Increasing Access to Healthcare in India

INCREASING ACCESS TO

HEALTHCARE IN INDIA

Overview of Healthcare System in India A few facts and figures to consider in healthcare sector/ system1 in India before looking at the challenge of access to healthcare:  At the time of Independence, the life expectancy at birth for an individual in India was 32 years; it has more than doubled to 66 years in 2013  The infant mortality rate (IMR or the number of babies who die before their first birthday in a given year per 1,000 live births in that year) has gone down from 164 in the early 1950s to 40 in 2013.  There are around 48 million children in India or 40% of the total under five years who suffer from stunted growth.  India has been able to eradicate polio and on March 27, 2014, was officially declared polio-free by the World Health Organisation. In the past, India has been able to eradicate diseases like smallpox.  The immunization coverage of DPT(diphtheria, pertussis, and tetanus) is 72 percent in India which is almost similar to sub-Saharan Africa's 71 percent  According to International Diabetes Association (IDA),

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there are around 67 million people in India, who fall in the age group of 20-79 years and suffer from diabetes.

Also, a study done by Global Burden of Disease (GBD) in 2013 has found that 15.87 lakh people lost their lives in 2013 due to Ischemic Heart disease. It has seen an upward trend from the 1990s.

India, according to a study published in Lancet in 2013 has an obese population of 30 million people just behind China's 46 million and US' 87 million. It is all the more striking as India is also home to 270 million people living below the poverty line.

Almost 60 percent of the people who do not have access to toilets in the world live in India.

The government has around 20,000 hospitals that serve both the rural and urban populations. The private healthcare system has capability of world-class hospitals at one end of the spectrum to quacks on the other end.

With low insurance penetration, out of pocket spending on health as a percentage of total expenditure on health remains high in India (60 percent), higher than all the other OECD countries as well as China.

1 For the purpose of this brief report the terms healthcare system/ sector/ industry are used interchangeably though there exists considerable difference between the three. However, here the term is used to reflect various actors and factors, which have a bearing on healthcare access.

Why Understanding of Healthcare Access Related Challenges in India is Important?

Goal 3 of the Sustainable Development Goals (SDGs) of the United Nations seeks to ‘ensure healthy lives and promote well-being for all at all ages’. As we approach the one-year anniversary of the adoption of SDG’s, a need is felt to look at some of the challenges highlighted by the United Nations during the adoption of the SDGs. There are a number of targets to be met for achieving the Goal 3 of SDGs. These targets aim to address the core issues like enabling health care access and helping people to lead healthy and productive lives.

An important reason is part Part IV of the Constitution of India2, which talks about the directive principles of state policy. Article 47 under part IV of the Constitution of India lists the ‘Duty of the State to raise the level of nutrition and the standard of living and to improve public health’.

Despite this being a directive principle, successive governments have not been able to cater to the nutrition and standard of living of a large section of citizens. This leads one to think about the issue as to why the present healthcare system has not been able to cater to a demand by a large section of the population.

Another reason is that healthcare access affects a vast population across the world. It is a challenge across the world and people not having access to even basic health services are estimated to be 400 million according to a 2015 joint report by WHO and World Bank3. Most of these people reside in developing countries, which have several access barriers. Therefore, a roundtable was organized by India Council on Competitiveness in association with Institute for Competitiveness, Shared Value Initiative India & Social Progress India to bring together the experts in

Accountability Affordability

this area and understand the key challenges of healthcare access in developing countries like India that must be addressed in order to make progress on both written in the Indian Constitution and identified as SDGs.

Understanding the Broad Principles for Healthcare Access A healthcare system that can look to cater to demand should look at providing the following. All these should be in a state of balance as compromising on one could have an adverse impact on the other principles.

Accessibility means the system should be physically accessible with minimal delays and to a large section of the population.

Affordability means the healthcare system should have minimal costs for inclusion of large segment of people.

Accountability means that the system should be internally accountable as well as accountable to patients groups and citizens.

Availability implies that the system should have adequate medicines, equipment and healthcare professionals to take care of healthcare demand.

Acceptability refers to the system and its elements like medicines/ healthcare professionals and their acceptance among the people and patient groups.

Awareness means that the system as a whole should try to reduce the information asymmetry between producers, caregivers, citizens, and patient groups.

Understanding the Key Actors for Healthcare Access The discussion was broad and helped formulate some of the models and ideas used to understand the issues of

Availability Acceptability

Accessibility

Awareness

Some principles for looking at increasing access to Healthcare Figure 1: Broad Principles (6A’s Framework) 2 Accessed from- http://lawmin.nic.in/olwing/coi/coi-english/coi-indexenglish.htm 3 Accessed from- http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf?ua=1

access. One of the fundamental things to be learned about the healthcare system is the actors and their interaction with the overall system.

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Government

Drugs & Medicine

Producers & Caregivers

Healthcare Equipment

Supply Side

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Healthcare Professionals Hospitals, Dispensaries PHC etc.

NGOs and Media Organisations Healthcare Insurance Products

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Regulators

Citizens

Demand Side

 Patient Health Groups

Figure 2: Actors in the Healthcare System Figure 2 depicts the actors interacting in the healthcare system from a demand and supply side perspective. The supply side includes producers and caregivers. These include pharmaceutical enterprises, equipment manufacturers, medical colleges, nursing colleges, government, and private corporates. The pharmaceutical enterprises manufacture drugs and medicines, the medical equipment companies produce health equipments, the medical colleges and hospitals train and provide doctors, nurses, and other skilled healthcare professionals. The government and private corporates create health institutions like hospitals/ PHC’s, dispensaries, clinics, etc.

On the demand side are primarily citizens who require access to healthcare facilities. Other actors in the system include the Governments, which are mostly held responsible for maintaining the healthcare system through policies and programs and supply of services in both the rural and urban context.

Another major actor in the system are the regulators who frame laws and regulations because of which the sector has some features like entry barriers, checks on drugs, etc.

The patient health groups are another group, which are part of the system but often do not have enough knowledge and voice to impact change. The patient groups are often empowered by NGO’s and media organizations who, work to deliver knowledge and relay their issues to policymakers as well as to the healthcare producers and caregivers. Broadly these actors are present in most healthcare systems of the world. It is an interaction of these actors with distinct factors, which has a bearing on healthcare access.

Identifying Major Factors Impacting Healthcare Access in a System There exist many factors, which need attention for addressing the healthcare access challenges in India. These are again looked upon from the supply and demand perspective. The majority of these factors have the direct link to the healthcare access challenges. These factors either have a positive bearing or a negative bearing on how the healthcare system in India overall operates.

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Finance & Insurance Newer Business Models

Supply Side

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Producers & Caregivers

Technology Broader Infrastructure (Roads, Railroads etc.)

Drugs & Medicine

Healthcare Equipment

Healthcare Professionals

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Independent & Govt. Policies Regulation & laws Changng Disease Patterns

Demand Side

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Citizens

Hospitals, Dispensaries PHC etc.

Healthcare Insurance Products

Figure 3: Interaction of Factors in the Healthcare System

Preventive Healthcare & Monitoring

Awareness

Business Models: Newer business models are emerging in the industry, which have a bearing on how access happens or how barriers are broken. Several models like that of Aravind eye care, Narayana Hryudalaya exists in the healthcare domain which has disrupted the traditional sector to an extent and breaking down barriers to access. Some older healthcare platforms have limited access due to issues like corruption, inefficiency, and delays.

Finance and Insurance: Finance and insurance pose challenges as healthcare delivery has costs. These costs in India often end up being paid by the citizens and patient groups as there is little or no insurance and often this also severely limits access to healthcare. Finances for healthcare delivery are also too low from the government side that adds to the problem of healthcare access. The country’s GDP expenditure on healthcare access is abysmally low. The annual healthcare spending needs to be increased to at least 7% of the GDP to bring an improvement in healthcare access for the masses including meaningful insurance for the poor.

Government Policies, Regulations, and Laws: Laws and regulations are not always designed and implemented in a

way that facilitates better access to health care. A strengthened system of stewardship and regulation, which is responsive to the needs of different health system actors, and fulfills the concerted goal of improving access to quality and accountable health services, is required.

Another related point is regarding the clarity on the role of the government as a "Payer" versus "Provider". Rather than focusing on public versus private debate, efforts should be made to create an environment of trust and complementary co-existence between private and public healthcare providers.

Technology & Innovation: Technology also has a distinct bearing on healthcare costs, business models as well as ultimately access. Telemedicine can reduce barriers, but this requires awareness and appropriate training and skilling to caregivers and takers. Also, some newer technologies like nanomedicine, genomics, health analytics, etc. have the disruptive potential for solving the disease burden in the future. The central idea is to promote incentives for investment in research and development in new treatments and medicines that will address significant unmet healthcare needs in Indian patients.

Basic Infrastructure and Capacity Building: In a country like India where people often have to travel from rural areas to urban areas for access, improvement in basic connectivity like road, railways, and airports can solve physical access problems tremendously. Also, there has to be an ecosystem for the consistent supply of skilled resources including doctors, nurses and health professionals to the healthcare system. There has to be a provision, which encourages the physicians and skilled healthcare professionals to work in rural areas.

Changing Disease Patterns: From a demand side perspective, the disease patterns in India have changed considerably. As mentioned in the facts and figures section, India is one of the few countries, which has to look at both communicable diseases and lifestyle diseases. Here the companies should invest in innovating and producing newer drugs, which cater to the changing disease patterns.

Systemic Behaviour Change Orientation: Again healthcare is one of the few markets where there is tremendous information asymmetry. This is because the care providers and producers have huge information while patients have very less information about their disease or its cure. The need is to help patients groups with increased access to information so as to reduce information asymmetry in the overall healthcare system. Besides this, there should be a control mechanism in place to enable control corruption and increase accountability at all levels in the health sector including consulting, medicines, diagnostics, resourcing, skill-building, licensing and audits.

Preventive Healthcare and Monitoring: Preventive healthcare again is a demand side phenomenon having an impact on healthcare access. The idea is to reduce ailments on the basis of some very basic principles like better hygiene and sanitation (washing hands, building and using toilets) and better environment (reducing respiratory and several other ailments). There should be increasing focus on peripheral and community level healthcare offerings. This can lower the load of the healthcare system and may release capacity.

Monitoring is necessary as central to healthcare delivery process. It starts from production and caregiving on the supply side to being central to several factors in both the demand and supply side.

Access to Affordable Drugs and Diagnostics: The majority of the population, especially in semi-urban and rural locations lacks access to affordable diagnostics and quality medicines. There are challenges of poor availability due to supply chain disruption, as well as duplicates and expired medicines in villages. There is a need to ensure the availability of integrated care where consulting is combined with diagnostics and access to affordable and quality medicines.

Coverage provided by the government or by private insurance should extend to medicines, in addition to physician and hospital care. Also, there should be a mechanism in place to monitor the availability and pricing of essential care medicines.

Citizen Engagement and Mobilization: Alongside supply side interventions, it is also critical to mobilizing communities and service user groups to demand improvement and accountability of existing health services, and better access to qualified health care. This approach requiring work across sectors and the improvement of mechanisms of local self-governance is a proven approach in different rural and urban contexts.

Conclusion The discussion highlights the fact that time has come for India to address the healthcare delivery challenges using a structured solution approach. This solution based approach will involve the focus on addressing the supply-chain challenges, increased government investments, access to insurance, integrated healthcare, resource capacity building, creating mass awareness and collaboration among different stakeholders.

Contributors at the Round Table The roundtable enabled a multi-stakeholder discussion, which included insights from the following experts: Dr. Ajay Sharma, Director, Government and Regulatory Affairs, OPPI Amit Kapoor, President & CEO, India Council on Competitiveness Anjan Bose, Secretary General, Healthcare Federation of India Barun Mitra, Founder & Director, Liberty Institute Bejon Mishra, Founder, Partnership for Safe Medicines India Brijesh S. Rathore, Business Director, South Asia – Diversey Care, Sealed Air Inc. Chesta Sharma, Healthcare Practice, PricewaterhouseCoopers, India Dr. Kabir Sheikh, Director, Health Governance Hub, Public Health Foundation of India Neera Vohra, Program Director, Institute for Competitiveness Pallavi Joshi, Research Associate, ICRIER Rajiv Bajaj, CEO and Partner, Nomura Research Institute India Pvt Ltd Sandeep Ahuja, Founder & CEO, Operation Asha, Dr. Sandeep Goyal, CEO, Shared Value Initiative India Sreedharan Nair, Director External Relations,FPAI Sunil Singh, IPR Attorney, Indian National Bar Association Sankalp Sharma, Senior Researcher, Institute for Competitiveness Udayan Dravid, Founder, ConnectHub Dr. Wilfried Aulbur, Managing Partner, Roland Berger Strategy Consultants

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