This is an edited version of Rohini Nilekani’s Uncommon Ground, where she brings together titans of industry and leaders of civil society to explore eight themes that are highly relevant for our future development. In this episode, she moderates a discussion on health services with Habil Khorakiwala, Chairman of Wockhardt Group, and Dr. Mirai Chatterjee, Director Social Security of the Self-Employed Women’s Association (SEWA).
Uncommon Ground brings together titans of industry and leaders of civil society to explore eight themes that are highly relevant for our future development. These conversations explore the middle ground between the ideological divisions that often polarise the business and voluntary sectors. In course of these rare dialogues between leaders who have sometimes been adversaries, a number of common concerns emerge. The host uniquely placed to moderate these discussions as she traverses both sides herself, demonstrates that the relationship between business, society and state need not be necessarily confrontational. Rich in insights, Uncommon Ground highlights the critical importance of dialogue in our democracy to create a shared vision of the future. It is a significant contribution to the ongoing debate on development and equitable growth in India.
Rohini Nilekani: India has one of the worst records in the world on access to health services and public expenditure. Dr. Chatterjee, with your experience of working with more than a million women in SEWA, how do you think your model is going to help us to improve access to health care services?
Mirai Chatterjee: We are a large and diverse country, with a rapidly urbanising population. When we plan for our nation’s public health, we have to take that reality into account. A lot of our citizens live in mountain, desert, and forest communities as well as remote villages. Just as it was 60 years ago, when the remarkable Bhore Committee suggested a bottom-up, localised, decentralised health care system, that model would serve our current reality. People need something that’s local and accessible to them at their doorstep. Having said that, referral care is also important. Where does a poor family take their loved ones when they need a higher level of care? That is where referral care or tertiary care comes in. We would like to see this kind of tertiary care available at a local level. We are not saying it’s possible or necessary to have a hospital in every village or urban slum, but they should be within easy access, which is not the case in all parts of the country.
RN: Can the private sector provide these kinds of services or does the public sector have to expand quickly and efficiently to meet India’s needs?
Habil Khorakiwala: If you look at India today, 80% of health care spending comes through private initiatives, even though 80% of the infrastructure that we have in this country lies with the government sector. Due to the seeming apathy of the state, the private sector has filled the vacuum. So there is no reason to believe that this cannot happen. What I think India needs more is major reform in the health care sector. We also need to rethink public-private partnership, because there’s a huge infrastructure sitting with the government, however, they are not able to deliver, and a public-private partnership may be a solution to this.
RN: What does a public-private partnership look like, especially since there is some resistance to the idea of the private sector’s role in health care?
HK: At Wockhardt, we have arrived at an agreement with the Gujarat government. We are taking over 300 beds at a civil hospital as a part of our non-profit approach. While the government will continue to fund it as they have done in the past, we have undertaken to raise the standard in terms of the quality of care, bringing new procedures and facilities. The government has allowed us to increase the charges to the patient so that these changes can be self-sustaining. So we are trying to work out a model that proves this is possible along with the public expenditure.
MC: India has the largest private health care industry in the world, one that is largely unregulated. The reality is that 80% of Indians go to private hospitals, for various reasons. One is the non-availability of the public health infrastructure, which is either absent or dysfunctional — there may not be doctors or surgeons staffing district hospitals, or there may be issues of quality in terms of patient care, time constraints, etc. Due to this, the private sector in health care is necessary and active. Our goal is to examine how we can get affordable, accessible, and appropriate health care to all. That is the starting point. The private sector is diverse, as it includes local healers and Ayurveda, as well as corporate sector hospitals. One of the main issues we have seen in our experience at SEWA is that insurance is a huge burden on the poor and working classes. So we are running an insurance program, including health insurance for women and their families, for people who fall below the poverty line. Over the last two years, we have tied up with both the public and private sectors, linked with the government and private charitable trust hospitals, to ensure that families can access better quality care. In our experience though, when the government is able to properly provide for them, people do gravitate towards public hospitals because of the lower costs involved.
RN: How can the private sector reach out to those below the poverty line? Is a sustainable corporatised model possible?
HK: In India’s health care space right now, there is a private sector but not a corporate body. For example, there are individual doctors in smaller towns who might set up nursing homes based on their own specialities and treat patients. This model actually serves people extremely well, and the whole system is a low cost model because the doctor is in on it. Many doctors have this altruistic approach. However, the gap between what we should have and what we currently have, is a massive one. I think there is a role for everyone to play. The government must spend much more than the 1% they are spending on GDP, they must triple or quadruple this in the next five years. Their focus needs to be on primary health care because that is where the infrastructure lies. So that is where they must make money available for medicine and for people to be there. Secondly, I think they need to change the structure of management. Currently, the Ministry of Health is managing things and it forms a typical bureaucracy. Instead, they should create an independent organisation to manage the public health care system as an independent body.
MC: I think there are two really important issues — resources and governance. We have to de-bureaucratise and bring health care closer to the people. This was the vision of the founding fathers of the country when they set up our public health care system. The premise on which public health is based is a decentralised approach, which is close to people and where people take control over their own health.
RN: 60% of central government expenditure is now moving into the National Rural Health Mission and a similar one is planned for the urban sector. Is that responding to the idea of decentralised structures?
MC: The conceptualisation of the National Rural Health Mission is very sound. Many community health workers as well as medical and health experts, and the pharmaceutical industry were involved in its formulation. So, I think conceptually it is very sound in that it’s primary health care and also village-based. The big challenge is how to get these resources down to the poorest, the weakest, the last person in our villages and urban slums, which is where we falter in our country. This time, the NRHM has taken a new approach which involves civil society and the private sector, so that we strengthen governance.
RN: We’ve seen that health is not a priority for the poor because of all sorts of other huge problems that they face. How do we build that demand so that people are asking the government to give better services?
MC: The major priority of people in our country is employment. They want work because they understand that livelihoods are the lifeline to survival. But health comes very close, because our members tell us that if they are constantly sick, not only do they not earn but they also have huge medical bills to pay that sink them further into debt and poverty. It’s the number one cause of debt in this country, with poor people selling their land and assets just to pay for health care. So it’s not that health is not a priority. People are willing to do anything to save their loved ones at any price. But until we have the structures and mechanisms that ensure that this money is properly utilised and reaches where it’s supposed to, then we will still fall short.
RN: Apart from a CSR kind of approach, how can the private sector enable the government’s role to be more effective?
HK: If we look at tertiary care facilities in major areas like cardiac surgery, neurosurgery, bone and joints, they are not readily available apart from 10-12 cities in the country. So our organisation has tried to go into second-tier cities, like Rajkot, Nashik, Nagpur, Bhavnagar, etc. where these facilities do not exist. The challenge is not only to put up a hospital there, but to get specialist doctors to work there. We think this is a viable model.
MC: From our experience, when these private corporate hospitals come in, not only are they not accessible and affordable to the poor, but they distort the market because there is a limited pool of doctors and specialists, so naturally people will go where they get the best opportunity and best remuneration. The net result is that we are not able to fill the posts of doctors and surgeons in our public health system. It’s a major issue, even in states like Gujarat, where doctors, nurses, and other medical personnel are just being absorbed by the private sector. It results in huge gaps in the public health infrastructure.
RN: India is seeing new issues of malnutrition and easily preventable diseases, as well as a host of lifestyle-related diseases. How will hospitals and drug development research address some of these high-end issues?
HK: As far as drug development is concerned, we have our own program of drug discovery and these things take a long time. We have been working for 10 years, and it will take another seven or eight years before we’ll see a drug. However, medicines for common diseases like diabetes or cardiovascular disease are already available. What we need to stay focused on is complete health care management. We have a huge problem at the bottom of the pyramid, but we should not lose sight of innovation and excellence because in India, both co-exist. There are new models that are emerging and ultimately we will see more affordable health care. Minimal access surgery is a great example of this. In medicine, more and more treatments are replacing the need to stay in hospitals, like minimal access or non-invasive surgeries. Our Bangalore hospital removed a brain tumour through the nose of a patient. These innovations are changing the landscape of medicine itself.
MC: However, medical technology and innovation is a double-edged sword. We do need excellence, innovation, and quality, but unfortunately all of this comes at a price and the question is what is our priority? Not that I think brain tumour surgery is not important, but large numbers of our children still suffer from acute respiratory infection. It’s not an ‘either-or’ situation, but the problem is when we put all our investments into new medical technologies or adopt a lot of the medical technologies which are coming from other countries, it’s at the price of other issues. This also generally leads to prices increasing because the whole market is influenced by this better technology. So this would be a concern from those of us who are promoting primary health care. Eventually, our dream is to provide universal health care coverage, perhaps along the lines of national health care in the UK, so that people are not pauperised when they get sick. We need basic health education and preventive systems like water and sanitation. When we do get sick, there needs to be a basic social security system, and this is in the bill pending in parliament for Social Security, which gives basic health insurance, basic maternity benefits, life and accident benefits. These need to become a reality for all Indian citizens.