Two articles that I read recently poignantly capture the challenges of establishing universal healthcare coverage in India, especially for India’s 26 million new or expectant mothers. One was about Lankatai Kharat, a 38-year-old woman pregnant with her 17th child, who birthed 16 babies at home, instead of visiting a primary health centre or hospital. A rag-picking family from Beed in Maharashtra, the Kharats are among India’s most marginalised. Out-of-pocket healthcare expenditures are not an option and even government subsidised healthcare is almost out of reach. The local authorities and civil society workers had a tough time convincing Lankatai to get medical help for the 17th child.
The other article was based on the last National Family Health Survey (NFHS 4 held in 2015-16) to show that only one in six pregnant women received the full package of antenatal care—regular check-ups, a tetanus shot and essential nutrients. Why? Because nearly a quarter of the respondents felt healthcare was ‘too costly’.
These are just two among dozens of articles that highlight the gaps in the health system. Clearly, India is far from achieving its goals for universal health coverage, and more so when it comes to reproductive healthcare services for women.
Making pregnancy and childbirth safer for Indian women, especially in non-metro and rural communities, is a gargantuan task. It is made exponentially more complex because India’s healthcare ecosystem is a mosaic of tiers, models, and regulated and unregulated service providers. There are primary, secondary and tertiary healthcare facilities, run by state authorities, for-profit private players, and charitable institutions. Moreover, while health is a state mandate, it is also covered by the Union ministry of health and family welfare.
In India’s seven decades of independence, this complex web has managed to drive health coverage and improve accessibility but, somewhere along the way, we have fallen short in terms of affordability and quality. Non-subsidised healthcare is expensive, there’s no gainsaying that. Data shows that as much as 70-75% of households in India incur heavy healthcare costs as out-of-pocket expenses (OOPE). For pregnancies, complicated deliveries or neonatal complications can drive up healthcare costs unforeseeably. High OOPE is a factor that stresses household finances to the extent that it can push households below the poverty line. Between Ayushman Bharat (National Health Protection Scheme) and private health insurance, there is a safety net, but it is partial at best, leaving most households uncovered. The Janani Suraksha Yojana is a government scheme for maternity care, but it is mostly restricted to public hospitals and leaves the private sector uncovered.
Affordability is perhaps the biggest stumbling block in India’s effort towards universal maternal healthcare. The rise in private healthcare facilities has improved access to maternity care, but also led to an escalation in healthcare costs. And yet, despite patients paying out more in terms of OOPE, India is yet to see a corresponding improvement in maternal health indicators.
The second biggest challenge to universal healthcare lies in ensuring quality of service delivery vis-a-vis maternal health. Although India’s healthcare landscape has seen advances in quality in urban health settings, the same cannot be said to be true for facilities in peri-urban and rural areas, whether private or public.
The solution perhaps lies in what the World Health Organisation terms as strategic purchasing—a model that calls for alignment of public and private sector healthcare service providers that is based on assurance of quality of care.
Quality assurance is the core of India’s health challenge. India’s complex health ecosystem lacks adequate quality certification initiatives. The country’s myriad private healthcare facilities are not anchored by a strong regulatory framework that can assure a mother that she will receive quality medical care before and during childbirth. The National Accreditation Board for Hospitals & Healthcare Providers (NABH) provides certification and training for private hospitals, but leaves a vast cadre of urban clinics and centres and a majority of rural facilities out of its scope.
Moreover, it looks at hospital management aspects and not clinical standards. There is a clear need for standardising clinical practices for maternal care in private facilities, which account for half the babies born under institutional care. Could this lack of standardisation in service delivery be the prime reason for India’s poor showing in maternal and neonatal indicators?
The answer may lie in enabling greater private sector participation in this essential aspect of healthcare. An example of this is the Manyata—a national quality improvement and certification programme that is administered by the Federation of Obstetric and Gynecological Societies of India (FOGSI).
There are multiple advantages of a third-party quality certification that recognises private maternity providers for meeting national quality standards in maternity care. It will complement the reach of government accreditations such as NABH and improve compliance in a larger pool of service providers. It will also spark an increase in capability building. Not all of India’s currently working health professionals are adequately trained. Within maternal care, of the 26 million births India witnesses annually, only 43% are supported by skilled staff—which puts at risk over half of India’s mothers and newborns. Accreditation could drive a higher level of service delivery as healthcare facilities give greater importance to regular training.
Accreditation will help address financial constraints such as OOPE. Insurance providers will be more amenable to link with smaller clinics and centres that are accredited to demonstrate quality of care, thus enabling greater insurance coverage.
Third-party certification will also provide a boost to private providers, who can be encouraged to enrol for accreditation through cash incentives from private insurers or the government. The return on investment on this will be high—in terms of patient safety and quality of care.
Improving our medical accreditation models could have a tremendous benefit—making the healthcare system, including the government, public and private providers, and healthcare insurers, accountable in ensuring accessibility, affordability and quality to the retail consumer.
India’s healthcare ecosystem thrives on successful public-private partnerships. While the goal of universal health coverage is still distant, there is hope that we are headed in the right direction. Data shows that maternal mortality ratio has dropped 22% in the last five years and that, unlike Lankatai’s example, as much as 78% of babies were born under institutional care. We have managed to build a vast canopy for healthcare. What is needed now is to ensure that the canopy assures quality healthcare services to everyone, and that the cost is not too high for anyone.