Build healthcare system from bottom up

Few people talk of the cost of Covid-19 to those people who have survived the disease, who did not have to be hospitalised and took only basic medicines. Even though a mild version of the disease that requires no hospitalisation, cures itself in two weeks, and its management advice is given free of cost by government doctors, forces an expenditure of at least Rs 10,000 on an individual.

This includes various blood tests and medicines. For a family of four, where everyone is likely to get it once one person does, this translates into an expenditure of Rs 40,000. This is the take-home salary of a college lecturer, a junior journalist, an office assistant, a senior shop assistant, a small trader and so on. It is many times the monthly earning of those who work as handymen, house help etc. When clubbed with the loss of income, this is enough to drive an emerging middle class in India back into poverty.

As per the Central Government’s figures, there have been 2.6 crore recoveries so far across the country of those infected by Covid-19. If 80 per cent of these people recovered at home and each spent Rs 10,000, at a minimum, it amounts to Rs 19,700 crore of expenditure.

According to a research reported by Pew Research Centre, US, before the pandemic, India’s poor, i.e. those with income less than $2 a day, were projected to be about 59 million. India’s middle-income group — those with income of $10-20 per day — was expected to reach 99 million. The pandemic has changed all that. Now, India’s poor are expected to reach 134 million — which is double of what was projected earlier. And India’s middle-income group is estimated to be 66 million or two-third of what was projected.

This heavy cost which is being borne by the people of India is primarily because of a lack of primary healthcare in India. To be sure, there is a loss of income because of jobs lost and businesses shut down. That is unavoidable in a country facing one of its worst internal enemies in history. But more importantly, the absence of primary healthcare forces a completely avoidable cost on everyone.

The sad and sorry thing here is that those who become severely ill have a greater chance of finding support from the government, from charity organisations. But those who are merely ill and then recover are left to fend for themselves; they have to bear extreme costs and face consequent demoralisation.

All this could have been avoided if only our country had focused on creating a robust system of primary healthcare, allowed a dignified life to the general practitioner, and not abandoned the system of the family doctor.

Many years ago, when we were researching the causes of farmers’ suicide, we discovered that almost 40 per cent of the suicides had happened because the farmer had been pushed to the brink by the costs of chronic disease in the family. In the absence of any healthcare — please notice, here it was not the absence of quality healthcare, it was the absolute and total absence of any healthcare. In these circumstances, the farmer felt abandoned, lost earnings and savings to quacks and chemists in distant district towns.

The reasons for the absence of basic healthcare, we discovered, were quite banal. They had nothing to do with shortage of funds. The policymakers of India were completely and desperately in awe of doing something heroic. The search for heroic interventions made them blind to the unheroic, banal, everyday strategies that were needed by the public at large. We talked to many people — ministers, MLAs, experts in the Yojana Aayog (Planning Commission), secretaries to various governments who were responsible for creating policy and implementing them — and discovered the extent of this seduction with the big and grandiose.

Unfortunately, there is nothing heroic or grand about primary healthcare. As a result, the policymakers preferred to concentrate on building physical infrastructure for grand hospitals and setting up tertiary care institutions and research centres. Even today, the number of such facilities may be too small in India for them to make any significant impact on the people at large. But that is where ribbons can be cut and inaugurations held.

The gap left in primary healthcare by the high-profile ideas of India’s policymakers was inevitably being filled by private doctors. Their numbers till now have been too small to fully satisfy the needs of the people. Most of them come out of fly-by-night private medical colleges. Yet, most of them actually make a heroic effort to earn their living by providing basic healthcare to those who reach out to them.

Ironically, the public health establishment actively disliked these basic healthcare providers. They talked of something called ‘moral hazard’ and refused to involve the private doctors in any scheme floated by them.

Our researches showed that there was no basis for distrusting the private doctors. The outcomes to patient care in the public sector were no better and no worse as compared to the private sector.

But long-held shibboleths have a way of persisting. So, this belief that only public healthcare providers can be trusted remains. So wary has the public health establishment been of the private sector that for many years, the Rashtriya Swasthya Bima Yojana, the precursor to Ayushman Bharat, was administered by the Ministry of Labour rather than by the Ministry of Health and Family Welfare. Such policy positions are completely unrelated to the ground reality.

Primary healthcare requires large numbers of practitioners and little capital investment; it requires a social relationship between the practitioner and the patient. The government is not strong in any of this and has no capacity to build it now.

Secondary and tertiary care facilities, on the other hand, require high investment, a certain commitment to research and results in the long term. These are things which the government can do best.

So, what does it actually do? It cuts out the private healthcare provider from all government schemes and promotes the private sector for providing secondary and tertiary care! Basically, it stands all commonsense on its head.

To take care of the ‘moral hazard’ in the case of the providers of private primary healthcare, the government should develop protocols that are used for everyday illnesses and tie the private primary healthcare doctor to these protocols. Building standard protocols for medical care is something which many senior doctors from some of the best medical colleges in India have talked of repeatedly in the past.

Once protocols are created, they become the basis for the interaction between the health seeker and the health provider, and leave little room for extortion by anyone. Such protocols are already in place in Maharashtra since 2013. They played a major role in ensuring that patients were not fleeced and got quality healthcare in private facilities at government expense.

What is needed in India today is a system of healthcare that is developed from bottom upwards, a system based on the general practitioner, who is based in and committed to a locality and is made to follow government-specified protocols for treating patients.