An Ernst & Young report released last week in tie-up with industry chamber FICCI reckons that public or government funding of healthcare should be raised to between 3.7 per cent and 4.5 per cent of gross domestic product from 1 per cent at present to achieve universal healthcare over a period of ten years. See here. That government spending has to go up is a given. And it’s important to know by how much. Yet, money might well be the least of our worries.
Let’s dwell for the purposes of this post on just one of the seemingly Herculean challenges facing universal healthcare – human resources. India’s density of human resources for health is among the lowest in the developing world at 0.6 doctors per 1000 population and 1.3 nurses per 1000. This stems from a shortage of supply – not enough educational institutions that can train medical and para-medical staff.
The demand for doctors will require the setting up of an additional 200 medical colleges by 2018 to meet the target of 1 doctor per 1000 population by 2030, estimates E&Y.
In a round table organised last week to discuss the report, Muralidharan Nair partner at E&Y and head of the team that created the report, rightly referred to the current sorry state of medical education as the “root cause of corruption” in medicine.
It is an open secret that those aspirants to a medical degree who cannot secure a seat in elite public institutions settle for private colleges often paying a capitation fee that runs into tens of lakhs. There is no guarantee of quality. And though open to private players, the field of medical education remains sufficiently murky to discourage honest competition. (Recall that former Medical Council of India chairman Ketan Desai was implicated in a bribery scandal involving permissions to a medical college.)
This can pose a real threat to the UHC agenda. Creating demand with inadequate or tainted supply (in other words doctors whose single-minded purpose is -almost forgiveably- to recover their college fees with interest) is a recipe for disaster.
Justifiably therefore, while advocating extensive private sector participation in key parts of healthcare delivery such as hospital bed creation or cost-effective medical technology, the authors have put the ball squarely in the government’s court in the matter of medical education. “Provision of medical education to doctors should be the responsibility of the government,” they say. “In case the government is not able to add medical colleges commensurate with the rate of doctor accretion required, the private sector should be allowed to participate within a well-defined framework to ensure transparency and merit in admission , quality of education, operational monitoring and financial viability.” (Italics mine).
A far cry from the current state of affairs where private sector colleges charge top dollar but span both sides of the quality spectrum.
Why is greater government intervention more doable in medical education than say, primary healthcare where E&Y foresees deeper private participation from the start? “Medical education is a lot more concentrated unlike, say, primary healthcare which is distributed and fragmented,” says Nair. “Also, the government does not have to spend a lot more, it can leverage existing assets.” He cites the example of the various district hospitals owned by the state that can be brought up to speed, for starters. Here, public-private partnership too could be encouraged, he says.
In a related suggestion, the authors also advocate the setting up of several more government-owned Centres of Excellence (CoE) along the lines of the All India Institute of Medical Sciences (AIIMS). Not only will CoEs create sophisticated human resources they will also advance care, they argue.
Besides, says Nair, it is unlikely that any private sector hospital or group will set up a CoE in the foreseeable future in the country.
To the extent that CoEs are motivated by the quest for research and scientific excellence, thought leadership and so on rather than profit maximisation, that is very likely to be the case. Nor, as Nair points out, has personal philanthropy in the country evolved to such an extent as to create an equivalent of a Johns Hopkins in India.
And while the report observes that “given the size of our country, private sector participation (in the creation of CoEs) will also be inevitable,” the authors leave it to the government to decide whether or not it is deemed essential.
None of this is unaffordable, says Nair, estimating that setting up the requisite number of medical colleges and COEs in India will require Rs 30,000 crore which is a fraction of the outside estimate of Rs 2,49,300 crore of capital expenditure estimated by E&Y to add all the required physical and human resource infrastructure. In 2011, India’s public spending on healthcare amounted to Rs 96,672.79 crore .
None of these suggestions can be claimed to be brand new though placing them in the current context of universal healthcare underscores their necessity and the urgency. From time to time, these measures have been discussed and in some part, implemented. But the absence of concerted action of the sort that can lead to a much-desired renaissance of medical education (or any other aspect of healthcare) has led observers and experts to conclude (rightly) that of all the ingredients what’s been lacking the most is political will.
Which is why debates on how much UHC will cost, though important, should form but a small part of public discourse. Leave that to the bean counters. What matters most is creating and harnessing the will to achieve it. As the report fittingly quotes Princeton economist Uwe Reinhardt as saying, “The issue of universal coverage is not a matter of economics… It is a matter of soul.”
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