Health Sector Reforms that the Modi Government can Initiate
Limitations of Indian Public Health System
The Indian public healthcare system has 3 tiers. The 3 tiers operate through a large number of Government i.e tax payer financed, primary secondary and tertiary healthcare institutions and a larger number of private (for profit) institutions and a much smaller number of private (not for profit) organizations. At the base of the pyramid of the health system, are the primary healthcare institutions in the form of dispensaries and small sized general hospitals. A substantial number of them are in the government-sector but they have a larger presence in the private sector. Higher up the pyramid are the secondary institutions (like district hospitals and private hospitals) and at the top are the tertiary services provided by few well equipped medical college hospitals and mostly by corporate, super specialty establishments.
Experts have identified a host of operational issues and gaps that plague the public health system. These relate to inadequate infrastructure, financing, human resources, drugs, HR policies, health information system, insurance and governance. It is therefore in need of radical reform. However since the government is the manager of the public health system, while the gaps do get addressed from time to time, reform happens in the typical piece-meal fashion, that characterizes government interventions.
The officially declared goal of the public healthcare system is free and universal primary healthcare. However even after 66 years around 70% of the population do not receive satisfactory or free healthcare and they are therefore forced to seek help from private providers and thus pay out of their own pocket.
Public health experts in recent times have observed that safe drinking water, sanitation, nutrition life style and the environment are key determinants of health and that the health system must address these needs. In practice however, the health system does not have any influence, mechanism or programs, to address these key determinants of health.
Skewed funding and poor integration denies the public of advantage of synergy arising out of the richness of India’s Medical Heritage.
The ‘content’ of India’s post-independence health system is mono-cultural. It is almost wholly based on western bio-medicine. In fact 97% of the national health budget, since 1947 has been allocated to Allopathy. Post-independence, the idea of integrating and mainstreaming 7 other legally sanctioned health systems with Allopathy has been mentioned in the introductory paragraphs, of all national 5 year plan and policy documents. In practice the 8 systems of healthcare viz., Allopathy, Ayurveda, Siddha, Swa-rigpa, Unani, Yoga, Naturopathy and Homeopathy function in silos. The 7 AYUSH systems receive only 3 % of the national health budget and the departments of AYUSH across all Indian States operate with this meager funding. The AYUSH department despite their limited funding, operate a parallel national health service, unconnected to the mainstream 3 tier health system, with around 25,000 dispensaries and 3000 small general hospitals, across 30 States. This service is uninformed by national health priorities and is mostly at the level of primary care.
The official AYUSH budget has sub-critical allocation for extramural research, education and for regulation of safety and quality. This is the reason why the AYUSH systems during the last 60 years have hardly generated any evidence based clinical, pharmacological or pharmaceutical outputs and also the reason why the regulatory system is ineffective.
The not for profit private sector in AYUSH, is the public face of AYUSH. Despite its limited coverage, it is the most effective provider of AYUSH health services to the community. The Indian public availing AYUSH depends on this sector for quality health services. The limited evidence based AYUSH research available in public domain, is generated by this sector through small, non-government funding.
An overview of the Indian public healthcare system thus clearly suggests that despite the fact that 8 legally sanctioned health sciences operate within the health system, due to their skewed funding and poor integration, the public does not receive the advantage of synergy arising out of the richness of India’s Medical Heritage.
The writing on the wall: Integrative healthcare appears to be the future framework for healthcare in the 21st century.
All over the world there is evidence of growing public demand for making available healthcare choices, based upon best knowledge and practices, drawn from different healthcare systems . In India also we see this trend reflected in the actual health seeking behavior of communities wherein people seek to combine or choose for different health conditions Allopathy or Ayurveda, Siddha, Swa-rigpa, Unani, Homeopathy or Yoga or a combination. For emergencies and surgery Allopathy is the first choice, for common ailments it is Ayurveda, Sidha, Yoga, Unani, Swa-rigpa or homeopathy, for chronic conditions it may initially be Allopathy and then a rebound to some other system, when there is insufficient relief. The public demand for pluralism in healthcare is based on a realistic assessment by ‘laypersons’ of the inadequacy of any single system of healthcare to solve all their contemporary health needs. Governments and regulatory bodies also appear to have accepted the imperative for pluralistic approaches in healthcare with the caveat that all new, potentially useful healthcare interventions, must establish their safety, quality and efficacy. An objective manifestation of the global acceptance of medical pluralism is reflected in the creation of government sponsored national research institutes for CAM in the United States and in Europe (Norway, Sweden) and in the introduction of introductory modules on Integrative Medicine (IM) in medical schools in many countries, spanning regions of the world. It is probably this public assessment that is responsible for the dramatic growth of the Complementary and Alternative Medicine (CAM) movement and the nascent evolution of different models of Integrative Medicine (IM) in both the public and private sector.
From the globally observed health seeking behavior trends, it is apparent that the era of monoculture in healthcare is coming to an end. Integrative healthcare appears to be the future framework for healthcare in the 21st century.