Binit Agrawal speaks with journalist Vidya Krishnan
in an exclusive interview for LSPR.
Vidya Krishnan is a New Delhi-based journalist with 16 years of experience in covering public health in India. She has worked with the Indian health ministry’s think tank, Public Health Foundation of India, which supports government’s decision making with research to ensure evidence-based policy making in the country. While working with PHFI, she also wrote for Mint. In 2013, she authored India’s National Health Profile for the India office of the World Health Organization. Previously, she covered public health for national dailies like The Indian Express, The Hindustan Times and The Hindu. She also contributes to the British Medical Journal and the Caravan magazine.
In this exclusive interview, LSPR asked Ms. Krishnan a series of questions ranging from the state of public health in India to the Ayushman Bharat Policy, and from child malnutrition to innovations in the health care sector.
LSPR: India has shown a continuous decline in its access to healthcare rankings. It is ranked 145 in a list of 190 countries. It has failed to improve its healthcare budget, and there has been negligible improvement in the healthcare infrastructure in the last many years. Why has healthcare not kept pace with economic growth? Is there a lack of political will to invest in healthcare?
Vidya Krishnan: To understand why our health system is the way it is right now, we have to look at historical reasons. Our founding fathers put great impetus on industrialization, self-sufficiency, and agriculture- which is why we heard sentences like ‘dams are the temples of modern India’ from the likes of Jawaharlal Nehru.
In contrast, the health sector, did not get championed in the same way. In fact, we did not have a national health policy until 1983. Our entire focus until that time was on responses to widespread health emergencies, like the campaigns to eradicate polio and leprosy. Thus, there was no policy inducement to invest in healthcare infrastructure.
Around 1978, India became a signatory to the World Health Organization’s Alma-Ata Declaration. This declaration required the signatories to have Health for All by the year 2000. That’s how we got our first national health policy in 1983. While trying to implement this policy, the government realized that our population was too big to be served solely by public health care units, and hence, they for the first time allowed setting up of commercial private hospitals. However, the government failed to draft necessary rules to regulate and standardize these hospitals. It is because of this lack of protocols that we hear cases of patients with the same disease being treated differently in different hospitals. Medicine has to be the same, whether the patient is rich or poor, urban or rural should not have a bearing on how an ailment is treated. That doesn’t happen in India. The private sector, has grown rapidly and now is a powerful lobby within the healthcare sector. This lobby has tried to ensure that policies like the Clinical Establishment Act remain unimplemented.
LSPR: Lately, India’s healthcare sector has attracted a steady stream of investment, and the industry has been growing at an unprecedented rate. Albeit, these investments are almost entirely concentrated at the higher end of the value chain, catering mostly to the rich. Do you feel entrepreneurship and innovation in the healthcare industry can improve access to healthcare? Is efficient and affordable private healthcare for the underprivileged possible? If yes, what shape can it take?
Vidya Krishnan: One of the best ways to improve innovation in the health sector is to increase funding for universities and research centers, which are the hotbeds of healthcare innovation in the country. Often great solutions and ideas emerge in these academic settings. However, the moment these ideas achieve scalability and commercial feasibility, they somehow move out of public hands into those of private investors. There is a complete absence of any returns to the public from such successful innovations. This needs to change and the academic institutions need to be made transparent and responsible to the public at large.
On the question of affordable healthcare coming from the private sector, I don’t think that is going to happen. Healthcare is completely different from other sectors. Free market forces do not act in a manner they would, say, in a market of consumer goods. Price efficiency in the market is a result of competitive forces coupled with a smooth flow of information. For example, if lots of people are making refrigerators, the prices will come down- due to increase in competition.
This doesn’t happen in the health sector. There is a strong ‘information asymmetry’ and no matter how well-read the patient is, she cannot tell whether a 500 mg Crocin or a 300 mg tablet will help her. She is completely dependent on her doctor – who is incentivised to sell her expensive medicines, over diagnose and over treat.
Furthermore, there is a moral component to this decision. I can haggle over the price of a refrigerator or wait for discounts to come by. I can’t do that when my family is in a hospital, in need of immediate attention. Families have no control over the decisions doctors take, but they bear the full price of it. The doctor-patient relationship is inherently unequal. So the patient relies on a government-funded setup to protect her rights. Government funded healthcare systems are foundations on which healthcare can be made accessible, affordable, and effective. This is what makes health, which is actually about an individual, public. Hence, I don’t think the private sector can be our answer to provide universal healthcare. Having said that, we cannot work without the private sector- given the scale of our country. A strong public healthcare setup, aided by well regulated private service providers is what we need in order to achieve our aim. This is not what is happening currently and the only way to make this happen is by promoting citizen awareness. The public must pressurize the government to bring about strong laws to govern healthcare, vote on the basis of health policy and elect political parties that will invest money in government healthcare. The elite will not care about the health sector until they have a stake in it. And it’s not like that the elite have it much better currently. In
a malfunctioning healthcare sector, we regularly read horrific stories about the rich and insured being killed by over treatment, while the poor being killed by under treatment
LSPR: India has an abysmal health insurance penetration rate of 20%. It is to correct this anomaly that the Modi government has come out with the Ayushman Bharat policy. But many analysts say that the policy is half baked and irrational. One of the most important criticisms is that a developing country should invest more in public healthcare instead of spending on insurance schemes, as they channel money to private players. What are your views on Ayushman Bharat? Do you feel that it has a high opportunity cost?
Vidya Krishnan: I am not a big fan of Ayushman Bharat, simply because it is a reinvention of a broken wheel. India has had government-sponsored health insurance schemes for quite some time now. We have had such schemes at the national level, at state levels, and the insurance sector is fragmented, and overlapping.
Moreover, the Ayushman Bharat policy is extremely exclusionary. It has conditions like if you have a fridge or a landline you are not entitled to it. A good majority of the people who need the support of the scheme are thus left out of it. Secondly, you need not be living in poverty to be entitled to affordable healthcare. I am part of the middle class, but god-forbid, if someone in my family is affected by a chronic disease like Cancer, the costs of the treatment can easily push my entire family into poverty. This happens in a large number of cases. Thus, Right to Health cannot be dependent on you being part of the poorest strata of the country. It is a universal right, and everyone is entitled to it. Ayushman Bharat doesn’t follow this principle. Thirdly, the scheme is designed to channel patients to the private sector. The Private sector, as I have mentioned, is unregulated and lacks standardized care. India’s current TB epidemic is fanned by private doctors : one gives different antibiotic; second doctor does something else, and before we know it the patient is drug resistant- and infecting more people. This affects not just the poor but also the rich. This can only be resolved when there is a uniform public healthcare framework, providing standardized and high-quality healthcare. Ayushman Bharat is completely contrary to this idea. The vision of the policy is that the government will only be active in running programmes like vaccination drives, while the private sector will be the actual health care provider. I don’t see how universal healthcare can be achieved by continued channeling of taxpayer’s money into an unregulated and confused private health sector.
LSPR: Many analysts say that a large share of responsibility for our malfunctioning healthcare system goes to its inefficiencies and misplaced priorities. They say one of the most important reasons behind this is the lack of a robust data collection and analysis system. Most people are unaware of the role data can play in creating a good healthcare setup. Why is it important? What are some of the steps needed to be taken to improve our healthcare data collection and analysis setup? How will it contribute to our healthcare system?
Vidya Krishnan: Data is the foundation on which good policy solutions are built, and increasingly, the world is moving towards a system of evidence-based policy measures. In India, we follow a system of anecdote-based policy measures. While I would not say our priorities are entirely misplaced or that we lack a good data collection system, what is problematic is how this data is used in policymaking. Our current government looks at data as bad news-as something which needs to be hidden from the public. This is dangerous and routinely leads to diseases spreading because we don’t trust citizens with information.
The most recent case was the 2018 Zika outbreak in Gujarat. The Modi government refused to share data when the outbreak happened. This put the people, and doctors, of an entire district in danger. Finally, six months later, the data came from a report by the World Health Organisation. In fact, the government lied about it in parliament, which meant the Members of Parliament and other key representatives too remained uninformed about the extent of the urgency as well. Thus, even though we have good data and determined priorities, our politicians choose to fly blind. This is a result of politics which is not meant to serve the public but to get into and to stay in power.
LSPR: India also suffers from a severe shortage of doctors. There is only 1 doctor per 1700 people, which is much lower than the WHO’s recommended 1 doctor per 1000 people. Even when doctors are available, it is often found that they are ill-trained and lack necessary skills. While increasing the number of qualified doctors is a long term project, many have suggested investing more in training paramedics for short term relief. It is argued that para-medics are well placed to provide affordable and immediate healthcare for minor and general ailments. Is there any substance to this argument? How do you think the next government can ensure better availability of healthcare personnel? What are some of the necessary steps needed to ensure we improve the number of doctors in the country?
Vidya Krishnan: Giving paramedics a crash-course in order to meet the shortage of doctors is a bad idea. We have few doctors, and they too are concentrated in the urban areas. The doctors, who have spent quite a lot of money to get their degrees, don’t want to live in villages, because of reasons like their kids don’t get good schooling there, their spouses can’t find employment etc. The government has tried to incentivize them to work in rural areas but we can’t expect doctors to move to villages unless villages have the infrastructure- roads, schools, safety etc- that will be conducive for them.
These are complicated social issues which require an informed debate. According to me, it is perpetuating a system of medical apartheid – where poor have it worse in every way. It would mean, that we as a country, have a policy of rich, urban patients having access to qualified doctors while poor, rural patients made do with half-baked doctors.
Many doctors themselves are empathetic to problems paramedics face. In India, doctors are the Brahmins of the health sector. They are higher than other allied health service staff- paramedics, nurses, lab technicians etc. Our health system revolves around the doctor- every small and big decision has to be taken by the him or her and there is hardly any delegation to subordinates.
LSPR: India is home to 31% of all the stunted children and half of all wasted children across the globe. The main culprit behind this is malnutrition. What are some of your suggestions on curbing malnutrition, especially that of newborns?
Vidya Krishnan: As a journalist my craft is to report events, not draft policies. However, this is an issue I’ve spent considerable time reporting on. It would help if we do not mix up religion in the policies addressing child health. With the rise of Hindu nationalism in many states, we see governments regulating access to eggs in mid day meal schemes. They are an affordable source of nutrition. Also, so far, Anganwadi centres across rural India, give pregnant and lactating mothers take-home rations — as supplementary nutrition, which is critical for reducing child and maternal mortality, child malnutrition, and stunted growth. However, Union Women and Child Development (WCD) Minister Maneka Gandhi sought to replace these take-home rations with energy-dense, factory-made nutrient packets. This policy will be harmful in the long term because factory-made nutrient packets are never as wholesome as fresh, hot cooked meals. This policy is driven by the interests of profit-seeking private contractors and not by what is in the best interest of women and children.
We cannot improve under-five mortality without improving maternal health. You cannot care for the dietary needs of individual women in Kashmir or in Kanyakumari by granting contracts for what they are going to be fed in Delhi.
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