Year : 2019 | Volume
: 35 | Issue : 3 | Page : 177--178
The health-care crisis in India – Can urology remain untouched?
Department of Urology and Renal Transplantation, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
Department of Urology and Renal Transplantation, Krishna Institute of Medical Sciences, Secunderabad, Telangana
|How to cite this article:|
Panda A. The health-care crisis in India – Can urology remain untouched?.Indian J Urol 2019;35:177-178
|How to cite this URL:|
Panda A. The health-care crisis in India – Can urology remain untouched?. Indian J Urol [serial online] 2019 [cited 2019 Sep 17 ];35:177-178
Available from: http://www.indianjurol.com/text.asp?2019/35/3/177/261922
It is the proverbial elephant in the room; everyone sees it, no one talks about it. Health care in India is in crisis. For more than a decade now, the public health expenditure in India has been between 1.3% and 1.4% of the gross domestic product (GDP). Considering that the world average is around 6%, this appears to be inadequate. Public health in India is a subject on the state list but in which the central government makes significant policy interventions. In the last decade, several state governments have started state-funded health insurance schemes which have been quite popular. In this context, the central government has introduced the National Health Protection Mission in the 2018–2019 union budget. This envisages a 5 lakh rupee cover per family for around 10 crore families. It will be primarily for hospitalization at the secondary and tertiary care level. It is likely that the vast majority of private hospitals will be empaneled in this scheme. While the intentions of successive governments are laudable, it does raise a few fundamental issues.
In India, the total expenditure on health has been estimated to be around 3.9% of the GDP of which only 30 percent (1.3% of GDP) is contributed by public health expenditure. Seventy percent is paid for privately, of which insurance contributes 5% and the rest 95% is met by out-of-pocket (OOP) expenditure of the patient.
Conventionally, health care has been considered as a basic human need. Governments throughout the world have invested in public health institutions to provide good quality, affordable, and possibly subsidized health care to its citizens. The large population of India has meant that government and public health facilities have been inadequate and private doctors provide for the bulk of health care. The introduction of government-sponsored insurance schemes is likely to disproportionately increase the proportion of health care provided by private practitioners and corporate hospitals. While public hospitals are also being empanelled, the income that they will accrue from this is unlikely to result in any significant upgrade of infrastructure or increased number of patients treated.
Why Is this a Problem?
The principles outlined by Aneurin Bevan in 1948 at the launch of the National Health Service in postwar England are regarded to epitomize the core principles that should guide publicly funded health care. The principles were (a) that it should meet the needs of everyone, (b) that it should be free at the point of delivery, and (c) that it should be based on clinical need, not the ability to pay.
An insurance scheme is a poor substitute for a proper public health-care network. In a cross-sectional study of 62,335 individuals over 3 states of India that analyzed the relationship of publicly financed health insurance, on the extent of health-care utilization, its relationship on OOP expenditure and financial risk protection found no significant difference between OOP expenditure among the insured and uninsured for an episode of hospitalization. The prevalence of catastrophic health expenditure was also similar. A systematic review of the impact of publicly financed health insurance schemes found that while utilization of health care improved among those enrolled, there was little evidence that it resulted in reduced OOP expenditure or higher financial risk protection.
These issues aside, most of these insurance schemes have clearly defined financial packages for common diseases. These for the most part are insufficient to cover the use of modern equipment required for minimally invasive procedures. Private hospitals tend to disallow the use of essential equipment for these patients and often the offered facilities are different from those who pay the regular rates or are covered by private insurance.
How Does this Affect Urology in India?
In 2017, the Government of India has regulated medical devices under the Medical Devices Rules. This lays down strict guidelines regarding the manufacture, sterilization, and use of medical disposables. Reuse of single-use medical devices/instruments is not permitted. The differentiating feature of urology has always been the use of cutting edge technology particularly in endourology and minimally invasive urology. With the current package rates that are approved for most urological procedures under the insurance schemes, it may not be possible to offer such procedures to the vast majority of the population. The alternative of substandard care and cost-cutting that endangers the health of the patient is clearly not acceptable.
Traditionally, the government has been a health care provider. The transition from being a provider to being a payer for health care services is fraught with risks- it means that health care in the long run will be privatized. In such an environment defining quality and value is difficult. Outsourcing of public health care and the assumption that state-funded insurance is a substitute for an effective public health network is unfortunate. The consequent reduced outlay for the maintenance and upgradation of state-run public health-care institutions and hospitals, and the possible lack of finances to set up sufficient number of new hospitals is likely to affect health-care delivery and medical research. This is also likely to have significant implications in the training of the next generation of urologists who are unlikely to see complex procedures that are not cost-effective under the current schemes. It is important that publicly funded healthcare institutions and health care systems be strengthened with a long term road map in place. Private healthcare can only only fill the gaps, it cannot be a substitiute.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
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