INDIAS HEALTH SECTOR IS PRESENTLY in the middle of a radical transition, because the health of Indians is

changing. We live longer than we used to. In 1990, Indian men had an average life expectancy of 57.3 years; this
is now 64.2 years. Life expectancy for women jumped from 58.2 tears to 68.5 years in the same time. The
countrys disease patterns have changed dramatically in the past two decades, thanks in part to economic
progress and increased incomes. Infectious diseases such as leprosy, plague and tuberculosis are no longer
considered the countrys worst nightmares. Instead, India now fears a near-epidemic incidence of noncommunicable diseases such as diabetes, respiratory disorders and cardiovascular ailments.
Private health care adapted to Indias new demands with exceptional skill. Large hospitals across the country
found ways to cut down on bureaucracy; they instituted preventive health check-ups; most major hospital chains
aggressively sold affordable package deals, loyalty cards and memberships to their patients. In contrast, the
government sector has continued to struggle. Its condition is alarming because most people, especially in rural
India, rely solely on public medical care. This means that, far away from the plush environs of the medicities,
the most vulnerable people cannot get assistance for even their most fundamental health needs.
In November 2014, a state-run mass sterilisation camp in Chhattisgarh was responsible for the deaths or critical
health failures of nearly a hundred women, after it conducted laparoscopic tubectomies using infected
instruments. The patients were given drugs laced with rat poison, the surgeries were conducted at an abandoned
hospital without proper permission, and doctors chasing monetary incentives contingent on meeting certain
targets violated a government guideline that restricted the number of surgeries they could perform to thirty per
day.
The private sector emerged by default because of the governments chronic under-spending on health, Srinath
Reddy, the president of PHFI, told me. After the liberalisation of the economy, businessmen also managed to
secure financing from multiple sources for private-sector expansion. During this time, the government should
have strengthened medical colleges and district hospitals, but that did not happen.
When Trehan got up to speak at the CII conference in December, his message to the audience was clear: he
wanted the private sector to provide health care to people, and be reimbursed by the government. The national
health policy draft, that is currently up for public discussion, reiterates this vision. Indeed, its proposed division of
responsibilities is exactly what private health care lobbies such as the CIIs health committee have been pushing
for. Primary care in semi-urban and rural India, largely focusing on mass campaigns such as polio eradication,
will remain the governments responsibility. The government is also tasked with promoting traditional medicine,
yoga, and other preventive health practices. These are low-profitin many cases, non-profitservices.
Meanwhile, the private sector will take care of secondary and tertiary requirements, with the government paying
for insured patients. Over the next financial year, the BJP-led government is set to activate its National Health
Assurance Mission, an insurance scheme that will cover a set of essential medical services for all Indians. This is
in keeping with global trendsthe prolonged debate in the United States over the enactment of Obamacare to
regulate the cost and quality of health insurance is a case in point. When unveiling the NHAM scheme,
authorities claimed that they would integrate previously existing public insurance schemes into a single-payer
system. Programmes such as the Rashtriya Swasthya Bima Yojana, or RSBY, a cashless scheme that provides
coverage to families living below the poverty line, and other existing state-level schemes, will all be rolled into this
arrangement.
In the coming years, small and mid-sized hospitals will benefit greatly from the government purchasing care from
them through insurance schemes. Meanwhile, large hospitals such as Fortis and Medanta will continue to serve
the rich, who can afford their own health care. The result is likely to be a tiered system, in which the gulf in
between the quality of care at large hospitals and smaller ones will increase significantly.
Trehan is a firm backer of what is called the providerpayer split in this scenario. If the government increases
RSBY cover to R60,000 and gives R2 lakh floating cover per family, over 70 percent of the people who cannot
access health will be brought into the loop immediately, Trehan explained when we met again, in late January. I
have said it so many times, the government needs to work with the private sector. That is the only solution.
At the CII summit, Trehan claimed that the private sector already provided for 80 percent of Indias health care
needs, while the government covered only the remainder. At least thrice in his speech, he asserted that the
government contracted private-sector health-care providers at unreasonable rates. The current government
rates do not cover the cost of tertiary care per international standards, he said. Smaller hospitals, without
overheads of proper sanitation, staff and clean environment, take up the government empanelment.

Trehans argument overlooked the fact that the government has always offered heavy subsidies to private
hospitals when leasing out land, providing infrastructural services such as water and electricity, and other major
incentives, such as tax rebates. The Indraprastha Apollo Hospital was famously given fifteen acres of land in
Delhis Sarita Vihar for a grand total of Rs 1, in exchange for the hospital providing a generous amount of free
care to poorer patientsbut the conditions of the lease, it turned out, were subsequently repeatedly violated.
Public health activists pointed out the flaw in this arrangement. There is ample evidence to show that whenever
a health sector is heavily dependent on insurance, private hospitals deny services for many categories of
illnesses, and there is oversupply of some services, Amit Sengupta, an activist with the India chapter of the
Peoples Health Movement, an international non-profit network, told me. They resort to various fraudulent
measures, including charging informal payments. The overall cost-escalation of services is a routine feature.
Empirical evidence from around the world does show that wherever governments have outsourced public health
duties through insurance schemes, costs have risen.
Many of Trehans views on Indias looming health care crises are at odds with the opinions and experiences of
others in the field. Experts agree, for example, that one of the gravest symptoms of the situation is the severe
strain on human resources. The former health secretary Keshav Desiraju said that the shortage of doctors and
nurses was a huge, fundamental issue for the government. According to Indias 2013 national health profile, the
country has 381 medical colleges with a total of 43,576 seats for undergraduate medical degrees. But right now,
Desiraju said, only about thirty thousand students graduated in each class. Of these, he explained, some go
abroad to study further, some get into post-graduate courses in India, some we lose to the private sector, and the
remaining come into the public health system. Even among the young doctors who start work in government
hospitals as a last resort, the majority prefer to work in urban areas.
To Trehan, this is simply a problem of hospital standards, in which private hospitals come out ahead because
they manage their resources better. None of the private hospitals have increased costs in the past five years,
he told me. This was in spite of the fact that human capital costs more and more every day, and hospitals like
Medanta only hire the best. We survive because we maintain and constantly improve efficiency. Compare that to
the per-unit cost of running a government hospital. Include subsidies. And you will see that a surgery in a
government hospital is actually more expensive than in a private hospital.
Trehans calculation of resource efficiencies illustrates why the decay in public health service suits private
entrepreneurs. Sengupta, the public health activist, pointed out that the stability of medical costs in private
hospitals did not necessarily indicate their concern for the public interest. As the volume of patients seeking
medical attention from private hospitals increases, there is no need to raise rates in order to maintain profits.
This is already happening, he claimed. Additionally, there remains no way for the government to prevent moral
hazardto stop private enterprises from pursuing unnecessary investigations and procedures to boost
revenues.
In 2012, Trehan was appointed to head the Healthcare Sector Skill Council, which is funded by the National Skill
Development Council, a government body that finances vocational training initiatives. To many observers, this
was yet another indication of the CIIs growing influence over the health sectorand a sign that the concentration
of talent in private medical enterprises was set to intensify further. Over the last two years, there appears to have
been no government participation in the functioning of the HSSC. Desiraju said the health ministry frequently took
a backseat in situations like these, because it lacked the expertise to participate in any dialogue. In an ideal
situation, a think tank or an academic body should have done it, he said, of the HSSCs direction and agenda.
But we dont live in an ideal situation. The government should be setting the curriculum and minimal standards
required for training as health professionals. Unfortunately, staying away from this discussion is now not even a
carefully thought-out policy decision by the health ministry. It is just incompetence.
The government currently invests 1.3 percent of the GDP into health carepaltry by global standards, where
many of the worlds most industrialised nations allocate well over ten percent of their GDPs to health care, and
even some significantly poorer countries, including Bangladesh, often spend more of their GDP on health than
India does. The national health policy draft promises to raise the investment to 2.5 percent of GDP in the next five
yearsa move that would partly ease the strain on health ministry budgets. But the Modi governments recent
budget announcements have followed a well-established pattern of slashing funds for health care. When I asked
CK Mishra, an additional secretary at the ministry, where this money would come from, he replied, There is no
money. There is going to be no money. We are doing our best, given the circumstances. Days after the CII
summit, news broke that the government had ordered a cut of nearly 20 percent in its next annual healthcare
budget, due to fiscal strains.
Mishra was also a part of the CII conference at the Lalit, along with elected officials such as Mahesh Sharma, the
minister of tourism, and Shripad Naik, the newly appointed minister of AYUSH, the department of Ayurveda, yoga
and naturopathy, Unani, siddha and homeopathy. To Sharma, Trehan suggested that the Incredible India

campaign, which promotes India to international tourists, could advertise medical tourism as one of the countrys
many attractions. If medical visas were made more readily available, and if the government reached out a little
more to private entrepreneurs, he said, they would all be ready in short order to conquer the next waiting markets
the SAARC and African countries.
Trehan had set the context for the conference at the outset by getting on stage and pointing out that no country
has yet been successful in really providing care for all. With Naik in the audience, Trehan launched into a welloiled performance. We know that the private sector is painted today as money-hungry, cutting corners, too
expensive, he said. But there were certain truths that the media simply did not understand.
There are some issues on our side but they are minor, he went on. The major issues are on the governments
side. The private sector wanted to participate in the growth of India. The countrys people are suffering, and we
need to surmount this issue. Trehans tone turned beseeching as he faced the governments representatives in
the room: Work with us.
- See more at: http://www.caravanmagazine.in/reportage/naresh-trehan-medanta-private-practice?
page=0,11#sthash.Zb2cmA4H.dpuf