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.)
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