Foun­da­tions for health pol­icy

A key in­put is net­works of health care providers that of­fer com­pre­hen­sive care to in­di­vid­u­als

Business Standard - - OPINION - AJAY SHAH The writer is a pro­fes­sor at Na­tional In­sti­tute of Pub­lic Fi­nance and Pol­icy, New Delhi

We in In­dia are get­ting poor health care as mea­sured by qual­ity and price. While solv­ing this is im­por­tant, the best sce­nario of all is one where there is less sick­ness. This re­quires an em­pha­sis on the tra­di­tional agenda of pub­lic health: A set of old-fash­ioned pre­ven­tive in­ter­ven­tions. And, it re­quires re-ar­chi­tect­ing health care. The ideal health care sys­tem is one in which an en­tire sys­tem of med­i­cal prac­ti­tion­ers en­gages with peo­ple, try­ing to make sure they do not show up at a health care fa­cil­ity.

Health care in In­dia works badly. There are trans­ac­tional re­la­tion­ships where a cus­tomer shows up in front of a for-profit doc­tor. The doc­tor is gen­er­ally con­flicted, and earns more when more pro­ce­dures and more drugs are pre­scribed. Doc­tors make more money when cus­tomers are less healthy. In the present sys­tem, no­body cares about the health of the cus­tomer.

The In­dian pol­icy dis­course is quite fo­cused on house­hold ex­pen­di­tures on health care. We like in­sur­ance pro­grammes where the health care costs of the sick are paid for by the non-sick. While this is nice in terms of con­sump­tion smooth­ing, it does not solve the deeper prob­lems: Of ex­ces­sive health care costs and of ex­ces­sive dis­ease.

Our prime fo­cus should be on the health of the pop­u­la­tion. Our dream for In­dia should be to get a healthy pop­u­lace. Ev­ery­one is vastly bet­ter off if a per­son does not get sick in the first place. The first bat­tle­front is the tra­di­tional con­cep­tion of pub­lic health, of dis­ease pre­ven­tion.

In­dia has one of the weak­est im­mu­ni­sa­tion pro­grammes in the world. If we did bet­ter on the num­ber of dis­eases cov­ered, and the op­er­a­tions of im­mu­ni­sa­tion pro­grammes, fewer peo­ple would get sick. Wa­ter and san­i­ta­tion are well es­tab­lished as the root cause of a great deal of in­fec­tious dis­ease. Fight­ing dis­ease vec­tors such as mosquitoes mat­ters, and we seem to do this less than we did in the 1970s.

New bat­tle­fronts have opened up in pre­ven­tive health. Air qual­ity has be­come a first or­der is­sue. There is car­nage on the roads. We are proud of our new roads, but high­way en­gi­neer­ing is weak, and we have one of the high­est ac­ci­dent rates per ve­hi­cle-kilo­me­tre in the world. Fail­ures of pol­icy are mak­ing dis­as­ters such as floods more fre­quent and more harm­ful, and earthquakes more harm­ful.

The ad­min­is­tra­tive bound­aries of our Min­istries of Health are part of the prob­lem. Most of the deep de­ter­mi­nants of the health of the peo­ple are out­side Min­istries of Health. This gives an ex­ces­sive fo­cus upon health care, which is un­der the purview of Min­istries of Health. If the Na­tional High­ways Au­thor­ity of In­dia tries to get more ve­hi­cle-kilo­me­tres done at the low­est pos­si­ble cost, they will tend to short-change the is­sues of road safety and dis­as­ter re­silience.

We need to re­ori­ent our pol­icy strate­gies so as to bring health risk into the think­ing of all de­part­ments of gov­ern­ment, and achieve state ca­pac­ity in the tra­di­tional ar­eas of pub­lic health. This will re­duce the need for health care.

Along­side this, we also need to re­think health care. When doc­tors are paid per pro­ce­dure, they have an in­cen­tive to over-pre­scribe pro­ce­dures, and make more money when pa­tients are sickly. Pay­ment per pro­ce­dure gen­er­ates wrong in­cen­tives.

Can we do this dif­fer­ently? The key in­sight is to have a con­tract be­tween a net­work of providers and the pa­tient, which un­der­writes all health care for the pa­tient for life, in ex­change for fixed monthly pay­ments. This must be not just one doc­tor but a net­work of providers that cov­ers all as­pects of health care. When I get sick, I would go to my net­work, and they would ren­der me health care ser­vices at no ad­di­tional cost.

Once this style of con­tract­ing is done, the in­cen­tives of the health care pro­ducer change com­pletely. Now, the health care net­work is paid by me ev­ery month, and these pay­ments are clean profit for them un­til I get sick. When I get sick, I im­pose costs upon them. They have no in­cen­tive to over-pre­scribe pro­ce­dures, and their in­cen­tive is to keep me healthy.

Now the health care net­work has the in­cen­tive to ask me to come in for reg­u­lar check-ups, so that prob­lems are caught early. At all ages, im­mu­ni­sa­tion will be pushed by the health care net­work so as to avoid the costs as­so­ci­ated with ill­ness. The choice of treat­ments will be done with a view to keep­ing me healthy.

At present, the con­ver­sa­tion be­tween a doc­tor and a pa­tient in In­dia is a trans­ac­tional one, where symp­toms are de­scribed and treat­ments are ex­plained. The time in that room is a pow­er­ful op­por­tu­nity to change be­hav­iour. A few min­utes spent by the doc­tor evan­ge­lis­ing bet­ter be­hav­iour tends to have a sig­nif­i­cant im­pact on be­hav­iour and health. As an ex­am­ple, a doc­tor might say: “I’m pre­scrib­ing a pro­gramme of ex­er­cise for you, and I want you to come back to me in three months and we will look at the im­prove­ments in your choles­terol num­bers.” This would be quite mo­ti­vat­ing for most pa­tients. Such prac­tices would re­sult in re­duced costs and higher profit for the health care net­work.

A doc­tor in such a health care net­work who sees a surge in the num­ber of peo­ple con­tract­ing an in­fec­tious dis­ease in her neigh­bour­hood would have the in­cen­tive to talk with pub­lic health of­fi­cials and ini­ti­ate pub­lic health re­sponses that ad­dress the epi­demic at its root. This would be ef­fi­cient be­hav­iour on her part be­cause the health care net­work makes more money when fewer peo­ple get sick.

In the present In­dian dis­course, there is a prime fo­cus upon re­duc­ing the fi­nan­cial risk for house­holds from a mal­func­tion­ing health care sys­tem. While this is an is­sue, we need to go deeper. The prime ob­jec­tive of health pol­icy should be to get to the best of all worlds: One where peo­ple do not get sick. This re­quires health-ori­ented think­ing that per­me­ates a wide ar­ray of de­part­ments of gov­ern­ment. And, it re­quires a health care sys­tem that val­ues pay­ing non-cus­tomers.


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