Affordable & accessible cure

Providing healthcare to people has always been a major concern for the governments. As the most populous nation in the world today, the task for India is much more challenging than ever before. Conventionally, the approach has been to provide free and universal healthcare to all, focussing on pre- and ante-natal care, treatment of communicable diseases, controlling of epidemics, and preventive care through vaccinations and awareness drives. However, the National Health Systems Resource Centre (NHSRC) Report 2017 says that around 70 per cent of the aggregate healthcare expenditure is through 'out-of-pocket' (OOP), and importantly, 75 per cent of the chronic ailments, mainly the noncommunicable diseases (NCDs), are treated in private hospitals at exorbitant charges, which is one of the chief factors for pushing the low and middle-income classes in to impoverishment. As the curative medicine is not only expensive but also specialised, accessibility and affordability are serious issues in rural areas.

With tremendous growth in Artificial intelligence (AI), Machine Learning (ML), and the Internet of Things (IoT), today, preventive care through early diagnosis, e-Health, and Digital Clinic has acquired currency. But studies show that awareness for prevention doesn't necessarily lead to a behavioural change in people, especially in the areas where human development indicators like education, life expectancy, purchasing power parity (PPP), per capita income etc. are below the desired levels. For example, while tobacco contributes to nearly 1.35 million deaths every year, around 1.70 lakh people die due to alcohol-related cancer and liver cirrhosis. However, it is not to undermine the importance of preventive care but to underscore the urgency to gear up the system to provide accessible and affordable quality curative care.

Noncommunicable diseases (NCDs) and the consequent social and economic liabilities are a serious concern in the entire world. According to a WHO report published in 2015, four major NCDs viz., cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, are responsible for 70 per cent of deaths worldwide; three fourths of them occur in lower- and middle-income countries (LMICs). In India, chronic diseases were responsible for 5.87 million deaths and 60 per cent of all deaths in the country, which was more than two thirds of NCD-related deaths in the whole of South East Asian Region (SEAR). The universal and free healthcare approach, of course, best characterises a welfare state like India, but somewhere, the prioritisation needs a rethink in order to strike a balance between curative and preventive healthcare.

India was the first country to adopt the global NCD target in its National Action Plan and Monitoring Framework for the Prevention and Control of NCDs (2013-20) and the National Multi-sectoral Action Plan for the Prevention and Control of Common NCDs (2017–2022) (NMAP); a follow-up to the Monitoring Framework aims at reducing premature NCD mortality by 25 per cent by 2025. Indeed, there is a National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS, 2010), but the fact that majority of deaths are caused by NCDs every year points to serious gaps either in the approach or in the executions of schemes and programmes.

The Ayushman Bharat (PM-JAY) 2018 was a historic landmark in the evolution of three-tier healthcare in India. The special focus has been on BPL and weaker sections of society, with a provision of up to Rs five lakh for beneficiaries in secondary and tertiary care. With more than 10 crore e-cards issued to beneficiaries, and 53 per cent of the hospitals empanelled being private with multi-specialty facilities, the scheme has been a grand success. It revamped existing PHCs into Health and Wellness Centres (HWCs) for providing a comprehensive healthcare i.e., preventive, promotive, curative, rehabilitative and palliative care. There are around 1,60,000 functional HWCs today, with more than 2.16 crore wellness sessions conducted with participation of 23.83 crore individuals. Nevertheless, the curative treatment for NCDs has been facing issues, since the scheme reflects a shift from supply-side financing to demand-side financing. The coverage is, of course, increased but continuity of care becomes an issue after discharge. The COVID-19 pandemic exposed the lacunae in curative care, as large number of people with chronic diseases like diabetes mellitus, hypertension, cerebrovascular disease, coronary artery disease, asthma, chronic kidney or liver disease etc. had either succumbed to the Corona virus or badly suffered vis-à-vis those free from such ailments.

Curative medicine is relatively a neglected area vis-à-vis maternity and childcare or preventive medicine in the healthcare system. Studies have found that without improving the capacity, a horizontal integration of vertical programmes only overburdened the primary healthcare in PHCs to the neglect of IEC activities and screening. ASHAs (accredited social health activists) are overburdened with tasks of an educator, link worker, service provider and activist, which dilutes their performance. Furthermore, there are issues at the community level, such as gaps in identification of eligible beneficiaries, dearth of Front-Line Workers (FLWs), inefficient functioning of community groups, poor awareness on NCD risk factors etc. As a result, conducting population-level screening, health promotion activities and timely interventions are becoming increasingly difficult. For example, according to a study by Nikhil Tandon, Ranjit M Anjana, et.al., (Lancet Glob Health [Internet]. 2018 Dec), 435 deaths due to diabetes in 2016 were in people younger than 70 years, which indicates inadequate management of diabetes in the country. While lack of standard treatment protocols lead to complications, inefficient referral systems hinder timely treatment and continuity of care. Poor facility infrastructure, inadequate knowledge provider on curative care for NCD, absence of multi-sectoral collaboration, inefficient programme management, and lack of monitoring systems are additional issues that need attention.

Ayushman Bharat is, of course, undergoing a lot of improvisation by fixing the gaps. A new system of evaluation of private hospitals is introduced, shifting the focus from volume to value of services. A new cadre of 1.29 lakh community health officers is created to lead ASHAs, ANMs and Anganwadi workers.

However, creation of a robust curative healthcare network in an institutional fashion is essential to tackle chronic diseases. With comprehensive information systems, the delivery services need to be augmented to effectively monitor risk factors, outcomes and health system responses, especially in the rural areas. In addition to Central schemes, states can also devise geographically specific models for treating NCDs, especially in hilly and tribal areas. Since the task is gigantic, a meaningful collaboration among state machinery, the private sector, charity organisations, and NGOs, will be ideal; guidelines in this regard are already made available by the NITI Aayog. It’s also high time that effective control on pricing in private multi-speciality hospitals is exercised. Finally, overdependence on the private health sector needs to be reduced in a phased manner by increasing the number of state-run curative facilities, along with improving capability and efficiency of the existing ones.

The writer is a former Addl. Chief Secretary of Chhattisgarh. Views expressed are personal