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Welcome to our interview series featuring changemakers across Asia, where we delve into policy and change processes that are shaping the region.
In this edition, Annapoorna Ravichander, talks to Dr. K. Sujatha Rao, a civil servant in the Indian Government for 36 years and retired in December 2010 from the post of Union Health Secretary. Since then, she has been engaged with policy work as a member of various committees and on the Boards of several non-profit organisations. And in 2017, she wrote the book “Do We Care? India’s Health System”, published by the Oxford University Press.
In this interview, Dr Sujatha Rao discusses the challenges of working in health policy, the use of evidence in developing India’s HIV AIDS strategy, lessons learned from the COVID-19 pandemic in India, and the ambitious Ayushman Bharat initiative that is helping more Indians to access affordable quality healthcare.
Question: As a Union Health Secretary what were the challenges you faced and how did you overcome them?
Health Secretary, be it at the state or federal level, is one of the most challenging posts.
Even though health is very political, with high stakes, it does not receive the political attention that it deserves.
Reforms in the health sector nearly always invite sharp reactions from those affected, which then requires very sustained political support to push through. Such support has been lacking, except in some internationally driven priority areas such as polio eradication and HIV AIDS control.
Lack of political attention also implies lower funding, which is not commensurate to the needs.
So, we have a health system that has examples of internationally comparable excellent quality of care, but also the worst; an advanced private corporate sector co-existing with untrained medical practitioners in an overcrowded, understaffed public sector.
We have not been able to achieve the right balance between privately provided and public sector care, and that is resulting in high out-of-pocket expenditure and consequent impoverishment.
The challenges, after all these years, continues to be ensuring universal access to affordable care of a reasonable quality delivered in an accountable manner.
Q: As Secretary of the Department of AIDS Control and Director General of the National AIDS Control Organisation (NACO) what did you focus on?
The HIV AIDS strategy was totally evidence-based. Evidence clearly showed that not all Indians had the same level of prevalence. HIV infections were several times more prevalent among certain identified groups of people – commercial sex workers, men who have sex with men, and drug users who inject.
We had to get access to these sub-population groups and work with them on a partnership basis to get their support to follow NACO guidelines, to ensure the decentralisation of the programme and enable people easy access to testing and counselling services and treatment.
All these initiatives helped us to scale up our programme and bring down prevalence levels in a substantial manner.
Q: In your opinion how should India tackle healthcare policy, keeping in mind the vast population? Can it have “one shoe fits all” approach?
Not at all. The first principle in health is active engagement and involvement of the people/patients/communities. Without that engagement, no system can be successful.
So, decentralisation and using evidence to formulate policy interventions and closely monitoring for course corrections are critical. Such processes cannot be achieved by centralising plan formulation or service delivery.
While centralisation helps standardisation, it is at the cost of innovation and long-term sustainability.
Q: During your tenure in government what funding was allocated to healthcare? Were there defined strategies to use allocated funds appropriately?
The health sector has had a perennial battle with the finance departments for funds and higher allocations.
India has very low public spending of about 1.3 % of GDP. Often by adding social determinants like water, sanitation and nutrition, the Government tends to show higher spending.
The reality, however, is very modest resource allocation. That said, the Government has very clear programmes listed in the Demand for Grants documents that shows how much money has been allocated for what and based on that, programme activities and interventions are drawn up.
But systemic problems such as delayed release of funds or funds release dependent on furnishing of utilisation certificates, which can take time due to delays in audits etc., result in slow or delayed release of funds.
Much more efficiency in spending can be achieved by releasing central funds directly to district-level health authorities as per the approved plans.
Q: Tell us about the Ayushman Bharat initiative. How has it helped India?
Ayushman Bharat was an ambitious but much-needed initiative. It has two components – one is social health insurance covering about 500 million households that are listed as per the Socio-Economic and Caste Census with a sum assured of about Rs 5 lakhs. That was a massive scale-up to the modest attempts earlier on.
The Ayushman Bharat initiative has contracted about 29,000 hospitals/facilities across the country that also include all government facilities and cover all inpatient care.
The initiative has certainly boosted the business of several thousands of small and medium hospitals on the one hand and enabled people access to timely treatment without having to struggle to shore up private finances.
It has several problems that will, with time, be ironed out.
The key objective of this component is to reduce out-of-pocket expenditures by householdsAchieving this objective is, however, difficult to achieve as outpatient care is not covered.
The second component is strengthening primary care. Buildings have been refurbished and facilities branded. But due to low allocations, the problem of human resources (HR) continues. Until more money is provided and policy is integrated with other HR and technology policies, this will continue to be a problematic area.
Q: What do you think are key lessons that COVID-19 left behind and how should we tackle it?
The first key lesson is to strengthen the health system, particularly at the primary level along the principles of decentralisation and community management and at the same time strengthen the secondary hospitals with access to basic facilities such as oxygen, intensive care units etc.
The second lesson is that the surveillance system needs to be drastically strengthened and priority be accorded to building up public health cadres at all levels – from the private health centres to the Ministry of Health.
The third lesson is to strengthen the Ministry’s response to such events that cut across states and national boundaries. Institutional boundaries specifying who is to do what must be clarified to avoid too many people giving contrary advice as we saw happen during the COVID-19 pandemic.
The centre must marshal the best technical opinions and frame guidelines, but implementation must be left to states. Much confusion could have been avoided if this principle had been followed. It ultimately was, but very late.