#HealthForPolls, Interview with Amir Ullah Khan: Health is not a political subject

Experts believe that India’s healthcare is in a dismal state because of lack of funds and now the implementation of Ayushman Bharat too is stuck for the same reason. As part of our ongoing campaign to pitch for health, we speak to Amir Ullah Khan – former policy advisor, Bills and Melinda Gates Foundation and Professor,  MCRHRDI, Government of Telangana – on why India has failed to increase its healthcare funding in several decades.

Ques: A Lancet study has concluded, “Until the federal government in India takes health as seriously as many other nations do, India will not fulfil either its national or global potential.” Do you agree with the statement?

Ans: This is an old debate now and there is no conflict in this argument. We definitely need to do much more as a country to improve healthcare in the country. About 70% of the country has no access to healthcare and 30% has access to poor quality of healthcare.

Ques: One of the biggest paradoxes of Indian healthcare is; it is cheapest in the world, yet unaffordable for many of its citizens. How can healthcare be more inclusive without compromising on the quality?

Ans: Many experts argue that privatisation is the solution for improving healthcare and that is also the basis of the approach under Ayushman Bharat. However, I would like to highlight three important points: Firstly, Primary healthcare has to be the responsibility of the state. Whether the state provides or finances, the state has to be responsible. The State has to be held accountable. What is happening now is that the State chooses to hold itself responsible for only the limited number of patients that go to district hospitals, Primary Healthcare Centres or Community Healthcare centres. However, the accountability has to go way beyond that. Being accountable would mean taking cognizance of each and every child that dies due to lack of timely or inappropriate action by the State. Secondly, what is important to understand is that who is responsible for health within the country. While in the constitution health is a state subject, we have a huge ministry at the Centre. When there is divided responsibility, ensuring accountability becomes difficult. So, it is important to have clear accountability. Thirdly, lack of regulation applicable across healthcare facilities is another major factor. There are always talks of regulating the private sector. However, regulation is required for government healthcare services as well. The quality in government facilities is equally terrible.

Ques: Ayushman Bharat is one of the biggest healthcare reforms India has ever seen, but it has been caught in controversies surrounding funding and implementation. How do you review its future?

Ans: I see both pros and cons in the way Ayushman Bharat has been implemented. The positive side is that it does cover a significant population and envisions comprehensive health provisions through continuum of care. Whereas, it is facing supply problems. When we increase demand, we have to ensure there is supply. While the NHPS is ensuring that the demand for healthcare goes high amongst the people, Ayushman hasn’t solved the supply problem. There are concerns over insufficient funds. For Ayushman Bharat to be effective, at least 1 lakh crores is required to achieve the results it promises. In its absence, the private sector even if empowered would continue to face problems of delay in payments as opposed to services provided. Hence, eventually, they would drop up. The same has been experienced in health schemes implemented so far.  Any such programme to be successful has to be a tripartite programme, that is, the provisions of healthcare has to be done by 3 parties, private sector, government in the state and insurance companies. Entire regulatory aspect, efficiency and billing is to be handled by the insurance companies. In India, the insurance companies hardly focus on these three factors which leads to issues with fraud billing etc. Mostly trust-based model is followed in India and it is often subjected to huge corruption and the above-mentioned factors are hardly taken care of.

Ques: Due to unavailability of quality doctors and diagnostic facilities in government hospitals people rush to poor private facilities and end up spending more. So how will Universal Health Coverage provide quality healthcare?

Ans: I’m not sure whether data justifies that people prefer private healthcare over public healthcare. In my opinion, people prefer public healthcare wherever it’s available. Therefore, problem is the supply of the health services through government offices. The out of pocket expenditure is just as high for a government hospital. The only thing that the government hospital doesn’t charge for is the doctor consultation fee. Everything else, travel from the village, medicine cost, employment loss etc also constitute the out of pocket expenditure. Therefore, it is inappropriate to compare the two.

Improvement in public health apparatus will ensure people going to the public sector and improve the attendance of patients. Otherwise, there is no choice but to visit a private healthcare facility, which several studies have shown that it is no better in terms of quality. An interesting recent study by the World bank study showed that the government sector makes faulty diagnosis in 50% of the cases, the private sector makes faulty diagnosis in 60% of the cases, if private sector is run by a government sector employee, then diagnosis is wrong in 70% of the cases. Hence, public vs private doesn’t guarantee better quality of healthcare. What is important is that the government ensures necessary regulation and there is healthy competition for the private sector to provide good quality healthcare.

Ques: What is the reason behind health expenditure being limited to 1.4% of its GD? Do you think by increasing the allocations India can increase healthcare quality?

Ans: The reason is that health is not an important political subject. People do not vote in or vote out a government on the basis of health. The second reason is that it is difficult to measure the outcomes of health. The impact is long-term. While political parties can take credit of certain interventions, their actual impact is not visible during the 5-year tenure. So, it isn’t talked about as an interesting political topic. Also, the majority seekers of healthcare in India are the mother and the child, and they do not have a significant voice in electoral politics. Increasing allocations would ensure better infrastructure . Off-late there is mention of the Ayushman Bharat, but it is towards fag end. No-clarity about what is happening under Ayushman Bharat. Hence it sounds hollow.

Article disclaimer: This article has been edited and updated to reflect Amir Ullah Khan’s present designation.