Darwin Signature T-shirt – “I think.” Two words that changed science and the world, scribbled tantalizingly in Darwin’s Transmutation Notebooks.

As India’s population continues to grow is the existing infrastructure adequate to address the impending healthcare needs?

When discussing healthcare needs versus overall health needs, it’s crucial to differentiate between the two. Since its independence in 1947, every successive government of India has aimed to provide universal health coverage. While the term “universal health coverage” might not have been in use back in 1947, the notion of the government assuming a leadership or stewardship role, alongside financing and delivery, has been widely accepted. This ideology has persisted across various Indian governments. However, over the past 30 to 40 years, there’s been a subtle shift. Instead of aiming for complete universality, governments have sought to primarily assist the poor. This is based on the understanding that the government might not possess sufficient funds for an all-encompassing, top-tier universal health coverage. Consequently, the wealthier population is nudged towards the private sector.

Currently, India has a two-tier healthcare system akin to the US. On one hand, the government offers ostensibly free healthcare to everyone accessing government facilities. However, in practice, it’s not entirely free for several reasons, but it does require less out-of-pocket expenditure than the private sector. Given its primary focus on the economically disadvantaged, the public healthcare system is mainly accessed by low-income groups. On the other hand, the expansive private sector caters to the more affluent sections of society and is also growing in appeal to the lower-income groups, who sometimes find the public sector lacking in services.

The most notable change over the past three decades has been the tremendous growth of the private sector, especially the corporate private sector. While private medicine has always been a significant component of India’s healthcare delivery, what has evolved is its nature. We’ve transitioned from individual practitioners running private clinics, similar to the US, to the rise of corporate entities treating healthcare as an industry. These corporations construct hospitals and employ physicians, moving away from the traditional model of self-employed doctors operating their clinics. This shift towards corporate healthcare has predominantly been a trend over the last 30 years.

The Union Minister for Health & Family Welfare, Shri Jagat Prakash Nadda visiting the Deen Dayal Upadhyay Hospital, for the surprise inspection of the Hospital, in New Delhi. (CREDIT: Ministry of Health and Family Welfare)

 I’m curious about the variation in healthcare quality within India’s governmental sector, excluding the private healthcare segment. Furthermore, you mentioned privatization earlier. Are large corporations beginning to see a financial incentive or opportunity in extending their reach to the core sectors of society in India?

To address your second question first: The PM-Jay program has undeniably been a boon for the private sector. Essentially, PM-Jay is a health insurance program, indemnity-based and fee-for-service, closely resembling private health insurance in the US. It funnels public funds to private providers to aid India’s impoverished population through an insurance market that primarily covers inpatient hospitalization. This setup incentivizes the private sector to hospitalize the poor, leading to substantial profits. While some private entities may resist participating in the BMJ due to perceived low reimbursement rates, a significant portion of the PM-Jay budget has been allocated to the private sector over the past few years. This indicates that the private sector is capitalizing on providing healthcare to the economically disadvantaged.

Drawing parallels with the US, India’s healthcare system exhibits numerous similarities, making many of the observations applicable to both nations.

Regarding your initial question on quality: Access to healthcare has dramatically improved in India. Most individuals can not only access medical services but can do so within their district. This represents a monumental shift from the situation in 1946.

However, the accountability front has been lagging. Very few have faced legal consequences for malpractice or irrational drug use in recent times. Yet, countless stories circulate about the irrational use of antibiotics, unnecessary surgical procedures, and unjustifiable diagnostic processes, mostly propelled by a corrupt commercial nexus. This lack of accountability not only jeopardizes India’s healthcare system but also poses a significant risk to the insurance market, as one can never be certain if the services charged were genuinely required.

You touched on a point I intended to discuss later, but I’ll address it now given its relevance. Considering the funding structure of the program and the various issues you highlighted that could lead to escalating costs, is the program sustainable in its current form as we look down the line? To rephrase, given the factors you mentioned, is there a long-term sustainability aspect to this program?

Generally, I’d argue against it. Consider the U.S., for example. Healthcare costs there have consistently surpassed inflation. Similarly, the budget allocation for the PM-Jay has exceeded inflation rates. When you have a system, like in both countries, where accountability is virtually absent and it’s paired with a fee-for-service model, problems arise. While the notion that the market will self-correct might work for industries like the automobile sector, it doesn’t apply to healthcare. This is because healthcare isn’t a mere industry; it’s a public good, akin to education. We wouldn’t strictly apply market principles to education, so why do so for healthcare? Both are public goods crucial not just for individuals but for the collective. The pandemic underscores this: a COVID-19 diagnosis isn’t solely the patient’s concern; it affects everyone around them.

Given that health is a public good, there’s a call for universal health coverage. This requires a steward, ideally the state, to guarantee access to quality, uninterrupted care at the population level. Introducing a fee-for-service model clashes with this ideology, as it’s inherently provider-centric rather than patient-centric. Under this model, providers are compensated for their actions, not necessarily for addressing patients’ needs. This setup can inadvertently encourage irrational medical practices. All the evidence, not just from India but globally, suggests that per-capita payment models or prepayment methods align better with high-quality, universal health coverage than do post-service reimbursement systems.

The Prime Minister, Shri Narendra Modi addressing the gathering at the launch of the Pradhan Mantri Jan Arogya Yojana (PMJAY), at Ranchi, in Jharkhand on September 23, 2018. (CREDIT: Prime Minister’s Office)

Given where we stand with PMJAY currently, what steps or measures would you suggest to transition towards a more sustained and sustainable model moving forward?

I am currently co-leading the Lancet Citizens’ Commission on Reimagining India’s Healthcare System. This commission aims to provide recommendations on the very questions you’ve raised. However, I’d like to clarify that I am not speaking on behalf of the commission at this moment, as these recommendations are still under development.

From my personal perspective, the ideal scenario would be where the government has a national health insurance scheme that doesn’t directly deliver healthcare. Instead, it would make payments to providers based on outcomes, using a per-capita financing model. The initial move should be to consolidate all insurance programs. Following that, strategic purchases should be made on a per-capita basis. This would allow a consortium of providers within a population unit, like a district, to bid for and secure per-capita payments. These providers would then offer comprehensive care across all health domains. This is a departure from the current insurance model where payments are made for specific interventions. While this vision represents a significant shift from the current system, and might not be realized in the immediate future, I believe it’s the most effective way to ensure comprehensive and quality coverage without overwhelming financial resources.

Considering the challenges that existed prior to the implementation of PMJAY, on a scale of one to ten, how effective would you say the program has been in addressing those issues?

It appears there’s some evidence indicating that the out-of-pocket expense associated with PM-Jay, which is a part of India’s national mission, specifically its health insurance component, has both positive and negative impacts. The negative aspect centers around the coverage of PM-Jay. Recent estimates suggest that, contrary to expectations, coverage is higher among the wealthier quintiles of the population and in wealthier regions of India, such as the South, compared to Uttar Pradesh and Bihar. These two northern states house about half of India’s impoverished population, indicating a significant inadequacy in beneficiary identification.

A major concern arises in identifying eligible beneficiaries, with the primary data source being a decade-old census. India faces a significant challenge as it hasn’t conducted a new census, partly due to the pandemic, breaking the traditional 10-year cycle. Additionally, the data on household expenditure, a crucial metric for poverty estimation in India, is outdated. Hence, the identification of beneficiaries is massively inadequate. Furthermore, there is a notable lack of accountability.

On a positive note, there’s preliminary evidence suggesting a decline in out-of-pocket expenditure. It remains unclear whether this decrease is attributable to the Irishman pirate, the PM-Jay, or the substantial shift towards the public sector in healthcare over the last three years. Recent findings from two extensive surveys indicate a significant increase in public sector utilization, accounting for nearly two-thirds of all consultations post-pandemic. This shift naturally leads to a reduction in out-of-pocket expenditure, although it doesn’t necessarily imply that insurance has facilitated this reduction.

This scenario presents a unique historical moment for the Indian government to enhance its public health system, spurred partly by pandemic-driven public sector services, including vaccinations, and the financial constraints of the last three years, especially among the impoverished population. However, insurance may not be the ideal solution to leverage this opportunity. Addressing other structural challenges, like the human resource crunch and the varying quality of medical practitioners, seems more crucial. While funding remains a concern, the primary focus should be on overcoming these structural barriers to improve healthcare quality and accessibility in India.

Interestingly, could the pandemic have inadvertently acted as positive public relations for the PMJAY program, shedding light on its significance or effectiveness?

Certainly, a historical review of the pandemic unveils the distinct roles played by the public and private sectors in India. The public sector emerged as a pivotal player, with its frontline workers spearheading vaccination drives and promoting social distancing measures. Their exceptional contributions earned them the World Health Organization’s special Director General prize. A significant portion of the vaccination campaign was carried out in the public sector, with vaccines being provided free of charge, courtesy of government funding.

On the other hand, the narrative surrounding the private sector was less favorable. Discussions often revolved around rampant profiteering and misuse of medications, shedding light on some of the sector’s troubling practices. The private sector presented a spectrum of medical practices, with instances of irrational drug use juxtaposed against pockets of high-quality care. However, a significant challenge remains: distinguishing high-quality providers from those whose primary interest lies in maximizing their profits at the expense of patient care. This lack of clarity underscores a critical issue that needs addressing to ensure a higher standard of healthcare across both sectors.

IMAGE CREDIT: Ministry of Health and Family Welfare.

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