Medical staff seen wearing masks at RML Hospital as a precaution in the wake of the coronavirus pandemic, in New Delhi, March 30, 2020. Photo: PTI/Ravi Choudhary
Several commentators have put forth the view (here and here) in the past that India needs a health system modelled on the National Health Service (NHS) of the UK. This is a popular view that is reinforced by calls made during the ongoing pandemic to nationalise health care in India. This is also the view put forward in the Bhore committee report (1946) which served as a blueprint for the development of health care services in India post-independence. While we agree that the current laissez-faire capitalism in health care must go, our conclusions from research (conducted for a forthcoming book) are at variance with previous recommendation on what should replace the current system.
The NHS is taxpayer-funded health care that is free for every citizen of the United Kingdom. It is appealing in its simplicity – there is a single-payer, the government – and administrative costs at 16% of healthcare spending are much lower than the 25% it costs to administer health care in the US. The NHS is so loved by British citizens that some have called it a “national religion”. It is no wonder the NHS is held up as an example of a well-run health care system, worthy of emulation by other nations.
If we could rewind to when the Bhore Committee (1946) made its recommendations, it might be possible to visualise India slowly building up a system of health care resembling the NHS. But 73 years have passed, and we have strayed too far from our post-independence trajectory to make a convenient U-turn. Private healthcare dominates the landscape in India, accounting for over 75% of health care spending and 65% of hospital beds. We cannot wish away this legacy. Any system that replaces our current healthcare system has to incorporate this legacy within its fold.
A nationalised health care system will pose a second challenge. Indian government hospitals are not paragons of virtue. Although free, the people they are supposed to serve shun them. Even the country’s leaders – politicians and bureaucrats – do not have faith in them. Except for a few elite institutions, much of government healthcare falls short of delivering acceptable levels of quality. In such a situation, expecting the government to replicate the NHS here in India would be a pipe dream.
So, what could such an alternate system be that could replace what we have? First, we see a continuing role for the government in any new system, especially in a system of universal health coverage, in which healthcare is not denied to anyone because of inability to pay. However, the primary role of the government should be as an “enlightened” regulator of health care and not as the sole delivery system.
Fortunately, we have good examples of how the government has played the role of an enlightened regulator. The Securities and Exchange Board of India (SEBI) of the securities market is an example. Like SEBI, a healthcare regulator should bring transparency into the workings of the healthcare marketplace. Since “Clinical Outcomes” and “Costs” are paramount, we will need our health care institutions to be completely transparent on these two measures. The national health care information technology backbone (the National Health Stack) that has been announced can be a key enabler in bringing “electronified” health care data from both private and public institutions out in the open for the regulator to analyse and use as a basis for setting standards and monitoring performance.
Apart from this, the government should also operate the core of health care – comprising primary health care, as well as emergency care centres. Government primary healthcare will serve as a gatekeeper to access tertiary care and coordinate care received by an individual throughout her lifetime. Government-run facilities will also provide emergency care. Private players should provide all elective care, where both costs and outcomes are predictable. This should be based on fixed-price contracts, similar to the current Ayushman Bharat model.
Such a mixed model will do several things. It will effectively control costs and quality through the disciplining role of the government-run components; it will make the best use of capacity in the private system, thus allowing an element of marketplace competition which will improve efficiency while ensuring through negotiated price-fixing that costs do not run away as in the current opaque fee-for-service system. Thus, the arrangement provides for a best-of-both-worlds scenario.
The principles of such a mixed system should be (1) move as much of health care as possible to value-based care from fee-for-service care (2) predictable (elective) care should be contracted to private players (3) there should be utmost transparency on metrics of performance – with a focus on clinical outcomes (4) a level playing-field should be created to encourage competition between multiple players/business models. This model comes closest to controlling costs while maintaining quality within a framework of universal health coverage.
Swami Subramaniam is CEO, Ignite Life Science Foundation, and Aparajithan Srivathsan is CEO, Intent Health Technologies.