Kenneth E Thorpe, a public health expert, talks about non-communicable diseases, universal healthcare and how health insurance will lower costs
Dr Kenneth E Thorpe, a professor of health policy and management at Emory University in the US and also the chairman of Partnership to Fight Chronic Diseases (PFCD), says that the government alone cannot do everything. “They don’t have the resources and capacity. So we have to find ways to engage private sector,” Dr Thorpe told Governance Now during his visit to India where he met NITI Aayog officials over public-private partnership in health care sector.
India is having double-disease burden – malnutrition and Non-Communicable Diseases (NCDs). How do you look at the current situation?
I see income, NCDs and nutrition linked because NCDs not only have health impact but productivity and work impact. It is one of the leading reasons why people are in poverty because they have cancer, tuberculosis or some type of health condition that prohibits work. By solving NCDs problems, we do a couple of things like keeping population healthy. It takes some of the heath care cost burden of the economy and it also increases productivity. What finance minister and others are doing is projecting economic growth, where India wants to be in global economy. It is very difficult to get there until you have productive, healthy workforce.
Where are we lacking in finding a solution to the problem?
Lacking is poor investment on health care. You cannot spend 1.1 per cent of the GDP on the health care and think that you can address the magnitude of the problem that India has. One of the good things about the National Health Policy 2017 is that it plays out a growth plan of 2.5 percent of the GDP by 2025. We will have to find ways for the private sector investment. Right now we need four percent of the GDP to bring down the out-of-pocket expenditure. If you are going to deal with these issues of nutrition, reducing the burden of disease, treating disease, doing a better job of surveillance, probably by 2025 you will be able to see an overall growth of seven to eight percent GDP.
Considering the current scenario of public health care, do we have enough capacity to properly utilise 2.5 percent of the GDP?
That’s a part of the investment. One of the things we have been working upon is the options for building capacity and building infrastructure. It is possible if you get private sector to bring a robust health insurance system and a comprehensive primary care package. Those are the types of investments that will bring in revenue to establish primary care clinics. There are models of primary care clinics that already exist in India.
Private players are already there. They are unregulated and out-of-pocket (OOP) expenditure on health is high. Will it be possible to avail services at a minimal rate if we have PPP models?
The government alone cannot do everything. They don’t have the resources and capacity. So we have to find ways to engage the private sector. We have to start talking about the options that build more capacity, understand what the implementation issues are or regulatory infrastructure you need. Like the central government health plan has to be a compulsory plan and every state got to participate. Also, what could be the mechanism by which we get the additional private sector investment to cut OOP? It could be putting money into monthly subscription fees or health insurance premium. We need a discussion on public-private health financing. We need to figure out how to draw the public-private partnership to get resources into the system to build infrastructure and the capacity you need to treat, survey, measure and monitor patients.
How can we bring down OOP expenditure?
Obviously, if we have insurance it will bring down the expenditure. In Indonesia, it is mandatory for everyone to have a health insurance. Since everyone has it, it creates a market for the health insurance companies. It’s true that currently there are isolated insurance schemes in India. If you have a compulsory insurance system then there needs to be a clear strategy on what kind of regulatory mechanism will be in place, what are the essential health benefits it will provide and rules for insurance companies as to what amount they can charge from people. There is a whole bunch of issues that arise to look at financing options.
Is insurance the only way to provide universal health care to all?
I would start out by saying focus on the direct comprehensive primary care. That probably provides 80 percent of the health care needs. It’s a big challenge because you have got 70 percent of the Indian population having no form of health insurance. There has to be a key mechanism to give them health insurance. There are insurance schemes, but that cover only five to six percent of the population. If we go forward, India looks at health reform. Central government has made commitment to invest more.
There are some good models of primary care clinics in southern part of the country. There are subscription based model where you pay monthly fees based on your income. And then you get access to comprehensive set of primary care services as well as screening, detection and management of NCDs. It’s not insurance per se, but it is giving access to certain set of services that people are entitled to. Look at other models globally that could be adopted but at the same time it has to be an Indian solution.
There are plans to convert district hospitals into medical colleges or to hand them over to private players? Is it feasible?
I think if we are doing public-private partnership, then there has to be some rules in the game. There’s got to be some type of expectation about services being provided and how they will be provided. So, I think rules which government facilities operate under and the expectations they have, private sector needs to have similar set of rules and accountability.
What is the difference you notice between India and other countries in terms of prevalence of NCDs?
India has same NCDs issues that you see in other countries. It’s a growing problem. The share of adults having NCDs is rising. From what we know in terms of numbers, a large number of people die because of hypertension, at least 80 million that is probably understated. If you don’t have policy directing the course then the problem will be worst, creating burden on existing resources.
Tell us about the national blueprint prepared by the Partnership to Fight Chronic Diseases (PFCD)?
To deal with health issues, we need to talk about financing, infrastructure in terms of physical and manpower available, facilities, a better surveillance and measurement system, and basic data/profile of the patient because we don’t have apt data. We talked to working groups in each of these areas. They came up with the recommendations. We have been working with the ministry of health, holding meetings with the officials and discussing those recommendations. We are very pleased with the new focus on NCDs. When we started working with the ministry, there was hardly any focus on the NCDs.