While it is good to see Niti Aayog championing the cause of increasing public health spending, it will be heartening to see the organisation promoting the need for public healthcare delivery too. That’s how the healthcare system can be transformed meaningfully
A three-fold jump in Central health outlay from over Rs30,000 crore now to one lakh crore rupees in the next three years is what the Niti (National Institution for Transforming India) Aayog is reported to have proposed, among other things, in its presentation to the Prime Minister and senior Finance Ministry officials, on its broad approach to the action plan. It is good to see Niti Aayog championing the cause of public health spending which is abysmally low regardless of the indicator used — as a share of GDP (1.3 per cent) or as a share in total Government spending (4.8 per cent in 2014-15) or as a per-capita Government health spending (less than $20).
Undoubtedly, the Government needs to increase its health spending. But public health spending is only one of the constraints facing the Indian health sector.
Health service, like any other sector, has two sides to it: The healtcare delivery side and the financing side. With an acute shortage of medical personnel (for example, doctors, including specialists) and weak institutional architecture, there are some binding constraints on the public delivery of healthcare. Constraints such as improving the supply of doctors that have a longer gestation period, can only be eased gradually with time. Easing of these constraints would definitely need some public funding, but not huge funding.
like the two wheels of a cart, both the funding and the healthcare delivery have to move in tandem. If one of the wheels starts moving faster, the cart will move in a circular fashion rather than straight ahead.
A three-fold increase in Central health budget over a three-year period implies an increase of health funding by over 40 per cent each year. That such a steep increase is unprecedented, is not really a matter of concern. The real matters of concern are the risks associated with such a steep increase. Some of these risks are:
Risk of under-utilising funds: Given limited capacities of States, particularly of the poorer States, to execute programmes, will mean that such an increase will not get absorbed effectively even if States were somehow able to spend it. Indeed, both under-utilisation and ineffective utilisation of funds have repeatedly been noticed during the implementation of National Rural Health Mission (NRHM). Further, in the presence of limited capacity, States tend to substitute Central funding for its own. So the actual increase tends to be lower than expected. In the implementation of the NRHM, the Government took 10 years to spend Rs1.3 lakh crore cumulatively, from 2005-06 to 2013-14. And this spending was significantly below what had been envisaged under the mission.
Risk of distorting priorities: If the objective is just to ramp up public health spending, there is no dearth of avenues to achieve that objective. Hospital care, for example, is one such area that can potentially guzzle any amount of public funding. It is said that hospital care is a bottomless pit! However, a public funding programme for hospital care will not make a huge demand on the exchequer if it is well-managed and if the health conditions of the people covered under the scheme are well-supervised. Managing the health conditions of people requires investing in primary care facilities.
For a huge step-up in its health spending, the Government needs to get the delivery system — particularly at the primary care level — right. The Government has a vast network of healthcare facilities which is not only broken but has also turned obsolete due to the changing disease burden, rising public expectations, and advancing knowledge on new ways of delivering such care. In keeping with the changing healthcare needs and demands of the population and the advancing knowhow, India needs to re-design its public healthcare delivery system.
How can the public health delivery system be re-designedIJ The current knowledge of best global practices is somewhat in a state of flux. Even the developed countries are having a re-think on the design of their healthcare systems, partly because of cost imperatives and partly to leverage IT-enabled new solutions for better performance. While the Indian States have much to learn from the experience of countries such as Thailand and Turkey, they also need to build on those experiences through their own experiments and experiences.
The idea that States conduct healthcare pilots was actually mooted in the 12th Five Year Plan but it never got off the ground in any meaningful way. But that doesn’t diminish the relevance of the idea.
To re-design the public healthcare system, the importance of systematically piloting transformative and affordable models of healthcare cannot be over-emphasised.
India is currently in a sweet spot where public health spending is low and the constraints on the healthcare delivery allow the Indian health planners/policymakers the much-needed time and space to invest in the discovery of appropriate care delivery models. India needs to seize this moment before the stakeholders mount further pressure on increasing public health spending.
In succumbing to such pressures before the healthcare delivery is sorted out, India runs the risk of missing the opportunity to address the much-needed transformation of the public healthcare delivery system. And, in addressing this delivery system, if India bypasses the necessary pilot phase, it runs the risk of choosing a sub-optimal path and paying a price.
To conclude, the need for a huge step up of public health funding is not in doubt; nor is the merit of making such investments. But let the discussion on public health financing not blind us from the imperatives on healthcare delivery. And in addressing the delivery challenges, let’s not continue thinking incrementally in a piecemeal fashion when the opportunity is to think of transforming the healthcare delivery system.
While it is good to see the Niti Aayog championing the cause of increasing public health spending, it will be heartening to see the organistion championing the cause of public healthcare delivery too.
(The writer is a development economist, formerly with the Bill and Melinda Gates Foundation and the World Bank)