By: Imran Shah
Foreigners recommending policies for the healthcare system of a country often run the risk of recommending policies that do not fit the context of the country. Recognising this risk, global health organisations like UNICEF have teams consisting of locals who can match the ‘global’ ideas to the ground. Indeed, how can ideas from developed countries be implemented in developing countries, even though excessive literature and statistical research has been done. However, while locals have the grasp of their context, this contextual knowledge can result in a lack of innovative policy recommendations. I posit that a foreigner can learn the healthcare system at a field level, and integrate his background knowledge of policies from his home country to draft interesting policy recommendations. This article will show my personal Singaporean attempt at studying and recommending policies for Mumbai’s primary healthcare system.
After studying the healthcare system in Mumbai through field trips, desk study and interviewing seasoned practitioners in the field, and drawing from my knowledge and experience of the Singapore health system, I decided to guide my policy recommendations with four principles.
The first principle is with regards to regulation. Many slum neighbourhoods have a whole range of medical practitioners from pharmacists to family physicians to AYUSH practitioners. However, many of these practitioners do not have the appropriate qualifications. AYUSH practitioners prescribe allopathic medicines and vice versa. Even among the specialties of practitioners, there are municipal ones, for-profit ones, trust-funded ones and those run by NGOs. There was no regulation of the different types of practitioners, which was evident by the lack of a directory of all the practitioners or any form of control by the state. Should we immediately work to regulate the primary care providers?
The lack of regulation mentioned above is unimaginable from the perspective of the Singaporean system, which is strictly regulated -I attribute the convenience of such regulation largely to Singapore’s small population of 5.4 million. Strict regulation means that practitioners are accountable to their patients through the records kept. Complains can be easily lodged and action taken against malpractice. Using the rule of law to enforce ethical medicine is also a policy tool used in India. However, the implementation of many of these policies ‘lack the teeth’ -as a Public Health Professor puts it. Mumbai has a population a lot larger than Singapore. The municipal corporation often has too much of other good work to do, rather than spend valuable manpower on regulating the sector.
Of course, regulating healthcare practitioners in Mumbai would be beneficial. However, I believe that harping on such an issue is not productive. Instead, why not look at the complex ecosystem of practitioners, that have grown out of a lack of regulation, as an attempt to meet the needs of the people? I do not mean that regulation should cease or be relaxed, but that we should realise that the disorganised nature of the system is what allows it to fulfil the varied needs of the people. Policy recommendations should appreciate this complexity by preserving the ecosystem as much as possible while putting in place measures to ensure safety.
The second principle is one that has already been adopted in many parts of India, even in some parts of Mumbai: public-private partnership. With the rise of capitalism, a system which encourages the growth of for-profit companies, governments across the world have seen many benefits in partnership with such private companies for provision of public needs. The profit-making objective pushes private providers to be efficient, which can the public health system can do with. Such partnership would be especially useful in the case of India which has numerous private medical facilities, some of which are first class. Medical tourism in India is reported to be as big as 3 billion USD, while public hospitals are overburdened with patients. This disparity in healthcare can be solved by efficient public-private partnership.
Public-private partnerships are useful because we can make use of already existing resources, in terms of private providers, to fulfil public needs. The alternative, which is resource intensive (and one that is challenging to efficiently provide in India), is to build more public providers to match the needs of the public. In fact, the rise of private providers, in some situations, is due to the public demand. In the slums of Mumbai, numerous private practitioners have sprung up. Patients from the slums visit both the municipal health centres and the private practitioners for different reasons. Hence, the state health department can engage these private practitioners for training them in the treatment and management of communicable diseases, data collection for slum populations and outreach to the slums. Such involvement by the state can encourage promotive and preventive healthcare which is often seen as non-profitable by private practitioners. Instead of using state resources to input more public providers, the resources are put to enhance the practice of the private providers in a way beneficial to society.
Indeed, partnership with traditional medicine at a national level greatly helped the authorities to reach out to numerous Indians who were seeking those treatments. Private healthcare also has potential to benefit the state departments. In fact, more than just outreach. Effective partnership should not be merely regulation of private providers by the state, but should also be in terms of guidelines, feedback and even funding.
The third principle is the use of economic mechanisms in drafting policies. One such use is realising that utilising private resources already available instead of expanding public resources for public provision of healthcare, which has been mentioned in discussing the first two principles.
Using economic mechanisms also means realising that simply outlawing unethical practices cannot be the solution because a black market will be created. An example is in terms of ‘cuts’ which family physicians receive from referring their patients to specialist physicians. Outlawing such unethical cuts would just result in those cuts being taken covertly. Instead, outlawing such cuts while implementing a referral fee on all referrals would put these payments on paper, discouraging illegal cuts while at the same time allowing the state to keep tabs on referrals. The state can then also track unnecessary referrals. Furthermore, such a policy acknowledges the private physician’s need to earn a decent salary, even though he/she practices in the slums. Understanding these economic mechanisms, so that we can deftly use them in policy making will evade the problems caused by capitalism which encourages profit-making regardless of ethics. Through utilising economic mechanisms in policies, the state can buffer such problems.
The last principle is in looking towards the future. India is progressing from a developing nation to a developed one. Health issues like infant mortality, vaccinations, malnutrition are becoming less of an issue in many states. The health indicators (infant mortality rates, maternal mortality rates, malnutrition rates etc.) are improving. State policies should continue in these areas. However, as India develops, she should also look towards diseases that come with development. These are long term illnesses like diabetes, hypertension and heart disease. These illnesses are usually a result of long-term uncontrolled conditions and/or family history, causes which can be effectively managed by good family medicine practised by primary care physicians (i.e. family physicians).
The role of the family physician needs to be realised better with the support of policies. One of the elements of good family practice is comprehensive care. Comprehensive care implies care that is long-term in terms of both social relationship and medical knowledge of the patient’s. In both these areas, policy can be designed to help physicians attain such a level of family practice.
The National Health Policy Draft (NHPD) 2015 suggests that ‘comprehensive primary care’ requires reliable and effective referral support with feedback and follow-up mechanisms. Comprehensive primary care requires more than just that. Social relationship with and medical knowledge of the patient can only be built when patients stick to the same family physician. Such a relationship between patient and physician is not beneficial to just the physician, but the patient also, since the relationship will make the physician more likely to make better treatment decisions for the patient and will safeguard the patient from long-term illnesses. In fact, policies which encourage effective family medicine can also help in terms of the currently managed healthcare issues (child and maternal health, communicable diseases etc.) because physicians have a relationship with their patients.
Effective family medicine can be practised only if physicians are able to benefit from it. Hence, the use of the third principle is useful. That patients visit the same physician regularly will occur when physicians are paid for such regular care. Rough systems like this are already in place in public healthcare providers, where patients pay a certain amount for physician care for a few days or weeks. Private physicians could be encouraged to set up such a system by the state. The state could even incentivise physicians who see the same patient for a considerable period.
These four principles are not bible-guidelines to stand by in policy making. In fact, the policy recommendations that I have drafted are not ready to be implemented. They still need to be discussed with the various stakeholders, especially practitioners in the field, to tweak them such that they are appropriate for Mumbai. However, using this four principles, I have illustrated how as a foreigner I have drafted innovative policy recommendations. These principles were simply thought up by myself as guidelines from my personal ideas, thoughts and beliefs. Hopefully sharing these principles might be of help in crafting innovative policies that prepare India, in terms of healthcare, for the exciting future which is in store for her.
 Phillips, W R, and D G Haynes. “The Domain of Family Practice: Scope, Role, and Function.” Family medicine 33.4 (2001): 273–277. Print.