The argument in healthcare must move from the conventional “should there be a unit cost?” to “who will pay the unit cost?”

Most developed nations regard healthcare as a fundamental right and quality healthcare services as an essential pre-requisite of development. Arguably, the finest example of national health service provision is the National Health Service (NHS) in the U.K. Developed by a Labour government in the post war years, the NHS soon became Britain’s answer to the global search for an ideal healthcare model. Its inherent simplicity, being a government managed, socially driven model of equitable healthcare provision, led to its achieving “cult status” among healthcare professionals worldwide, and to its becoming an enduring symbol of British pride and sentiment. Indeed, many countries around the world, especially those in the commonwealth, replicated it unquestioningly, developing extensive links with it, for training and skills development.

Why then has the NHS model experienced significant change over time? The answer perhaps lies in its inherent un-sustainability; the government being wholly responsible for the costs of healthcare delivery, the consumer having to share only an insignificant part of the direct costs incurred, whatever his station in life. Not only did this make healthcare provision very expensive for the State, it resulted in inappropriate health service utilisation. The devolution of health service provision to local health authorities, in an attempt to “cap” costs, led to the NHS being increasing managed by professionals, many from non-healthcare domains, as also increasing disenchantment and attrition among key stakeholders; doctors, nurses and other senior healthcare professionals.

India can learn much

As the NHS in the U.K. strives to reinvent itself, we in India can learn much from its remarkable evolution, rise and perceptual decline. While government delivered models of healthcare guarantee social equity, governments in general perform poorly in the service sector, airlines and hospitality being classic examples in the Indian context. Evaluated objectively, the argument that government supported healthcare initiatives should be exclusively carried through public investment, in public healthcare agencies, is backed neither by logic nor by experience. Healthcare delivery, unlike health policy development, is not an area of governmental “core competency.” A measured and rational approach that explores various healthcare delivery models, pilots chosen models judiciously, finally adopting those that have both relevance and viability, is called for.

The unit costs of healthcare: Whatever the preferred healthcare model, we must accept that every healthcare intervention, from a consultation-interview-examination process, to the conduct of the most advanced investigations and procedures, has a “unit cost” appended to it, this being the cost incurred by the provider in delivering that intervention. The argument in healthcare must move from the conventional “should there be a unit cost?”, to the more contemporary, “who will pay the unit cost?” The responsibility for “unit cost payment” may rest entirely with the state, as for the person below poverty line, or one who is disabled or otherwise disadvantaged; partly the individual and partly the state as in those from lower income groups, the unemployed, public and NGO service employees and other selected populations; and entirely with the individual or other parties contracted on his behalf as in the higher income group individual or private sector employee with employer cover. Any healthcare model that disregards this “unit cost” that every healthcare intervention attracts, is doomed to fail, for sheer lack of sustainability or viability.

There are many examples of “unit cost sharing” world-over, with responsibility for health related costs being vested in both the individual and the State depending both on the nature of the service sought and provided and on the concerned person’s socio-economic status. Many countries have also experimented with insurance managed participatory models of healthcare, with government taking responsibility for the insurance premium, wholly or in part, private providers contracted through the insurance company being responsible for healthcare provision, a model that is gaining increasing acceptance among various State governments in India. While insurance managed healthcare models are not without problems, as caricatured in the Michael Moore documentary “SICKO”, a critique of the American managed healthcare system, they are arguably both robust and sustainable, thereby meriting consideration. Expanding these models to include premium contributions from government, employer and individual in varying proportions is another possibility.

It is important we acknowledge here that the majority of non-government healthcare services including health insurance are “for profit” enterprises, accountable to stakeholders and cannot on their own accord guarantee equity of care. Private providers also tend to marginalise those they perceive as “bad clients”, people with chronic diseases, pre-existing medical conditions and those who cannot contribute to healthcare payments on regular basis. However, social responsibility dictates that all healthcare service providers participate in delivering healthcare to the have-nots in society and this is possible today in the context of government-driven health insurance schemes that cover families below the poverty line (BPL) for emergency and specialist treatments. Other participatory healthcare models include the contracting out select healthcare services to private providers and State support for charitable hospitals and NGO agencies through grants for subsidised healthcare delivery. Senior government officials point out that such government-private engagement in healthcare through contractual arrangements, are by no means new, and have existed for decades.

Making PPP models of healthcare operational: Can government engagement with the organised healthcare sector be operationalised more systematically nationwide, so that no PHC anywhere in the country suffers due to lack of staff or services? Can private and NGO providers step in to formally cover for the government in regions that lack healthcare provision; tribal areas and hill regions for example? To take the argument a step further, can we not envisage a time when one could walk into any registered healthcare provider (private, NGO or public) and expect a proportional healthcare cost subsidy based on one’s ability to pay? Will this not guarantee “fair price healthcare” and thus greater health equity? These and many other questions beg answers in the contemporary global context.

The “H1N1 Swine Flu” epidemic has once again highlighted, like the HIV experience before it, the need for close and effective cooperation among the government, private and NGO-run healthcare service providers. The government reached out spontaneously to the private healthcare industry, engaging it in the national effort to fight the H1N1 epidemic. It seems eminently possible that such cooperation can extend far beyond the scenario of national healthcare emergencies, to include standard healthcare provision, primary, secondary and tertiary, especially at a time when we are contemplating “unique identification” for all Indian citizens. Even those sceptical of PPP (public-private participation) healthcare models will acknowledge that the private and NGO sectors have developed in the six decades after independence, impressive core competency in healthcare provision, often overshadowing the government sector with all its abilities of scope and scale, ophthalmological (eye) care being a good example.

Sense of urgency needed

PPP engagement in healthcare must therefore be approached in the spirit of greater common good, combining high standards of quality and efficiency with accountability, equity and transparency. PPP engagement must develop through a national healthcare blueprint, amalgamating government, private and NGO sectors in tripartite arrangements for healthcare provision, with the participation of all stakeholders, patient groups and healthcare professionals included. We must also engender the political will to legislate alongside for a “national healthcare guarantee” covering all Indian citizens. Health being a crucial indicator of human development, our failure to act with a sense of urgency, will only lead to further widening of the gulf between economic and human development indices in India.

(The writer is Honorary Secretary of the Voluntary Health Services at Taramani, Chennai, and convener of the Healthcare Panel (Tamil Nadu) of the Confederation of Indian Industry (CII). The views expressed in the article are his own. E-mail: tins_vhs@dataone.in)

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