By Jay Desai
As India continues to debate how best to implement universal health coverage, two recent and seemingly unrelated news items beg careful analysis.
The first one pertains to a report released earlier this year by the National Research Council and the Institute of Medicine in the US. This elaborate 378 page document concluded that despite having the world’s most expensive healthcare system, the US ranks below 16 other rich countries for life expectancy with poorer health across the entire life of its citizens. The report noted that, compared to other countries, Americans fare worse in 9 important domains of health including but not limited to birth outcomes, diabetes, heart disease and chronic lung disease. Most unexpectedly, it also noted that highly advantaged Americans (educated, insured and rich) also do poorly when compared to their counterparts in other countries. Several explanations were offered for such inferior health including various societal factors and higher degree of inequality of its citizens compared to other rich countries. However, the US healthcare system was blamed at least in part for the dismal numbers. The countries that the US was compared to included Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the United Kingdom. The US mostly employs the managed care model and is in the midst of implementing universal healthcare. Many of the other countries listed above have universal healthcare implemented through the single payer system with care delivered and paid for mostly by the government and public funding.
The second news item pertains to a statement made by the Indian health minister Ghulam Nabi Azad late last year at an event organized by the Confederation of Indian Industry (CII). Mr. Azad conceded in his address that the public private partnership (PPP) model was necessary to improve India’s healthcare system. Perhaps not coincidentally, Mr. Azad also released a report titled “India Healthcare: Inspiring Possibilities, Challenging Journey” at this event. This report was prepared by McKinsey and Company, a US based management consulting firm. It is no secret that prior to this concession, Mr. Azad was opposed to the public private partnership model which is favored by Montek Singh Ahluwalia, the deputy chairman of the Planning Commission of India. It is also noteworthy that the High Level Expert Group (HLEG) on Universal Health Coverage in India favored predominant involvement of the public sector. The HLEG was constituted by the Planning Commission in October 2010 under approval by the office of the Prime Minister. Although there is no official word, it is now becoming increasingly apparent that India plans to follow the US healthcare model. If we go by the recent reports in certain sections of the media, the universal health coverage dream already appears to be a secondary goal. While no healthcare system is faultless, what would be a logical explanation for attempting to implement a model that has largely been unsuccessful and costly? Is it misinformation? Is it complete lack of trust in the functioning of the public sector? Is it the powerful corporate lobby? Is it conflict of interest? Or is it blind faith in the world’s foremost superpower?
The answers to these questions are not obvious but the shortcomings of the private healthcare sector and the managed care model are. The first and foremost fault lies in the fact that they lead inevitably to large scale corporatization of healthcare. This corporatized model leads to the creation of the costly middleman. It generates hordes of medical administrators on the side of the corporate sector. It necessitates doctors to add layers of administrators to their own practice to navigate the system which usually becomes too complex to handle. Moreover, in this corporatized model, higher reimbursements are usually for treatments and procedures rather than for preventive strategies. Thus, it usually rewards doctors and hospitals for fixing a problem and not for preventing it, leading to comparative neglect of maintenance of health. For the patients that do need interventions, the for-profit companies place hurdles in order to cut their own costs. Finally, this model also provides disjointed care based solely on the contractual relationship of various healthcare providers and agencies.
The single payer system of universal health coverage also has its faults and its critics. However, it diminishes the business aspect of medicine. It decreases the administrative costs. It streamlines care. We have ample data to guide us towards adopting a system that is better for improving the health of a nation, with necessary modifications to suit local conditions.
Jay Desai is a faculty member at University of Southern California Keck School of Medicine