Our tier 2-3 cities not strong enough in public health services: K S Reddy

Even efficient urban and variable-quality rural health services will be unable to tackle coronavirus in case of a community epidemic, which will gain ground and possibly acquire greater virulence

K Srinath Reddy is president of not-for-profit Public Health Foundation of India and former Head of Department of Cardiology at All India Institute of Medical Sciences (AIIMS). He is also an Adjunct Professor of Epidemiology at Harvard (2014-2023). Speaking with Aditi Phadnis, he shares his views on the health outlay in the 2020-21 Budget and the novel coronavirus threat to India

The novel coronavirus has again raised questions about India’s capacity to handle public health crises. So far, the situation is under check, but do you think capacities are adequate?

All countries are nervous about the novel coronavirus assuming pandemic proportions and are taking measures to: (a) prevent its entry in the first place; (b) contain its spread through quick case and contact identification if it has already surfaced and (iii) provide appropriate medical care, based on clinical severity. 

India’s response to H1N1 and H5N1 outbreaks was panicky and patchy, but valuable experience was gained in the process. That helped to strengthen our outbreak response planning and preparedness. The efficiency displa­yed in containing the Nipah outbreak in Kerala was commendable. However, the novel coronavirus poses a greater threat because of speedy spread by the respiratory route, making it difficult to tackle if it becomes a community infection. Since the virus is highly-infective in its asymptomatic incubation period, it may slip in via seemingly well international travellers and spread with ease in the community. 

But, our tier two and three cities are not strong enough in public health services. Even efficient urban health services and variable-quality rural health services will be unable to tackle the virus in case of a community epidemic, which will gain ground and possibly acquire greater virulence. We need an impregnable wall-like defence of (cricketer) Rahul Dravid to not let one get past the guard of our public health screening, the agility of Sachin Tendulkar to surely and swiftly send each suspected case and contact to clinical care fence and the calm de­meanour and masterly monitoring of M S Dhoni to ensure that the rate of infection does not mount beyond our capacity to control, while assuring anxious spectators that there is no reason to panic.

We will wait to see how the Indian health sy­stem performs. So far, we are batting well. How­ever, we should earnestly strengthen the public health systems in the country. 

Budget 2020-21 was hailed by the PM for its health outlays. Yet, experts are less than satisfied. Many feel the government has its priorities wrong. What are your views?

For apex policymakers who have to adjust fiscal allocations between several competing priorities, the outlay on health may have appeared generous. However, given the state of our health services and even the avowed goal of National Health Po­licy (2017) to reach 2.5 per cent of the GDP for public financing of health, the near-stillness of central financing brings a fresh dose of disappointment to public health advocates.

The notional increase of four per cent fades in the face of inflation. The National Health Mi­ssion (NHM) gets no leg-up, while the much publicised Pradhan Mantri Jan Arogya Yojana (PMJAY) remains short of the projected expansion. The scale of expansion needed in our health workforce, infrastructure, essential drugs and diagnostics, technologies and health information systems is huge. A weak health system cannot adequately absorb increased funding or appropriately utilise it. We need substantial front-end spending to make it capable of efficient programme spending. The state governments will have to raise the allocations for health in their Budgets. The National Health Po­licy of 2017 calls upon states to allocate at least eight per cent of their budgets to health, by 2020. The central Budget should have set the trend.

The government is looking to withdraw from public health in district hospitals, and hand over some of these to the private sector in a public-private-partnership model. What do you think?

Strengthening of district hospitals and linking them to new medical colleges, especially in the states, which have less number of medical schools, is a measure, which had been recommended by a high-level expert group on Universal Health Coverage in 2011. It also featured, as an intended initiative in the National Health Policy of 2017.

However, the intent thus far has been to allocate public finance to upgrade district hospitals and develop new medical colleges to link with them, within the public sector ambit. Startlingly, the Union Budget of 2020 proposes to hand over the district hospitals to the private sector to link them to new medical colleges, which the private sector will set up with several incentives and viability gap funding provided by the government. Two vital elements of health system – secondary healthcare and medical education — are thus to be handed over to the private sector without a clear commitment that public good will prevail over private profit.

Will doctors coming out of these colleges be oriented to a private sector mindset of paid patient care and perpetuate costly care practices, resulting in high out-of-pocket spending? Since viability gap funding for incentivising private sector participation in this scheme will come from a tax on medical devices, will it lead to private managements to push for ex­cess use of costly devices to expand state funding through that route? The scheme will also administratively disconnect primary care (provided through a public-run primary healthcare ladder) from secondary care in district hospitals. The state governments will also lose their control over the pivot of the district health system. This disrupts continuity of care and undermines the integrated delivery system essential for universal health coverage.

In the Budget, the NHM was not granted an increase. But Ayushman Bharat, which made use of just half the budget allocated last year, was still given a huge chunk. Is this a good policy? In your view, is Ayushman Bharat even working?

The PMJAY is one of the two components of Ayushman Bharat. It is still being rolled out and expected that it will see higher levels of utilisation this year.

However, it is the other component —Comprehensive Primary Health Care — which is embedded in the NHM that needs more support. Primary care is pivotal for an efficient and equitable health system. It is the fulcrum of universal health coverage, as it serves everybody in the population, offers the widest range of essential health services and is cost-optimising as it yields the most health benefits across the population, while obviating much of the need for advanced care through prevention and timely protection at early stages of disease.

The NHM certainly needs more funding than has been offered. Over-reliance on hospital care, while neglecting primary care, will be counterproductive and stall the journey towards our health goals. 

There is a debate about the prices of medical devices, with many arguing that forcible pressure from government on price, is only going to drive down quality. But it is also true that medical devices need to be affordable. What is your view?

Several medical devices, especially those at the high end, are overpriced and expensive. Their prices need to be controlled. In a large country like India, the usage, both in public and private sectors, is high. The high volume of use should offset the reduction in price markup. That will still provide a reasonable profit to the manufacturer.