HEALTHCARE

The Problems

1. Ayushman Bharat, the new publicly funded universal insurance scheme, will be difficult to implement given that the government will have to decide and settle disputes about which treatment patients should receive and how much it would cost.

2. India faces a surge in non-communicable diseases like diabetes and cancer; poorly qualified health practitioners with no accountability also cause the spread of antibiotic resistance.

3. Particularly in North India, patients have largely turned to under-qualified or informal private providers of primary healthcare – partly because government primary healthcare centres are poorly staffed and under-equipped.

4. Public hospitals and community healthcare centres are generally overcrowded and under-resourced – patients are forced to use them because private secondary and tertiary care is expensive.

A Note on Healthcare

Abhijit Banerjee

The biggest news in health and healthcare is Pradhan Mantri Jan Arogya Yojana (PMJAY) or Ayushman Bharat, which is a publicly funded universal insurance scheme that mainly covers hospital care. The coverage of this scheme is generous and, if properly implemented, it will protect people from the often-devastating economic consequences of a serious illness or an accident.

The concern with this scheme is that it is not easy to implement. Rampant fraud led to the closure in Rajasthan of the Rashtriya Swasthya Bima Yojana (RSBY), the previous edition of a publicly funded insurance scheme. These issues have not been tackled explicitly, so the scheme may run into problems.

In particular the model’s reliance on the trust model means that the government, as against insurance companies, has to adjudicate claims about the appropriate prices and treatments.

There is also the problem of what to do when there is prima facie evidence that either unnecessary procedures were carried out or false diagnoses were made. Or when there are claims that patients are being forced to pay extra for services that they are supposed to receive for free. Would the patient know what she is entitled to and what goes beyond her entitlement? And how do you settle the dispute, given that there will typically be no hard evidence either way – did the patient demand something the government won’t pay for, or was it imposed upon them? Relying on our already overburdened court system will not work except in the most egregious cases, so it has to be based on threats of exclusion from the system in the future. But not every disputed claim is illegitimate. Therefore, some judgement will need to be exercised, or else legitimate hospitals will not want to participate in the scheme. But who will provide that judgement?

In the United States, under Obamacare, these tasks are carried out by professionals who have a great deal of expertise in healthcare and healthcare costs and can therefore detect patterns that do not add up, and make credible arguments against dubious claims. So far there seems to be no awareness of this issue and no plan to hire very large numbers of professionals to manage the system (indeed, it is not at all clear where so many professionals would come from). There is the idea that hospitals will hire Ayushman Mitras to guide patients through the system, but it is not clear that they will have the right incentives (they are hospital employees, after all) or the right skills.

However, even if the scheme eventually works well, which we certainly hope, it is not clear that it will solve the main health challenges we face. We are still the economy with the largest number of malnourished in the world, despite some recent improvements. We are also facing a surge in NCDs like diabetes, blood pressure and cancer – in part because of ageing, in part because of the poisoned environment in many of our cities and in part because of various lifestyle issues (lack of exercise, bad diet and tobacco/alcohol use, for example). Finally, we face rising resistance to antibiotics, largely because of overuse.

The obvious way to deal with these issues is to make use of people’s primary point of contact with the healthcare system – the person they regularly see for what they believe to be minor ailments. This is the person who can spot any worrying changes in the patient’s health, do a quick check of their haemoglobin, blood pressure and blood sugar, or measure a child’s height and weight, and encourage them to take the required action. They are often close enough to be able to check up on whether the patient did take the recommended action (or whether he or she continues to take their medicine), and to put pressure on them if not. They can also pass on useful public health messages, such as the importance of wearing sandals, immunizing children or not cooking in closed environments.

Here is where we have a huge problem. Ayushman Bharat does very little for primary healthcare. It has been announced that 1.5 lakh health and wellness centres will be set up, partly to deal with primary healthcare issues including NCDs – but, given the budgetary allocation of less than Rs 1 lakh per centre, this looks more like a very minor upgrading of the existing sub-centres and/or primary healthcare centres (PHCs). Similar and sometimes more ambitious upgrading, including the provision of some free medicines, has been attempted by a number of states in the past; but, for the most part, there has been no reversal of the trend towards wholesale exit from public healthcare, especially in North India.

There is now a substantial body of work that documents that, in many states, more than three-quarters of visits to primary care centres are to private providers – even though most of these providers have no medical qualification whatsoever. This is in part because the sub-centres are open intermittently and unpredictably, and doctors and nurses are often missing from the PHCs. In part, it may also reflect the lackadaisical attitude of doctors in the public system; Das, et al. (2016) report that doctors in the public sector, while well qualified, spend very little time with the patient and do not make much use of their superior training – except when they are acting as private physicians, when they perform much better. It seems unlikely that small investments in these sub-centres and PHCs will change all that; the patients will probably continue to stay away, and therefore using these as the basis of outreach for NCDs and other public health interventions probably has limited potential.

The obvious alternative is to make use of the informal providers who do have access to the patient population. It should certainly be recognized that they have the potential to be a public health hazard, especially because they abuse antibiotics and steroids – which contributes to rising resistance.

However, the policy response to this phenomenon has been mostly to declare these informal providers illegal and then to ignore their existence. This essentially deprives us of the primary tool for dealing with the very serious health problems that we are facing. We need to think of ways to integrate them better into the overall healthcare project and give them better incentives, which would be easier if they had something to lose. Based on this we suggest the following steps.

1. Recognize and train informal healthcare providers. A randomized control trial that was carried out in West Bengal (published in Science, 2016) shows that training private sector informal healthcare providers improves their performance (measured by sending them ‘fake’ patients) by a very significant amount.

2. Develop a set of cell-phone-based checklists for treatment protocols for these practitioners to use, to react to the common symptoms they face. This is similar to what Atul Gawande has proposed for the United States (but much more basic).

3. Develop a simple test that allows the government to certify these practitioners as health extension workers. Passing this test will allow them to deliver various public health interventions and perhaps be paid for participating in them. Moreover, evidence suggests that the patients are aware of the value of such certification and trust those certified more.

4. Recognize those who are certified as the front line of defence against NCDs and malnutrition. Think of ways to reward those whose referral leads to the detection of a serious ailment.

5. Enforce existing laws that make it impossible for these practitioners to dispense high-potency antibiotics and steroids. This includes shutting down stores which violate the existing laws about who can prescribe what. At the same time, make it legal for informal providers to prescribe a range of less critical medicines, much like the nurses.

6. Expand the number of MBBS doctors and trained nurses coming out of the system and consider introducing some other intermediate degrees for practising a limited range of healthcare. This is the model we had before Independence and the one that many other countries have adopted.

In addition, it is not clear that the government should rely entirely on the private sector to deliver tertiary care within PMJAY. Conflicts over the appropriate payment for treatment and accusations of fraud in private sector providers is common in the United States. There are already complaints from the healthcare sector about the prices the Indian government is proposing, which might result in many hospitals opting out and others selectively refusing to deliver certain treatments (even if that is against the rules).

PMJAY will probably relieve some of this pressure on these public hospitals. However, for the reasons we suggest in the previous paragraph it still makes sense for the government to try to simultaneously improve the delivery of secondary and tertiary care in the public sector. Given that public hospitals will be able to bill their patients to PMJAY, which gives the public hospitals stronger reasons to compete with the private sector, it is a natural moment to expand this part of the government system. Therefore, we recommend, for secondary and tertiary care:

· Build a second district hospital in every district headquarters outside the state capital. Once it is built and is operational, refurbish and modernize the existing district hospital and bring it to acceptable standards.

Finally, it is very difficult to improve healthcare substantially unless we get the customers to demand better care (to fear antibiotics, seek out tests, and so on). This has to be a priority for any government. This is our final recommendation:

· Carry out public health campaigns to raise the awareness of NCDs, immunization and the dangers of overmedication. Recent evidence suggests that entertainment education may be a very powerful device in this regard.

References

Abhijit Chowdhury, Jishnu Das, Rashmaan Hussain, and Abhijit Banerjee, 2016, ‘The Impact of Training Informal Health Care Providers in India: A Randomized Controlled Trial’, Science, 354(6308).

Jishnu Das, Alaka Holla, Aakash Mohpal, and Karthik Muralidharan, 2016, ‘Quality and Accountability in Health Care Delivery: Audit-Study Evidence from Primary Care in India’, American Economic Review, 106(12).

The Solutions

1. The government will have to recognize that informal providers of primary healthcare are not going anywhere and should instead find ways to train, test, certify and reward them. Medical education should also allow for ‘intermediate’ degrees that produce practitioners licensed to practise a limited range of healthcare.

2. To control antibiotic resistance, it will be necessary to crack down on practitioners who mis-prescribe antibiotics and steroids, and on the chemists that fill these illegal prescriptions.

3. A second district hospital should be built in every district headquarter to take the pressure off the existing one – which can then be given upgraded technology and facilities.

4. Public health campaigns should be carried out so that Indians in general are more aware of the dangers of overmedication – as well as of the need for immunization and the lifestyle changes needed to minimize non-communicable diseases like diabetes.

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