Ashok Alexander, Founder & Director, Antara Foundation, shares his insights on the major pillar of a successful healthcare system for India
What are the changes you think are needed to strengthen India’s public health scenario?
Two key changes are needed – government should reach for its wallet and then know how to spend money well. India’s public health spending is abjectly low at around 1.2 per cent of GDP. Public health expenditure of each of the BRICS nations exceeds 3 per cent of GDP. Even smaller south Asian nations like Nepal and Bhutan have public health spends over 2 per cent of GDP. Consequently, the poor are forced to pay. India’s out of pocket spending as a percentage of total health expenditure is among the highest in the world at over 62 per cent.
This money must be spent to address severe infrastructure gaps. Only 36 per cent of primary health centres (each serving 20-30,000 people) have operation theatres. 20 per cent of sub centres (each serving 35,000 people) don’t have regular water supply.
Investments must also be made in strengthening the hands of frontline workers (ASHAs, Auxiliary Nurse Midwives, Anganwadi Workers), especially with respect to data use. Technology can enable this process.
What according to you are the major pillars of a successful healthcare system for India?
Adequate spending, sound policy framework, visionary programmes, adequate facilities from sub-centre level upwards, well trained and fully capacitated frontline workers, win-win public-private partnerships and an informed, aware community strong enough to demand health as a fundamental right are all important.
How should India go about achieving these goals?
To begin with, India needs to spend more on health. Spending must match up to citizens’ needs and global benchmarks. Then, the nation must know how to spend that money well. Inadequate spending on primary health and under-utilisation of funds by states should be well documented.
What is your opinion on the National Health Protection Scheme (NHPS) which has been recently announced by the FM?
It is a well-intentioned scheme but has many unanswered questions. First, funding needs to be sorted out. Estimates vary from Rs 10,000 crore by a NITI Aayog adviser to 10 times that figure by a professor at NIPFP (National Institute of Public Finance and Policy). The initial corpus announced in this year’s budget is Rs 2000 crore. Will states pick up their share of 40 per cent? Bengal has opted out already. Recurring needs are yet to be addressed.
Moreover, gaps in public health facilities must be addressed to ensure effective implementation.
What lessons India should learn from the US and UK’s healthcare systems?
The US healthcare system is no exemplar. While it has premier institutions, strong doctor-patient relationships and superior care for serious issues, it has major flaws. It is prohibitively expensive and there are wide disparities among income groups. This is reflected in outcomes. Infant mortality rate (deaths per 1000 live births under one year of age) is close to six, among the highest for developed countries. It is close to double for the African-American community. Repealing Obamacare is a step backwards. The lesson for India is to invest in primary healthcare for disadvantaged groups in rural areas.
UK’s National Health System has received some criticism for its inefficient spending. However, there is much to learn from its emphasis on access, affordability, and preventive healthcare. The ubiquity of ‘family doctors’ also ensures that care is well-coordinated. The Commonwealth Fund’s ranking of 11 wealthy countries’ health system puts the UK near the top on several parameters.
What are the pre-requisites for an effective implementation of the National Health Protection Scheme?
To achieve desired results, emphasis must be on implementation and learning from the scheme’s predecessor, the Rashtriya Swasthya Bima Yojana (RSBY). Few important actions – One, effective monitoring of private facilities and accommodation of providers’ reasonable needs to keep them interested. Two, build awareness in the community. Only 35 per cent of eligible households knew about the RSBY, according to a study by TISS. Importantly, strengthen quality and accessibility of rural health facilities.
Swift rollout is preferable. If the scheme doesn’t get rolled out in the current government’s term, questions of accountability and fixation of responsibility may arise.
What is Antara Foundation’s focus area in healthcare? What is your vision for public health in India?
Antara Foundation’s focus is on bringing the know-how of scaling up public health delivery, working in partnership with government. The foundation currently works on Maternal and Child Health and Nutrition in Rajasthan.
My vision is for all elements of a good healthcare system to be well on track in five years. To recap, these elements are adequate spending, sound policies, visionary programmes, adequate facilities down to the lowest rung, well trained and effective frontline workers, dynamic public-private partnerships and an active, empowered community demanding public health services. Would also want to see spending increase, in real terms, from the next budget.
You have worked with the Gates Foundation, what are key strategies and models of healthcare delivery that you would like to replicate in India?
It was a privilege to lead the inception and growth of the Gates Foundation in India. Establishing a model of delivery at scale through the HIV prevention programme, Avahan, and knowing to spend money effectively was a great learning experience.
Elements necessary to build a model of scaled delivery are threefold:
- Supply – Enhancing effectiveness of frontline health workers through use of data and technology
- Demand – Nurturing active, empowered communities who demand public health services
- Enabling ecosystem – Working with government and ensuring effective data-voice i.e. backing influential voices and channels with fool-proof data.