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Opinion » Comment

Updated: January 31, 2013 02:02 IST

Wrong prescription

Jay Desai
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FOLLOW THIS: While the single payer system of universal health coverage has its faults and its critics, it diminishes the business aspect of medicine and streamlines care. Photo: Nagara Gopal
FOLLOW THIS: While the single payer system of universal health coverage has its faults and its critics, it diminishes the business aspect of medicine and streamlines care. Photo: Nagara Gopal

By opting for a U.S.-style medical care model, India is endangering its universal health coverage goal, and paving the way for a corporatised, for-profit system

As India continues to debate how best to implement universal health coverage, two recent and seemingly unrelated news items need to be analysed carefully.

The first one pertains to a report released earlier this year by the National Research Council and the Institute of Medicine in the United States. This elaborate 378-page document concluded that in spite of having the world’s most expensive health-care system, the U.S. ranks below 16 other rich countries for life expectancy with poorer health across the entire lifespans of its citizens. It noted that Americans fare worse in nine important domains of health compared to other countries including but not limited to birth outcomes, diabetes, heart disease and chronic lung disease. Most unexpectedly, it also noted that highly advantaged Americans (educated, insured and rich) also did poorly when compared to their counterparts in other countries. Several explanations were offered for such inferior health including various societal factors and a higher degree of inequality of its citizens compared to other rich countries. However, the U.S. health-care system was blamed at least in part for the dismal numbers.

The countries that were compared to the U.S. included Australia, Austria, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the United Kingdom. The U.S. mostly employs the managed care model and is in the midst of implementing universal health care. Many of the other countries listed have universal health care implemented through the single payer system with care delivered and paid for mostly by the government and public funding.

On the PPP model

The second news item pertains to a statement made by the Union Health Minister, Ghulam Nabi Azad, late last year at an event organised by the Confederation of Indian Industry (CII). Mr. Azad conceded in his address that the public private partnership (PPP) model was necessary to improve India’s health-care system. Perhaps not coincidentally, Mr. Azad also released a report titled “India Healthcare: Inspiring Possibilities, Challenging Journey” at this event. This report was prepared by McKinsey and Company, a U.S.-based management consulting firm. It is no secret that previous to this concession, Mr. Azad was opposed to the PPP model which is favoured by the Deputy Chairman of the Planning Commission of India, Montek Singh Ahluwalia. It is also noteworthy that the High Level Expert Group (HLEG) on Universal Health Coverage in India favoured predominant involvement of the public sector. The HLEG was constituted by the Planning Commission in October 2010 under approval by the office of the Prime Minister. Although there is no official word, it is now becoming increasingly apparent that India plans to follow the U.S. health-care model. If we go by the recent reports in certain sections of the media, the universal health coverage dream already appears to be a secondary goal. While no health-care system is faultless, what would be a logical explanation for attempting to implement a model that has largely been unsuccessful and costly? Is it misinformation? Is it conflict of interest? Is it the powerful corporate lobby? Or is it blind faith in the world’s foremost superpower?

No focus on prevention

The answers are not obvious but the shortcomings of the private health-care sector and the managed care model are. The first and foremost fault lies in that they lead inevitably to large-scale corporatisation of health care. This corporatised model leads to creation of the costly middleman. It generates hordes of medical administrators on the side of the corporate sector.

It necessitates doctors to add layers of administrators to their own practice to navigate the system which usually becomes too complex to handle. Moreover, in this corporatised model, higher reimbursements are usually for treatments and procedures rather than for preventive strategies. Thus, it usually rewards doctors and hospitals for fixing a problem rather than preventing it, leading to comparative neglect of maintenance of health. For the patients who do need interventions, the for-profit companies place hurdles in order to cut their own costs. Finally, this model also provides disjointed care based solely on the contractual relationship of various health-care providers and agencies.

The single payer system of universal health coverage also has its faults and its critics. However, it diminishes the “business” aspect of medicine. It decreases the administrative costs. It streamlines care. We have ample data to guide us towards adopting a system that is better for improving the health of a nation, with necessary modifications to suit local conditions.

(Jay Desai has cared for patients in India and the U.S. and in the public and private sectors.)

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The health care of the citizenry should not simply be handed over to
the corporate sector and the system which has failed in US must not be
implemented from top to bottom but after some necessary alterations.

The points highlighted by the author are graver in nature.The argument
that the doctors will be rewarded for fixing the problem and not for
preventing can't be accepted at all. In addition,the emergence of
costly middlemen is a serious issue .

Why not work for a indigenous system rather following a failed system
and most importantly 'Health care' must not be a 'for-profit policy'
of the government.

from:  mohit kumar
Posted on: Jan 31, 2013 at 13:21 IST

Amongst things that we should not follow/adapt/mimic from US, foremost
is their health care system. It's ridiculous and insane. Period.

from:  Arthy
Posted on: Jan 31, 2013 at 13:08 IST

Why is no one considering the primary care model which has worked so well in countries similar to India in terms of demographic and health profiles? Management consulting firms guide investors to park their equity into trees that will bear much fruits rather quickly; the speed of return on investment is equated with efficiency. The primary health care model is unfortunately a slow growing tree that bears counter productive fruits from the investors’ perspective, which is better health of the populations. If preventive interventions work, where is the market for the 64 slice CT scans and the drug eluting stents? Market penetration is the key to rich dividends. It is important to note that consulting birds of similar feathers would have recommended through timely strategic reports on the exponentially growing opportunities in health innovations. The decision makers dilemma is which of the Ps in the "PPP" is at the crux of the strategy: principles, people or paisa ?

from:  Dr. Oommen John
Posted on: Jan 31, 2013 at 12:32 IST

If Indians first get over the psyche of dishonesty the commonest formulation of which is corruption, any model of universal health care will work wonderfully.The fact however remains that India is heading towards yet another major move to entrust to private predators an important sector like healthcare which is verily a facet of Right to life which is not only a fundamental right but also a human right or natural right if correctly viewed from the angle of the poor and needy people that India abounds. It is a step directly in conflict with the letter and spirit of preamble which signifies the basic structure of the constitution and more than that the Directive principles of state policy. It is a matter of common knowledge that corporate hospitals loot the unwary. The law does not simply work to regulate them. The insurance companies try their best to repudiate even genuine claims driving poor patients to unending litigation.Constitutional obligations should not be abdicated askew.

from:  Satyanand Kattamuri
Posted on: Jan 31, 2013 at 12:12 IST

Single payer health care system, as the name suggests, is run by one central organization, which collects all dues and payments, employs the medical and other staff, runs the hospitals and dispenses health care to the population. The cost reduction accrued from the lack of profit motive and the elimination of advertising and promotional expenses can be substantial. The mass scale and standardization further cut costs and spread the benefit to more patients. This single payer has to be the government since no private operator has the resources to deal with hundreds of millions of patients in two dozen states, and will not agree to operate without profit. Thus the single payer system in India will operate like the post office, railways or the national electricity grid – provided by the government presumably under a new level cabinet minister. We already know how government run hospitals are run. Clearly, there is room for more than one “payer” in India.

from:  Mukundagiri Sadagopan
Posted on: Jan 31, 2013 at 09:00 IST

Every place has good and bad things. Yes, one of the bad things in the US is the healthcare system. I completely agree with the author that the corporatization of healthcare leads to costly middlemen, such as insurance companies. I really appreciate the affordable healthcare available in India - the ability to visit a doctor and pay completely out of my pocket when the need arises. Thankfully, I have not had to go to the doctor much in the US, but it is frustrating to even witness others' travails. Right from getting a doctor's appointment to buying prescription drugs (drug companies surely have a hand in the prescriptions!), it is a nightmare. Instead of imitating another model, it might be prudent to come up with a system that fits the needs of the local communities.

from:  Joseph B
Posted on: Jan 31, 2013 at 08:43 IST

This article along with the one published yesterday add to one common theme. India has lost its moral compass and the debate in health is one more clear indication of the loss. I agree that no system is faultless, but in a country where poverty statistics is shining through, a system as exists in the US will eventually weed out the poor even more. In the US it unfortunately affects the ethnic minorities more than the others. Similarly, it will affect the poor the worst. Primary care will become non-existent as has been highlighted. A simple headache will be treated by a CT scan, a perfusion scan followed by paracetamol! In a country where states are fighting for water, one essential commodity that will alter health statistics, we have a long way to go with some fundamental concepts. Universal health care needs to be reinforced with universal access to water. Canals up and down the country as was suggested by Subramaniya Bharathi could do a lot to the health stats of the country.

from:  Thodur Vasudevan
Posted on: Jan 31, 2013 at 05:32 IST

Intresting read.... would like to read more on Universal Health care idea

from:  kgaipal
Posted on: Jan 31, 2013 at 05:16 IST

There is no perfect solution to India's public health services. I
think it is wise to combine the best of both US and European models
and develop a uniquely India specific public health service. Shunning
private sector as it is allergic Indian socialists will not work.
Health care is expensive and has to be paid for by some equitable
means. Compulsory universal health insurance for routine check up and
maintenance is the only practical way to go. Indian bleeding heart
liberals must know that their approach has been tried for the past
sixty years without much success. Now is the time to different
approach. Only private sector knows how to innovate and public sector
is clueless about innovation.

from:  Dr. Shanthu Shantharam
Posted on: Jan 31, 2013 at 05:09 IST

The author is missing the big picture. When well to-do citizens from these so called better-than-US western countries have a complex or major medical need the first Country they turn to is US. Invention occurs in the US and cost of living and quality of life is superior in the US so things, including Healthcare, are very expensive.

Universal Healthcare countries have a death-panel, higher taxes and smaller population. You wait in a line to get a procedure done while people who are not elected sits in a room and decides your fate. And that very fate will depend on how much government can afford at that time. This system eventually degrades the quality of healthcare and the incentive to invent.

Obamacare only provides (actually forces) people who are not insured a way to get insured. Rest of the people are left to their own devices.

from:  Sena
Posted on: Jan 31, 2013 at 04:58 IST

A fundamental principle, we learn in Economics is "Demand and Supply".
In Health Economics, if we consider, the Producers of the Health i.e.
the professionals, are rising fast, ( CBI Health Infrastructure Report
2011 ) with nearly 250 Medical Colleges ( MBBS only ) have been added
since 2000. Is resulting in a perfect storm, since the affording
consumers of Private Healthcare are completely mismatched. Corporate
Healthcare strips a poor patient even further depriving their
resources, which could supply their needs for Healthy Nutritious diet.

India's unregulated healthcare environment, is causing massive level of
competition and frustration amongst medical students, who are competing
for ever decreasing medical seats, and upon graduation for ever
decreasing "Affording" patient population. Not to mention the rise in
unethical practices.

from:  Ankit Sura
Posted on: Jan 31, 2013 at 04:52 IST

This article hits it on the nose. The US model has not worked and will
not work even in the USA, let alone a country like India with so many in
need. It will lead to enriching private insurance and health care
providers. The media needs to be alert to make sure that an informed
decision with public consent is made unlike in the case of FDI in
retail.

from:  V. Ramaswami
Posted on: Jan 31, 2013 at 04:37 IST

I fully agree with the view that copying the failed health polices of the USA that India is going
to mimic will not work. It is like blind leading the blind. Let us see what other models are out
there that works. The so called socialized medicine work only in those country whose
population is small and the people in those countries are also willing to be progressively
taxed to avail this service. India's problem are simply too huge to comprehend. To start of
it's huge population is real drag on any meaningful solutions. That is the crux of the problem.
India's tax collection from its citizen is are also equally poor. So, the burden to fund this
program in India will solely fall only on those who pay their tax honestly, which is not enough.
Additional burden on the society comes from the fact that people are also living longer in
India. The best way forward in this vexing issue is education and prevention. Nothing else,
am afraid is going to work in India.

from:  Raman
Posted on: Jan 31, 2013 at 04:34 IST

Another sign of intellectual bankruptcy of our political class!The State
is slowly but surely abdicating its social responsibilities and
embracing Capitalism!

from:  umesh bhagwat
Posted on: Jan 31, 2013 at 02:51 IST
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