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Better Healthcare~II

Such a scheme has the potential to usher in a new era in healthcare with a highly developed system of reach, quality and professional management leading to enormous socio-economic benefits for the country in the long run

VIKRAM SEN | New Delhi |

The scheme outlined in this article envisages creation of two statutorily constituted authorities. The first one would lay down binding standards for hospital infrastructure and day to day functioning including patient care, outdoor and indoor treatment and allied matters. The second authority would be responsible for all financial aspects relating to fixation of charges for all indoor and outdoor treatment according to the grades of hospitals determined by the first authority, categorization of families or households for sharing of charges between patient and the government, online and digital verification of patients as per an assigned social security number, online examination of bills, arranging payments within a fixed time schedule and other connected matters. The need for constant connectivity and provision for mutual consultation between the two constituted authorities to ensure a robust system of universal healthcare across the country cannot be overemphasized.

The members of the first authority may be entirely from the medical community with a record of professional competence and integrity. The second authority may include both medical and financial experts.

As this chain of private hospitals become fully operational across the country, the Union and state governments may gradually withdraw from direct health delivery at the tertiary level and concentrate more on spread of quality medical education by setting up new UG and PG medical colleges with at least one in each district headquarter. These medical colleges may also serve as referral hospitals treating mostly critical or referred patients. Of course there will be difference in fees structure between government and private medical colleges because of the subsidy element but that gap should not be so wide as to be out of reach for students coming from the poorer sections. In fact it is advisable that the difference between the two sets of fees may partially be subsidized by the Government so that established and reputed private medical colleges can also exist and become accessible to poor but meritorious students. It is also time to consider if admission to all UG and PG medical courses should be determined solely on merit without reservations or quota in any form just as in super speciality or post PG medical courses.

Innovative ways to meet the huge financial liability for the proposed improvement in health infrastructure need be explored. For example the present enrolment under EPF and ESI cover around 13.5 crore employees with monthly salary limit of Rs 15,000 and 21,000 respectively. If the definitions under both are modified to include all factories and establishments without any stipulation as to number of workers or salary limits at least for the purpose of this scheme, the expected increase is likely to be more than threefold to around 40 crore.

In case statutory provisions are made to deduct two per cent of salaries being one percent each from employers and employee or minimum of Rs. 50 (25+25) per month, whichever is higher the annual contribution to the scheme is likely be more than Rs 24,000 crore. Similarly in case of present active MGNREGA workers, a deduction of Rs 5 from the current daily wage of Rs 202 is likely to contribute Rs 1,150 crore if we take minimum 50 days of work per annum. It may of course be argued as to why any amount should be deducted from the wages in a subsistence level welfare scheme like MNREGA. While the amount proposed to be collected is not a substantial one and can easily be done away with, such contribution may generate a sense of ownership of the scheme.

Out of around 45 crore registered individual PAN card holders the number of actual income tax payers is only about 6 crore. Graded monthly contributions at Rs 100, 300, 500 and 1,000 respectively may be levied from individual PAN card holders corresponding to current four individual Income Tax slabs. If half the number of PAN holders agree for voluntary enrolment under the proposed health scheme there is potential for collection of at least Rs 30,000 crore excluding those already enrolled under ESI, EPF and MGNREGA. The calculations are of course purely speculative but may be a starting point for a more rational exercise.

We are also assuming that in case of more than one income earner per household each will be liable to contribute as the project would cover every member of the household. Finally we may come to contribution from corporate tax-payers.

As social security is in the Concurrent List, the Union Government may legally impose a social security tax on all corporate income. Such tax at 5 per cent at flat rate on all corporate income is likely to yield Rs 32,500 crore over and above the present annual collection of about Rs 6.5 lakh crore.

Thus the expected collection as envisaged above is likely to be around Rs 87,650 crore at the minimum. If we add to this the present budgetary outlay for the Health Ministry of about Rs 69,000 crore and that of the States and UTs at Rs 158,800 crore (in 2018-19) the total would be roughly Rs 3,15,450 crore which is nearly 2.3 per cent of India’s GDP of around Rs 141 lakh crore in 2018-19. It is true that even this outlay on health would be awfully short; expenditure on health in developed countries is generally above 10 per cent of GDP. However, with expected substantial increase in private investments in health, one would hope that growth on health-related expenditure as percentage of GDP will go up gradually as more and more families opt to come under the scheme. This has the potential to usher in a new era in healthcare with a highly developed system of reach, quality and professional management leading to enormous socio-economic benefits for the country in the long run.

Enrolment under the scheme has to be voluntary with option to remain outside. At the beginning, many may opt out of the scheme leading to questions on its viability. But as the spread and quality of health delivery improves, general realization as to its benefits will follow with increasing enrolment. Thus need for patience and ability to endure the initial hiccups and criticism, which is common in India in case of any radical departure from the past, will be needed to sustain the scheme in the long run.

Many private hospitals may refuse to come under the scheme fearing regular scrutiny of their service delivery and regulated charges. Apprehensions of late payment of bills by the Government may be another factor. As we have seen in case of the Central Government Health Scheme (CGHS) for serving and retired Central Government employees, majority of reputed private hospitals have opted to stay out because of long pending payments. To address this issue there must be an acceptable time limit within which the designated authority has to clear all bills. A time bound reconciliation procedure in case of disputes should also be provided for. As for the initial reluctance to submit to third-party surveillance with regulated service charges it is again a matter of time. If more and more patients opt for hospitals listed under the scheme those outside will either fall in line or be forced to close down.

Amendments to the Clinical Establishment Act to ensure that similar norms and standards of service are applicable to all hospitals across the country will also go a long way towards improvements in our health delivery. Many may reasonably ask why such stress should be placed on creation of a new hospital network, specially private ones, and whether it would not be better for the government to provide insurance cover to the poor and let new hospitals come up as per free market demand and supply equations.

Basically the choice is between the two sets of public health care systems prevailing in most developed countries. First, the British and the French model of National Health Service (NHS) which with minor variations is in force in many European countries. The other one is the US model of Medicare and Medicaid and further modifications under the ‘Affordable Care Act ‘, generally referred to as ‘Obamacare.’ These provide insurance cover against premiums paid by the beneficiaries and are partly subsidized by the State as per income slabs.

The problem with the British model of government chain of hospitals under NHS is the long waiting time for patients requiring hospitalization and enormous strain on public exchequer making it almost impossible to set up additional hospitals. The US model of health insurance, apart from absence of state-run hospitals (except military ones) and high premium costs, provides for coverage only in selected ailments. The scheme proposed here attempts a third alternative where public and private healthcare facilities will function simultaneously under the supervision of independent regulatory authorities.

The need of the hour is to make available quality, easily accessible and universally affordable healthcare to all our citizens.