India is going through a tough challenge of facing illness burden emanating from communicable illnesses and growing burden from NCDs. Our health system today is focused on communicable illnesses and not that much on NCDs. India needs to take a view on health systems and how effectively they use various modulators of financing, regulation, technology, communities, PPP etc. Government needs to focus on basic package of health services which is available to everyone and then use insurance mechanism for NCDs. We also need to make sure that people are protected from catastrophic financial burden arising out of acute and chronic illnesses. This can be dome by properly developing insurance and not the way it is done today.  

Dear Ramesh Bhat

Sincere thanks for your intelligent opinion.

Regards

You will find some of the reasons why in this WHO publication on how health systems may be assessed. India's problem is a small health budget and a very large population with limited infrastructure. Unfortunately you cannot make one thing better while leaving everything else the same. Complex problems require complex solutions.

Thanks Dear Deon.

The major problem in health care management is how to approach the problem . Health care consists of preventive health & health care which includes primary , secondary & tertiary care . Preventive care consists of availability of safe drinking water , indoor toilets , good sanitation , hand wash & control of mosquitoes . The primary care is detection of both Infectious diseases & non communicable diseases & outpatient treatment of these diseases , including immunization of children & ante natal care of pregnant women which can be done by primary care centers . Secondary care is admission in taluk & district hospitals of common diseases . Tertiary care is providing high technology care in urban teaching medical college hospitals . Private sector plays a major role in secondary & tertiary care .

    The above facilities need trained manpower , such as doctors , nurses & trained technicians in adequate & large numbers . This needs opening a large number of medical & nursing colleges through out the country . These trained man power have to work in primary , secondary & tertiary care institutes , as they are the tools to provide a comprehensive health care .

 In India , the majority of the population belong to the poor & lower middle class & need the support of the public sector Institutions . It is essential for the government ( central & state ) to take care of this population by funding the public sector Institutions in both urban & rural areas & concentrate on preventive health , primary & secondary care . The rich & the upper middle class can utilize the private sector through health insurance .

  The evidence that health care has improved should be assessed by IMR , MMR & Life expectancy data . MDG's & the recent SDG's goals have also given guidelines on how to improve health care .

Dear Singh

Thanks. You have provided a very good description of the things related to health care.

Sir, the major problem, in India is that the government is receding badly from health care system. In the North India, where do I reside, the government system is both insufficient and incapable of delivering the desired outcomes. Things are mostly left to the private doctors, clinics and mushrooming nursing centres claiming to provide a panacea. They are a damnly con and costly and a poor can never afford them. Most of the rural and low-end population segments are left to nothing like a worthwhile health care. Now, the government seems to take resort to an insurance based system. 

I am puzzled whether the insurance based system caters to the poor and whether it reaches the poor. In a system where there is a clear demarcation between the rich and poor market segments, how to provide a universally available quality care is a problem that begs feasible answers.

With regards

Dear Khan , 

  I agree with you that the state is retreating from providing health care to poor people . It is the responsibility of both the central & state governments to provide health care & there is wide variations between states . In Tamilnadu , the health care is good ,as the government plays an important role by opening more medical colleges & improving the rural & urban medical infrastructure . It also utilizes the National Health Mission funds . There has been a significant reduction in MMR & IMR in the state . A state health insurance system is utilized only for government Institutions for poor patients . The state of Kerala also has very good indices of heath care . It is essential for other state governments to invest heavily in health care . The recent epidemic of Dengue in Delhi has highlighted the role of the state in health care 

Dear Mohammad, I am not familiar with Indian health system. But my ideas would probably be of some interest for you.

In principle, people want to become healthy and to do it at the lowest possible cost. But there exists asymmetric information between doctor and patient. Also doctors have their own economic incentive: it depends on payment system.

In the former USSR there was a doctor (therapist) serving certain area. Visits were free for patients and doctor got fixed salary. That is why there were queues. Still doctor (if he was smart) had an incentive to make patient healthy as soon as possible (because then he will not come again). If somebody died, then he will also not come again. So queuing was bad for terminally sick patients but was good for not too sick (because doctors had incentive to make them healthy if possible).

In EU the system is different. Doctors receive payment from social insurance (patient typically pays a small fraction of it, contrary to the USA). In Austria the salary of doctor depends on how many people visited the doctor during 3 months. So a specialist has an incentive to have more chronic patients.Transition to pure healthy state or to death is both bad. Then a patient is often locked in visiting narrow specialist, but nobody observes what happens in his other organs. If he will want to visit all narrow specialists, probably there is no time for that and also high cost for social security.

I do not know to what extent India uses Eastern medicine (with chakras, general view on health). I also heard that somewhere doctors get salary for healthy patients, so there is an incentive to treat quickly and well.

Dear Yuri Yegorov , 

 In India , doctors work both in the public & private Institutions . Doctors , who work in public Institutions are given a salary based on their seniority & pension benefits & work in primary , secondary & tertiary centers in both urban & rural areas . These doctors can also work in private Institutions after completing their daily work in public sector Institutions in the evenings .

  Many doctors work in private Institutions & collect their fees directly from patients & also through insurance from rich patients . But , as I mentioned in my previous discussions , there is a shortage of doctors in both urban & rural areas , which is responsible for poor health indices .

  We also have medical professional from other native branches , such as AYUSH ( Ayurveda , Yoga & naturopathy , Unani , Siddha & Homeopathy ) who participate in health care .

Dear Singh,

when there is shortage of doctors, quality of their service is a secondary question. But right incentives for doctors becomes an important issue in more developed economies. Good that you also have traditional medicine. In some cases it may help more. But why then India does not teach sufficient number of doctors?

Dear Yuri Yegorov ,

  India has 29 states & 7 union territories & each state has its own policies . In some states , the health care is very good in the primary & secondary care sectors . This is because the local governments have invested heavily in health sector . The state of Tamilnadu , where I have worked has done an excellent job in health care , in addition to the private sector . In addition , the central government has given funds through the National Health Mission to improve health care . 

   I agree with you that more doctors must be produced & trained . This can be done by opening more medical colleges by the states . A lot more steps are needed to improve the health care in India , but this appears to be a global problem also , which has become very expensive. There are also small middle income  nations which have invested heavily in primary care with excellent results .