Amarjeet Sinha, who spearheaded two flagship government programmes, tells Forbes India that public health cannot be left to the markets alone
Designation: Outgoing joint secretary, ministry of health and family welfare
Career Path: Played a key role in Sarva Shiksha Abhiyan and National Rural Health Mission.
Education: BA History-honours, Delhi University
Interests: Reading, meditation, music, walking, jogging, travelling across India. Has visited 570 out of 643 districts to understand social development
You have served for almost 17 years at the Centre, helping to design and run two of India’s flagship programmes. What is your assessment of the projects?
I look back with a lot of satisfaction, though a lot remains to be done. Making public systems deliver better services in both Sarva Shiksha Abhiyan and the National Rural Health Mission is a big challenge. These are subjects in which the state governments have a leadership role.
But there is a role that the central government plays in pushing the reforms with resources and in also sharing good practices across states. I think today everybody is making a case for public expenditure to increase in the social sector. A case also needs to be made for the public system to be crafted differently, in such a manner that it guarantees quality services to citizens.
There are a whole lot of challenges in public management involving issues of systems of public recruitment. How do you change the mindset of job guarantee to one of service guarantee? How do you ensure accountability to a facility or an institution, to a school or a hospital rather than to a larger unknown bureaucracy? Lot of issues surround communities and their role in holding public systems and services accountable, affordable and of a certain quality. There are a lot of public management skills that need to be evolved constantly. Both the programmes allow for innovation in service delivery, new thinking and addition of professional skills, whether it is to do with skills like information technology, centralised planning, or financial management. Many such skills are not reflected in government systems to the extent that they should.
What needs to be done next, after NRHM?
The Planning Commission has set up a high-level expert group on universal health coverage. I think there is a lot to learn from what Brazil, Canada and Thailand have done to provide universal health coverage.
Today health care and health cost is a major drain and a major reason that families in poverty cannot fully develop their human potential. The time has come to make similar efforts in the urban areas as projections show, over the next seven, eight, ten years, more than half of India’s population will be urban.
Health systems need strengthening in urban areas. The time has come to evolve an accountable universal health coverage system that invests and strengthens the public health system. We will also have to use the public framework to enlist the services of non-governmental providers both not-for-profit as well as for-profit, to provide the range of services which communities need.
What is delaying the Urban Health Mission?
A lot of consultations have gone into the preparation of the framework for implementation of the Urban Health Mission. It is on the Web site of the Ministry of Health and I am sure decisions will be taken to start work on the Urban Health Mission. Each time public health problems like chikungunya or dengue or malaria arrive, there is realisation that public health needs attention. The West has fought the challenge of public health with clean water and sanitation. We are trying to do it with antibiotics and I don’t think we can ever succeed.
We have perhaps to build public health regulation in a more systematic manner. Again, I know that the times that we live in, regulation is thought of as an obstacle. But I think health is a sector, given the information asymmetry and given the characteristics of the sector, it’s not something we can leave to the market alone. Health creates public expenditure; but it needs public provisioning and a reasonably strong regulation framework.
Is it possible to scale up the Devi Shetty model across the country?
Ultimately, health is not only about medical care. A lot of wider determinants also need to be addressed — the fact that preventive and promotive care can make a difference to the cost of secondary and tertiary care.
So I think Karnataka’s experiment with the Yashaswini model of franchisee private hospitals providing hospitalised care at fixed rates for farmers in the farmers' cooperatives does work reasonably well.
But the only issue is that somebody has to play the gate-keeper role because where we have hospitalised care through cashless facilities and arrangements, there could be an incentive to perform surgery where it is not required. Or there is incentive for a patient to spend more time in a hospital even when it is not needed.
In any arrangement of this kind where provider payments are determined by the number of surgeries carried out — because this is a problem which is reported worldwide — if the gate keeping role is not played very well, it may well lead to irrational care.
Do we need to spend more money on health care?
In India, may be 5-5.5 percent of the GDP gets spent on health. Only a fifth, a little more than a percent, is public expenditure. The rest of it is private expenditure.
If you compare this with other countries, even overall — public and private put together — we are spending a reasonable amount at about five or five-and-a-half percent of our GDP. Because when you look at inefficient systems in many other countries or may be systems with greater costs in most of the developed countries, which are providing universal health coverage — Canada, Brazil, some of the European countries — you'll find seven to eight percent of the GDP is the public expenditure on health.
Of course, in the case of the US, unfortunately, they've not been able to check their costs. And I think there are a lot of inefficiencies because of private insurance as well. The US spends 17 percent of its GDP, public and private put together, and the projections are that it could go up to 25 percent at some point.
In India we have an opportunity to provide universal health coverage. But for doing so we will need more money. We will need a larger public expenditure because the costs of care have gone up. I think by making rational choices for diagnostics, for drugs, for pharmaceuticals, for a whole set of standard treatment protocols, it may well be possible that if the public expenditure goes up, say, by two to three percent of GDP, it will make a difference.
I think we can go up to three percent of GDP public expenditure and also allow for some private expenditure over and above that. Health is a sector where if we can get the balance right between preventive, promotive health and curative rehabilitative, naturally a lot of costs are manageable if we put an equal focus on public health. That's why the need for a public health act, the need for public health regulation, for health promotion, wellness, is important.