The comprehensive healthcare alternative

Rescuing Maternal and Child Health-only systems, which have become under-resourced and have built a very high-cost but low-performance culture, will be a challenging task.

Given the rising burden of non-communicable diseases, there is an increasing demand to build health systems that can address these concerns. However, given how large the unfinished agenda of the Millennium Development Goals is, the Indian government has chosen to stay focussed on Maternal and Child Health (MCH). But is the most effective way to deliver on the MCH goals to build an MCH-only health system, or does it need a completely different approach?

Medical and staffing issues

Medically, since the most important drivers of infant, child, and maternal mortality are haemorrhage, sepsis, abortion-related complications and hypertensive disorders, it is clear that it is no longer adequate for a health system to focus on preventive-promotive messages and limited facility-based treatment options. Instead, at the community level, there needs to be clinic-based obstetric and emergency care on offer, and, within a reasonable travel distance, hospital-based emergency care. If recent data relating to infant mortality rate (IMR) and maternal mortality rate (MMR) are examined, it appears that higher availability of more advanced medical care at proximate hospitals in, for example, Kerala and Tamil Nadu, is indeed associated with much better MMR and IMR outcomes. Equally wealthy States such as Himachal Pradesh, which do not have these advanced facilities at proximate locations, are not able to show similar rates of improvement despite spending more money per capita on healthcare.

Recognising this issue, the Indian government has recently mooted the concept of a health and wellness centre (HWC) that is intended to be more comprehensive rather than merely connoting “first contact care or symptomatic treatment for simple illness with some elements of care for pregnancy and immunisation included”. And, if indeed the HWCs (the erstwhile sub-centres) are able to address all of the necessary MCH conditions, then it becomes possible for the next level centre to provide a much broader range of care upon referral by the HWC. Clearly, building such a system to serve only MCH needs will not be cost-effective nor will it keep all of the necessary personnel gainfully employed. Having a much wider range of conditions would be the only sustainable way to address this concern.

Building such a broad-based system will need a substantial amount of investment for which political commitment has not been very forthcoming. Because of this, in addition to resource shortage, front line personnel such as nurses and doctors often offer low-quality services and display a high degree of absenteeism without fear of political reprimand. While there are a number of reasons for this, one of them is the fact that the Indian (MCH-focussed) health system is currently able to cope only with conditions that account for fewer than 25 per cent of the Years of Life Lost (YLL). Even in high-fertility States such as Bihar, in a typical year, fewer than 20 per cent of the households are likely to have maternity-related needs. Broader health systems which are able to address a much larger proportion of conditions have the potential to engage a much larger number of voters. Arguably, the politician under such a system is much more likely to both allocate more resources as well as monitor performance. The health system thus develops the capability of handling a wider range of issues, while simultaneously positively impacting the MCH agenda.

The difficulty that health systems in India unfortunately face is that since they were designed as MCH-only systems, they have become chronically under-resourced and have now built a very high- cost but low-performance culture and a concomitant reputation. Rescuing these systems may now become very challenging. Politicians have shown a strong reluctance to provide additional funds to the government-run health system “driven by the idea that it does not make sense to throw money at a system that hardly works, performs or is a big black hole.” They instead prefer to put additional investments into fragmented and “cheap” in-patient insurance and ambulance schemes that are operated by the private sector but are funded by the government. Such an approach is resulting in significant fragmentation of the health system, with a low-quality, skeletal MCH-focussed government-run primary care and secondary care system. There is also a separate, private sector-owned secondary and tertiary care system with very high variations in the levels of quality, which is accessed by low-income families through government-sponsored insurance programmes and by everybody else using out-of-pocket payments. This prevents the evolution of both an integrated government health system or a privately run managed care system. This is an example of a situation where building an MCH-only health system has actually hurt our ability to grow it into a well-functioning health system of any kind, including one that fully serves MCH needs.

For various good reasons, 68 countries, including low income and middle income countries, have chosen to use health-specific taxation such as mandatory payroll deduction. For countries such as India and China, which also have a large informal sector, since mandatory payroll deduction is not an available option for a large segment of the population, the direct sale of healthcare packages or insurance becomes additionally necessary. This is much more difficult to do, but not impossible. This is because while it is clear that health shocks have a very large impact on those below the poverty line, it is also clear that even those at the 90th percentile are not very far above the poverty line, and a health shock can indeed quickly send such a family down to the lowest one per cent in terms of income and wealth. However, unlike families below the poverty line, those above it do have the financial ability to pre-pay for healthcare services because it is not their average out-of-pocket expenditure that is their problem, but their inability to obtain proper care when needed and the high variability of actual expenditures. However, getting the non-poor populations to participate in financing through pre-payment (by, for example, requiring the purchase of a comprehensive family health cover along with auto-insurance for all vehicles, including two wheelers), an integrated delivery system is going to need a much broader health system and one that performs at a much higher level than it currently does. But, unfortunately, once again the decision to build a MCH-only health system, which performs at a poor level of delivered quality, has left consumers with low confidence in government-run health systems. To now persuade the non-poor to pay-in to a health system that is operated by the government is likely to be an uphill task.

Historic opportunity

For the States, the larger availability of untied funds from the Centre presents a historic opportunity to design health systems that far more closely reflect their own objective ground realities. While centrally sponsored health schemes have offered a number of benefits, they also came with the associated baggage of standardised design. Bihar, for example, continues to battle with high levels of IMR and MMR and a high level of poverty. Tamil Nadu and Kerala have brought those rates under control but, unlike Bihar, are seeing a climbing suicide mortality rate, particularly amongst their 15-25 year olds. Himachal Pradesh, which has a much smaller and significantly wealthier population and over five times higher per capita income, has very similar IMR and MMR numbers to Bihar, combined with a high accident mortality rate. Building comprehensive healthcare systems which reflect the realities of each State will not only yield strong benefits on problems such as IMR and MMR but will also, over time, help build health systems that respond to a much a wider set of concerns. Narrowly focussed health systems on the other hand risk falling short not only on their goals but also make it difficult, if not impossible, to build broader health systems for the future.