Robert Yates is impressed. A globally acclaimed expert on Universal Health Coverage (UHC) and project director of the UHC Policy Forum at the London-based Centre on Global Health Security, Yates is visiting Delhi to understand the state’s strategy. He cannot think of any example in the world, where new facilities have been introduced in such a short time in one city.
He is not the only one. Reputed medical journal, The Lancet, and former Secretary-General of United Nations (UN), Kofi Annan have lauded this free clinics model of healthcare delivery. Other state governments are trying to emulate it. Treating high-incidence low-cost illnesses like cold, cough and viral fever for free at the doorstep of Delhiites makes financial sense too.
That’s also the first ladder of universal healthcare, seen as a holy grail because it’s a tricky game of execution and political will. Letting people buy healthcare through myriad insurance schemes is less head-scratching than providing care at doorsteps, sort of, to check costs. And disease escalation. Nearly 30 emerging economies are moving towards it. In Delhi, the Aam Aadmi Party (AAP) government began this experiment in July 2015. There’s no qualitative data to show how it’s working, but there are initial signs that people and care providers like it even though the opposition doesn’t.
Money is not a problem
Delhi’s annual health budget is Rs 5736 crore. It could, like India as a whole, do with more but for now, this money is good. Director of the state health mission, Dr Tarun Seem, explains that primary healthcare is very cheap. So cheap that it could be done under a tree. It is not about reinventing the wheel but sticking to a simple and minimalistic design with some innovation. And innovate it did. The state has nipped redundancies like employing full-time staff, buying equipment and acquiring space by hiring temporary General Physicians (GPs) and other staff, who are paid for each consultation. It has also outsourced the diagnostics. For the 29 lakh outpatient consultations provided via mohalla clinics, the state pays Rs 30 to the doctor and Rs 70 is spent on support staff, basic drugs, diagnostics and maintenance.
For patients who need specialised care, the state has decided to outsource that task to private diagnostic labs and hospitals at heavily discounted rates. A sum of Rs 500 crore assigned for mohalla clinics is more than sufficient to achieve the state’s target of 30 million OPD consultations. The rest is for expanding secondary and tertiary care services.
This partnership between the public and private sector in Delhi is a cliched win-win for everyone. The private hospitals, which profit from in-patient services like surgeries, say they are happy to be rid of the cough-and-cold crowds. The doctors employed by the government on contracts are content with per patient incentives as the patients they consult are large in numbers. They can establish or continue with their private practice in the evenings.
The state seems to have found a way to offer universal healthcare. Why, then, is the mood bitter at this celebratory lunch? Health minister Satyendra Jain, in a Kafkaesque manner, with his hand on his forehead, responds in a helpless tone, “Once you tell a bureaucrat to get something new done in a new way, for months you will hear the rules and regulations that prohibit it from happening.”
Keeping it simple
The central and state governments together spent 1.3% of the country’s GDP on public health in FY2016, against a world average of 6%. The new National Health Policy promises to increase the public spending to 2.5%. Taking it a step ahead, Delhi’s health department has not only increased the expenditure on health but also focused on making it count by improving the efficiency of the health systems. No point in pumping money down the same inefficient systems, they say.
Dr Seem—an Indian Revenue Services officer, who has worked with the Delhi-based Public Health Foundation of India and helped frame the National Rural Health Mission with the union ministry of health—has found that primary healthcare is inexpensive. He points towards an audit report of a state government-run maternity home. Over 1 lakh rupees were being spent on each delivery. This report is one of the many audits that the AAP government conducted in the initial stages of planning UHC. However, he understands that public systems cannot always care about efficiency. A train has to run even with one passenger, he says. However, the costs can be optimised.