Rethinking healthcare in India

The Indian government is easing, slowly, the lockdown of 1.3 billion people. India’s trajectory of COVID-19 deaths (in the few states with reliable mortality statistics) appears to be less steep than Europe, but it is still growing. Maharashtra is struggling, and fears about a widespread flood of hospitalisations have yet to materialise.

Prime Minister Narendra Modi’s government was caught unawares by the massive migration that followed the sudden lockdown — which must have affected about 400 million workers. The government quickly organised some remedies. The public health priorities in the battle against COVID-19 are clear: Expand testing and contact tracing massively, pay infected people to quarantine, protect staff in the hospitals from infection so that these facilities do not become hotspots of transmission, and invest in data.

The record to date on these is mixed, with some success in testing and quarantine, but only partial success on preventing hospital infection. On data, the government has been far too conservative, worried about adverse publicity. Innovative, often youth-led efforts, have resulted in a set of databases and apps that are available on the web and social media. Yet, the data gaps are not being met sufficiently so as to map a route out of the pandemic and to reopen the economy safely.

Although spared the dreadful death rates as seen in the US, the COVID-19 crisis has highlighted the glaring holes in India’s social safety nets. COVID-19 could drive 10 million Indians below the poverty line: Already, over 40 million Indians become poor annually from catastrophic healthcare costs (costs exceeding 10 per cent of a household’s total expenditures). Eighty per cent of health services are paid out-of-pocket. Hence, millions of Indians depend on daily wages not only to eat, but as their modest safety net.

Savvy political leaders encourage us to never let a good crisis go to waste. Barack Obama pushed the Affordable Care Act on the heels of the global 2008 recession. The Act has not only substantially reduced the number of uninsured (which remains higher than in countries with universal health insurance), but also reduced poverty. The Act, eventually, gained wide public support, and it will be a key issue in the 2020 election. England launched its National Health System (beloved across party lines) after World War II, while it was relatively poor.

Could India seize a similar opportunity? In 2018, Modi launched the National Health Protection Scheme to provide about Rs 5 lakh (about $10,000) in health insurance to the 100 million poorest households. However, a programme focused only on the poor is likely to end up as a poor programme. Universal programmes garner broader public solidarity, and avoid the inherent stigma of targeting. Importantly, India has an unparalleled opportunity to develop digital insurance platforms, given the mostly successful national identity cards, wide use of e-payments (a side effect of the demonetisation experiment), and a high level of access to broadband internet, even in rural areas.

Public financing of universal health care (including discretionary clinical services) would substantially free Indians to use their money better. Current out-of-pocket spending consumes a large proportion of poorer households’ income, precludes more productive household investments, often remains untaxed, as doctors and hospitals are frequently paid under the counter and creates few jobs. Aspirations to be internationally competitive in manufacturing and services requires a publicly insured, mobile Indian workforce with little or no financing burdens on workers or corporations. COVID-19 has demonstrated the impact of reduced income in populations facing catastrophic health costs in India and also in the US, where much of health insurance is inefficiently linked to employment.

Moving to tax-payer and prepaid universal health insurance will not be easy. Such an idea would need a few states to start carefully on it to demonstrate its viability. A hefty price tag need not deter financing or borrowing: This human capital investment yields huge economic and social returns. Indeed, net costs would be far less than the COVID-19 economic relief — costing 10 per cent of GDP — that’s currently underway. The most politically demanding task might well be the requirement to turn India’s notoriously unregulated private hospitals into autonomous trusts. Steps to move decision-making away from politicians onto accountable technocrats and public health cadres, and rapidly expanding open data systems that build on the Indian ethos of democracy are warranted. This would involve local trusts or regional health authorities who can be held accountable by their neighbours and community.

The principle that “everyone is covered, but not everything is covered,” means documenting the most cost-effective services as well as ineffective or expensive services that should not be publicly financed. Insured services can expand as incomes and government revenues increase. And wise choices, like a substantial increase in cigarette taxes, can yield a triple win — reduce disease, protect families from catastrophic healthcare costs of smoking-attributable diseases like cancer, and raise more revenue. Finally, public finance need not mean only public delivery. Public payment of private or franchised services is possible, provided good data on quality is agreed upon as part of the contract. Indian governments can draw upon their experience with the now-(mostly) dismantled “license Raj” to build regulatory approaches.

COVID-19 offers a chance to choose a new direction for the health of Indians. India has occasionally been tagged as the country “that never misses an opportunity to miss an opportunity”. This might not be fair. If this label is rendered obsolete, a stronger and healthier post-COVID India could emerge.

The column was published online by Indian Express and can be accessed here