| Now that the government has a little bit of money, courtesy buoyant tax revenues, it is time to take on the appalling state of healthcare in the country. Not only is virtually nobody satisfied with what is available, the country is in serious danger of effectively adopting the US model, which is globally discredited. In India, anyone who can afford it is opting for private delivery via health insurance, third-party administrators and private care. However, the option that uninsured Americans have of being able to walk into any emergency room and get treated is absent in India as private hospitals don't feel obliged to deliver emergency care and public hospital emergency facilities are mostly appalling. |
| US per capita healthcare expenditure is about the highest in the world but Americans lag behind European nations in general health and life expectancy. Unsurprisingly, healthcare reform to make it universal is a key issue in the current US presidential election campaign. Leading Democratic candidates have unveiled plans to deliver universal healthcare "" the buck stopping with the federal government "" and California's Republican governor Schwarzenegger has chided his party's aspirants for having no plan at all. |
| European country practices vary but they have one thing in common "" universal state-funded healthcare. In India, publicly-delivered healthcare is theoretically available to all and free for the poor. But usable state-provided healthcare is available to a minuscule share of the population "" public sector employees like the defence forces and railwaymen. The rest who go to public hospitals mostly do so because they are too poor to go elsewhere and decide to take a chance instead of dying on the streets. |
| If private healthcare was costly but satisfactory then that would have been something. But it is riddled with corruption and inefficiency. Quacks among private practitioners abound in the countryside. Doctors routinely recommend unnecessary and exorbitant tests as part of a nexus with laboratories. Private hospital bills shoot up as soon as the provider learns the patient is covered by health insurance. The experience with TPAs, even where treatment is supposedly cashless, is miserable. There is anecdotal evidence of how till lately employees of reputed firms, from high-profile industries like software covered under substantial group insurance, would check in for a few days' stay in a five-star hotel-like corporate hospital for no good reason. |
| Health insurance firms, particularly the private ones, are dedicated to cherry picking the juiciest part of the business. Both the insured and insurers play an endless dodging game over pre-existing illness. TPAs have been trying to bring some order into the rates for standard procedures and have been taken to court by healthcare providers. The CGHS (Central Government Health Scheme) rates provide a useful starting point for benchmarking but an association of providers has now formally moved against this. |
| It is axiomatic that everyone should be entitled to healthcare irrespective of his ability to pay. In insurance the cost of bearing risk comes down as the base widens "" the risk is spread out more. Logically the entire population of 1.1 billion should be covered under a single policy. Since inability to pay is not an issue, the government should pay the entire premium for the whole population out of general revenue. A health insurance surcharge should be levied on the income tax we pay. Those earning less than the minimum taxable income should naturally get the health cover free. The government's healthcare budgetary allocation should be need-based. |
| This is already happening up to a point. But even the little that is allocated is often appallingly misspent. This has prompted most who can afford it to go for private care. On the other hand, most of the best hospitals in the western countries, the topmost teaching and tertiary care ones, are non-profits. But there also, standard services like, say, catering or laundry are delivered to universal (equally applicable to public and private providers) benchmarks. |
| One way to bring some accountability to all hospitals, public and private, in urban and semi-urban areas is to introduce a voucher system. All citizens will get vouchers up to a certain value, with which they can exercise a choice, where a choice exists. Where there is no choice, as in rural areas served by only government heath centres, the only way for people to get value will be through activism, either via citizens' groups or the panchayat. There are some great success stories of such activism but these are exceptions. |
| If trade union leaders and the politicians backing them allow a voucher system to work, even on a pilot basis, then that will mean progress. But even then, ordinary people will not be the best equipped to shop for healthcare as they don't know enough "" suffer from information asymmetry "" on a technical subject. The bedrock of an acceptable healthcare system in any society is a large number of non-profits which are run by dedicated public servants where standard services are delivered to universal benchmarks. The citizenry has to fight for this, pay decent salaries to public servants and honour them. Private care will remain a choice but can never be a substitute. The US experience says so. |
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