Before starting national coverage, fix primary health care first

When Finance Minister Arun Jaitley delivered the Union Budget for 2018-19 last week, he included a promise to roll out a major government subsidised health insurance scheme that covered catastrophic medical charges up to Rs 500,000 for 500 million Indians. Many questions have been asked about the design and funding of this proposed scheme. Yet the secondary and tertiary care this scheme will likely fund is only a part of the problem. Primary health care — the first contact between a patient and the health care system, usually within their own community — is indeed perhaps even more important. The government could claim that, at the moment, it does indeed provide for primary health care — but that is almost entirely on paper. The Budget speech this year also talked about the government’s resolve to expand primary health care, but the fund allocated is grossly insufficient to make any impact.

In fact, India is suffering at the moment from severe under-capacity when it comes to primary health care. The number of doctors for every 1,000 Indians is 0.76, which is one of the lowest such ratios in the world. Already too few of those training in medicine want to be general practitioners; most want to follow up their MBBS degree with some form of specialisation that will allow them to rake in cash from secondary and tertiary medicine. This dynamic will only be enhanced by the government's focus on these sectors through the new insurance scheme. Even those who graduate with MBBS degrees at the moment show little inclination to go to rural areas. Methods have been tried to incentivise them. The Karnataka government has piloted an ingenious project in which doctors bid their preferred salaries for rural postings, and the lowest bids win — but so far the bids that have come in have been so high that the entire programme has been called into question. The Union government has tried various short-cuts to solve this problem, including certifying homeopaths and Ayurvedic practitioners to conduct some of the basic duties of general physicians. This is, of course, an absurd notion and should be dropped. Already the National Rural Health Mission has reported that several such practitioners have been recruited as the sole care providers in certain primary health centres (PHCs) in India. This is no solution to the primary health care provision problem.

Malcolm Grant, who heads the United Kingdom’s National Health Service, was recently asked to comment on the Union government’s plan for subsidised secondary and tertiary medical insurance and insisted that the “NHS has been founded on primary care” and that what is needed is to “roll out simple diagnostics across the country, especially in rural areas”. The government needs to focus on this road map. It will need to take several difficult steps. First, it will need to take on the medical mafia: as Mr Grant pointed out, “Do you need someone who has trained in medical college for six years, trained for another four years, and worked for 20 years to take your blood pressure?” Cartelisation in the profession needs to be addressed. Technological diagnostic interventions that cut costs need to be rolled out at scale, and quickly. Finally, public spending on health — which is about 1.3 per cent of GDP — needs to be doubled as a proportion of GDP. There are no cheap ways to good primary health care.