Profit and Charity in Healthcare: Universal Healthcare is a Right

1. Human rights are universal rights of all human beings, regardless of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.
2. The right to health and other health-related human rights are legally binding commitments enshrined in international human rights instruments. WHO’s Constitution also recognizes the right to health.
3. Every human being has the right to the highest attainable standard of physical and mental health. Countries have a legal obligation to develop and implement legislation and policies that guarantee universal access to quality health services and address the root causes of health disparities, including poverty, stigma and discrimination.
4. The right to health is indivisible from other human rights, including the rights to education, participation, food, housing, work and information.
5. Universal health coverage (UHC) grounded in primary health care helps countries realize the right to health by ensuring all people have affordable, equitable access to health services. 

Read sentences above carefully and examine every word mentioned in them 

WHO Site Sentence	Reality of India
Human rights are universal rights of all human beings, regardless of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.	This is only on paper. The disparity of rights across nations, races, sexes and geographical regions is stark and glaring and the situation in India is even worse than other nations. The difference between Kerela and Bihar can illustrate this in the most obvious manner.
The right to health and other health-related human rights are legally binding commitments enshrined in international human rights instruments. WHO’s Constitution also recognizes the right to health.	India is a signatory  to the WHO Constitution and legally obliged to provide the same. Article 21 talks of the Right to Life and liberty so health is a part of that right. Although even preindependence the Bhore comitee created a structure integrating preventive and curative healthcare with decentralisation. Primary Health center for population of 40,000 with a network of referral hospital, District Hospital and State Hospital units was suggested. The reality today is that more than 70% population spend out of pocket for healthcare from private sector which has uneven geographical spread.
Every human being has the right to the highest attainable standard of physical and mental health. Countries have a legal obligation to develop and implement legislation and policies that guarantee universal access to quality health services and address the root causes of health disparities, including poverty, stigma and discrimination. The right to health is indivisible from other human rights, including the rights to education, participation, food, housing, work and information.	The framework for this in the form laws is present but there is no implementation of the same as the resources allocated for this are less than 2% of the GDP of India. Right to Education, food, housing and employment have received scant attention as the Governments in the history of India have abysmal records in this context. In the present scenario whrere healthcare has become complex and expensive even the US and UK fail to reach this committment. However, basic primary healthcare coupled with the other rights to education, food, housing, electricity and drinking water are still not universally given. All of these are a work in progress.
Universal health coverage (UHC) grounded in primary health care helps countries realize the right to health by ensuring all people have affordable, equitable access to health services.	This is what we can realistically aim for and achieve even today. The Government in collaboration with the other two stakeholders the Private charitable trust hospitals and Private for Profit hospitals can achieve this if all work together.

 

The three ingredients to provide UHC are Human Resources, Financial outlay, Infrastructure backed by Tehnology all governed by a Legal framework.

The support for the same comes from basic food, water, sanitation, housing, education and employment.

The question is that despite a relatively early start ( pre-ndependence) we are worse off than the West, Sout east Asia and even our neighbours like Bangladesh, Nepal, SriLanka and Pakistan.

Demand for Healthcare rights:

To address any problem with economic ramnifications we need to examine the demand and supply side of the equation. It is indeed my lament that the people of India do not really demand healthcare, education and BSP (Bijlee, Sadak, Paani) and never have I seen it become an emotive election issue for the poor. The way caste, religion and gender issues dominate elections, if only healthcare and education was even given 30-40% extra weightage then we would have incentivized our politicians to provide UHC. The expectations from the state are so low that non performance on these fronts have never cost politicians their seats even in local body elections. To that extent I would blame the people of India for this.

Supply of Health care:

Human Resource: India has a situation where it supplies to the world the best and most talented medical doctors and nurses to the Western and has a doctor population ratio of 1:834 and Nurse population ratio of 2.06:1000. The doctor ratios are better than WHO norm of 1:1000 and nurses are less than WHO norm of 3:1000, but the problem in both the cases is of the uneven distribution as all these are more in the cities than villages and small towns. These data are also misleading as AYUSH (Ayurvedic, yoga, Naturopathy, Unani, Siddha and Homeopathy ) non-allopathic doctors and ASHA (Accredited Social Health Activist) workers are included in this calculation. This is clearly reflected in the quality human resource and Healthcare in India.

The medical training is not well standardized and the reserved quotas seem to allow persons who do not qualify on merit to become doctors. In addition the recent ruling where minimum criteria of 40th and 50th percentile have been relaxed to ensure all seats are fulled means even those who have failed miserably or even merely attempted to pass the common entrance can become doctors. Is there a solution? Yes we need to create more medical and nursing colleges  colleges but regulate them and compel them to make post graduates in more Family medicine specialists. The incentive to these institutions is guaranteed jobs and facilities in the geographical areas where healthcare facilities are scarce. Good pay and an assurance of help in providing quality education to the children of such parent doctors and nurses can mitigate the problem to a large extent. 

Financial Outlay Public and Private sector: India still spends 2.1% of it's GDP on health which is a  lot lower than a large number of countries. While pious statements are made every year, healthcare has never been a priority for the government of India and this is reflected in the choice of ministers and the importance given to public sector of health. 

The difference is glaring and since the graft is small this statistic is even worst when we know that 70 % of spending on health care is not free or covered by insurance. A major illness in the family can push persons on marginal incomes into poverty on account of spending, loss of work and travel for treatment as healthcare distribution by region is not equitable. The condition, facilities asnd medical care provided by our public hospitals is extremely poor barring a few exceptions.

Private healthcare accounts for about 60% of hospitals, with only 20% of beds and 80% of doctors. But this accounts for 70% of the services. While it is said that the quality of private healthcare is better, this is not entirely true as in public sector which is serviced by medical education institutions the presence of resident doctors help in providing better support to consultants and superior care in emergency situations. The tendency to over treat, over charge, over investigate leads to higher costs. This actually is not desirable and the middle class who are unwilling to go to the crowded public sector hospitals and cannot afford the best of private doctors and hospitals get trapped into a cycle of suboptimal care and expenses which push the lower middle class fixed income families into a cycle of poverty. 

In the private sector there are three kinds of players, private corporate for profit players, charitable trust hospitals who are charitable in name but actually for profit only trying to use the charitable tag to get concessions from government and the NGO and private charitable hospitals ready to do genuine charity. 

Despite the public health care being virtually free the hospitalizations in private sector is between 60-70% compared to the 30-40% share in public sector hospitals. The Government's failure to spend on public healthcare and unwillingness to incentivize doctors and nurses adequately has given the private players this open field. Nonregulation leads to private players distorting the prices and increasing the cost of treatment The middle class are left with little choice but to spend more to save their lives. In the private sector the for profit hospitals and the charitable in name trust hospitals share a larger proportion of this blame. The Government in it's health polict advocates public private partnership models but even this they are trying to regulate prices rather than quality of care. Public sector government health scheme and National and state free insurance schemes offer package rates which do not cover even basic hospital costs. On top of this the forced reservation of 20% of beds for indigent and weaker section patients, based on unrealistic criteria of family annual income of Rs.1,80,000/- being eligible for free treatment and an annual income of Rs.3,60,000/- being eligible for 50% discount on treatment. Many of these certificates are fake and this leads to misuse of this facility. Politicians and middlemen encourage and help persons get these fake proof and indulge in corruption. 

The false propaganda that charitable trust hospitals have received major subsidies creates a feeling of mistrust among the people and leads to a climate of discontent among the people and genuine charitable trust hospitals. Subsidies on Electricity, water, fire compliance and pollution norms compliance will be of enormous value to make healthcare sustainable for genuine charity hospitals. The pricing of healthcare packages should be based on actual costs based on moderate to high quality standards rather than arbitrary pricing which characterize the Ayushyaman Bharat Insurance schemes. These are unviable and hospitals availing of these compromise on quality of care. Government must offer subsidies and make realistic pricing policy and help genuine private charitable hospitals and prevent them from becoming unviable and getting picked up by corporate for profit giant hospital chains

 Leveraging Technology: Digital Hospitals:

The concept of the digital hospital of the future is an utopian state wherein it is linked to wearable devices of users and is constantly monitoring the state of health of it's customer. It ensures medicines are taken on time and dose of medicine is automatically adjusted to the status of the monitored parameters. Preventive maintenance in the form of monitoring vital parameters and measuring levels of all measurable risk factors is done in customized packages. This to me makes Digital hospitals different from hospitals which practice medicine as we know as treating symptoms after they manifest. The new kind of hospital will anticipate risk and detect changes in health long before any symptoms manifest and action will be taken to prevent or minimize damage long before it affects the body. Home services, emergency tracking and door to needle golden hour will be automated. This is what is meant by making digital Hospitals compatible with Internet of Things or Internet of Medical Things (IoT or IoMT). 

 I think the Digital Hospitals of future have the potential to change the basic structure of hospitals, which may transform to service stations of the body for preventive maintenance and minor repairs. Minimally invasive day care procedures to remove or ablate pinpoint lesions before they grow will become the order of the day. Genetic labs will be used to detect high risk genes and modify or alter them to halt progressive disease. Rehabilitative medicine, physio and occupational therapy will be extensively offered on digital platforms with home gymnasiums being commonplace. Futuristic care will make large brick and mortar large hospitals relics of the past. Preventive healthcare and human body day care service repair and maintenance centers will be the hospitals of the future. 

Solutions:

• Improve spending on public sector to 5% of GDP.
• Medical and Nurse Education aligned with healthcare needs and incentivizing doctors and nurse to go rural areas. Create enough family medicine and surgery generalists and incentivize them to remain in India. Focus on quality nurse and support staff trained personnel.
• Provide subsidies to private genuine charitable hospitals.
• Pricing of healthcare based on real costs rather than notional costs.
• Invest in Preventive health and water, sanitation, clean fuels, clean air and cheap electricity along with healthy nutrition. 
• Technology for digital healthcare to create a preventine and preemptive intervention model of healthcare. 

Can we do this? Yes we can if we resolve to vote in elections parties which give emphasis to education, healthcare both preventive and curative.

Vispi Jokhi