Understanding the fundamental problem of fragmentation in India’s disintegrating healthcare system would be an important step towards universal health coverage
There are more than 460 million people in India with insufficient access to basic healthcare. When this is combined with increased life expectancy and high chronic disease prevalence, there is a need for long-term comprehensive care and interventions. Though the Ayushman Bharat scheme and initiatives like the National Medical Commission Act and the National Digital Health Blueprint have created a foundation for health integration, the issue of a fragmented healthcare system needs to be addressed urgently. This can be done through better profiling of patients, better organisation of healthcare delivery, besides creating a seamless, interoperable and integrated digital health landscape. With the 154th position in global rankings in quality and accessibility, the sub-par performance of the Indian healthcare sector — in comparison to countries with equally mature economies and democracies — is a critical yet underappreciated problem of a disunited healthcare system. The delivery system focusses and acts on various parts in silos without adequately appreciating their interrelation and position in the larger picture.
This imbalance is at the root of the more obvious healthcare crises of poor quality service, inequality as well as inequitability. This divide is at the heart of the ineffectiveness of our increasing efforts to nurture improvement.
As Sir William Osler, the world-renowned physician and author, said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” The experience of healthcare in our country, however, is often one of not being known as a person. This experience affects the poor, who have difficulty getting access to basic medical care until their problems become emergencies. It is also experienced by the rich and the middle class, who receive as much (and often more) of the sometimes dangerous commodities of healthcare but feel abandoned when they need help putting together the pieces of their illness-shattered lives.
For instance, a working mother of two from a middle class family in Delhi went from doctor to doctor trying to find the reason for her fatigue and decreasing energy levels. Each specialist examined her and prescribed the latest drugs and tests. However, they were unable to help her and the patient got worse each passing day. In the end her problem remained and she went into a depression.
The above experience of a patient is what is exactly the opposite of healing. Because, healing requires relationships, which in turn build trust and hope. They also provide a sense of being known to the care provider and thereby feeling secure that s/he will get the best treatment. The emotional connection between the healer and the sick is unique and priceless and imparts health benefits to the patient.
The country’s current healthcare system doesn’t contemplate on this aspect of treatment. It doesn’t deliver empathy and give a patient hearing to a person’s health issues. Increasingly, it delivers care/commodities that can be quantified, incentivised and sold or bought while the person, the whole system and communities get worse in spite of massive investment of time, effort and money.
Focussed research is must to understand the behaviour needed for discrete treatments of different diseases. But improving health is fostered by a different science, one that considers the behaviour of multiple interacting factors which advance the health of people.
It is a poor healthcare professional who considers only the disease and not the person. It is a poor policymaker who designs healthcare systems that deal only with discrete diseases and fails to create environments that support interaction among different parts of the system.
Fragmentation at times renders well-intentioned actions into the unintended consequence of making things worse. This results in an inefficient, ineffective and unequal care delivery that is commoditised. A cacophony of narrowly-focussed programmes and services may be a good strategy for expanding revenues for service in the private sector but definitely not a strategy for efficient public healthcare delivery. Efficient healthcare requires an ability to personalise and prioritise problems based on “an acquaintance with the particulars,” seen in the context of a person as a whole or whole people, communities and systems.
Today the efforts of public health, healthcare systems and philanthropists are directed at narrow programmes with insufficient focus on the larger picture. The lack of an integrative way of making sense of the world and the need to control and understand narrowly replace the greater promise of whole-system approaches.
Doctors treat whoever comes through the door, often oblivious to the many barriers to entry. Manufacturers make their products based on the economic niche more than public good. Hospitals and healthcare systems strive to attract “the right case mix” to maximise profits, or just to stay in business.
Knowledge generation is narrowly partitioned in disease-specific institutes and initiatives without sufficient balancing research that crosses these boundaries. Specialists, drug and device makers, hospitals and service agencies focus on delivering their well-reimbursed services without a way to consider their effect on the whole person or system, or the opportunity costs on the social determinants of health, such as education and employment.
The promise of healthcare is reduced when it is treated as a commodity. When patients become customers, citizens become consumers and healers become providers. By focussing their role narrowly on a technical skill, procedure, or body part, healthcare professionals have completed one part of their contract with society. But in focussing just on expertise without also attending to their responsibility to the whole person and to society, most of the healthcare providers have not acted responsibly towards society. In our system, we definitely can’t settle for technicians in place of compassionate healers. We have to remember that higher levels of healing are possible by balancing the biotechnical with the biographical.
Patients appear to be dissatisfied with healthcare in more fragmented systems. Indeed, the failure of repeated attempts to fix the problems can result in a kind of shared hopelessness. When we see only parts, disconnected from the whole, we lose our ability to find incremental actions that are connected to a larger evolutionary improvement.
The search for single sustainable solutions gets in the way of fostering development toward equitable, integrated, personalised, prioritised healthcare. Furthermore, the fragmentation of healthcare leads to a get-what-you-can mentality among all involved. Developing shared goals requires continuous attention but discernment of how each person’s health and healthcare affects the others can provide a platform for seeking a better way together.
With rapidly aging populations and an increasing burden of patients with chronic conditions and their complex needs, there’s a pressing need for a comprehensive healthcare delivery system in our country. In an effort to cope with this growth, public health spending has been raised consistently since 2014, with an increasing share of the country’s Gross Domestic Product (GDP) being distributed towards public healthcare. An estimated Rs 1.6 trillion were spent on public healthcare in 2018. The total per capita Government spending on healthcare has nearly doubled from Rs 1,008 per person in the financial year (FY) 2015 to Rs 1,944 in FY20, but is still low. The total expenditure by the Centre and States for the FY20 was Rs 2.6 trillion or 1.29 per cent of the GDP, including establishment expenditure comprising salaries, gross budgetary support to various institutions and hospitals and transfers to States under centrally-sponsored schemes such as Ayushman Bharat. Of the total public expenditure, the Centre’s share is 25 per cent.
In a fragmented healthcare system, spending more on some parts does not improve the whole system. Similar criticisms of fragmented disease-by-disease efforts by the World Health Organisation have been raised on the 30th anniversary of the Alma Ata plan for “providing a comprehensive, universal, equitable and affordable healthcare service for all.”
The benefits of integrated care have been widely acknowledged and it has been adapted extensively in North America and Europe, especially for the management of patients with chronic diseases. Understanding the fundamental problem of fragmentation in our disintegrating healthcare system would be an important step forward towards universal health coverage. Viewing healthcare as an evolving “whole” instead of as fragmented parts can help us instill hope where now there is cynicism. It will lead to personalisation of care and relationship with the healer where now there is detachment and isolation. There will be professional and corporate shared responsibility where now there is narrow self-interest. High-value healthcare where now there is ineffectiveness, waste and inequality as well as inequity.
(The writer is an author and a doctor by profession. The views expressed are personal)
