Swami Subramaniam, Aparajithan Srivathsan. Mission Possible — Paving the Road to Universal Health Coverage. Notion Press.com, India, 2024. INR 499. 279 pages. ISBN 979-8-89186-388-0.

Universal Health Coverage (UHC) is the most recent global health agenda backed by Sustainable Development Goal (SDG) 3.8 to be realised by 2030. Globally, a vast amount of research on this subject is being done and published. Mission Possible is one such book which explores the possibility of India moving toward UHC.

The book, which has four sections, begins with an assessment of the various components of the current healthcare system in India and provides suggestions for the changes needed to transform the healthcare system towards achieving UHC. The first section, called “The Ecosystem”, explores the dynamics of each component of healthcare in the country and rightly identifies the poor foundation of primary healthcare and a fragmented approach to healthcare as the key obstacles to India’s developing an organised healthcare system conducive to the delivery of UHC. In the second section, titled “Healthcare Down the Drain”, the authors focus on waste, fraud and errors in the Indian healthcare system, which are bleeding the system, leading to misuse of the limited tax funded resources, unnecessary out-of-pocket burden on households, and huge frauds being committed due to poor regulation and lack of ethics in medical practice. The third section looks at “Health Technology” with a focus on the aspects of digitisation, technological innovations and skewed investment in high tech. The final section titled “Mission Possible” discusses the possibility of implementing UHC, projecting various options and models from global experience.

Identifying challenges

While the authors raise very relevant issues and offer suggestions that have merit in moving towards UHC, there are many contradictions and gaps in their arguments throughout the book. For instance, they correctly flag strengthening of primary healthcare as the foundation stone to achieve UHC; but their solutions are as fragmented as the current system of healthcare. They talk about the public health system not finding enough doctors to work in primary healthcare and mention the strengthening of Community Health Workers (CHW) as an alternative to doctors on the frontline. No doubt the CHWs have an important role as a link between the community and the healthcare system but they can certainly not be an alternative to strengthening primary healthcare, where doctors and nurses have to be at the core. The authors should instead have suggested mechanisms to bring in doctors to serve primary healthcare. The authors rightly point out that the issue of doctors is not inadequate numbers, as India produces a large quantum of doctors — including for the world market — but that of distribution of doctors. The authors should have focused instead on how to persuade doctors to work for the primary healthcare system. For example, in many countries across the world, graduate doctors as well as specialists have to engage in supervised practice or compulsory public service for one to two years before they get their licence to practice independently, because health systems are structured and regulated by standards and ethics in medical practice. Australia requires 6 years of supervised practice, Thailand 3 years, Turkey 2-4 years and Vietnam 5 years among others [1]. Thus, in India with an annual production of nearly 1 lakh MBBS doctors, over 45,000 specialists and another 60,000 AYUSH doctors, a policy mandate of a minimum of two years public service could give us more than five doctors per primary healthcare centre (PHC) (including AYUSH), and as many as 45,000 specialists available to serve the public health system each year [2].

The authors suggest renaming primary healthcare as comprehensive care, rather than talking about structural transformation of the existing primary healthcare system. Our political regime likes renaming and has already renamed PHCs as Aarogya Mandirs; but that does not structurally transform the primary healthcare system. While mentioning comprehensive care the authors do talk about integration, about family practice, about referral systems and about the gatekeeper function of primary healthcare, but in the same breath, reject the National Health Service (NHS) model of primary healthcare and family practice which is intended specifically to improve integration, promote family practice, and act as a gatekeeper for referral.

Towards a UHC model

The authors in their exploration of global experience with primary healthcare and hospital care appear lost and confused when it comes to making suggestions for India. While they point out the failure of the American insurance-based health financing system, they are at the same time sceptical that a tax-funded healthcare system in India can work, and therefore an NHS model is overruled. However, much later in the book, they do seem to favour the Canadian system of healthcare from which India can learn while shaping its own UHC. The Canadian system, while also a national health system, is different from the UK NHS in its system of payments. While the UK NHS has a capitation system where per capita payments are made to providers for the targeted families; in Canada fee-for-service payments are made to providers for each service rendered by the single payer health authority. So, the authors are unsure if they should go with a socialised healthcare system like the UK and Canada and many OECD (Organization for Economic Co-operation and Development) countries, or if they should support the US insurance-based model which Ayushman Bharat tries to emulate.

The above confusion is perhaps due to the authors failing to recognise healthcare as a public good and a fundamental right. While they do make a few passing references to this in the book they should have, at the outset, clearly defined the character of healthcare as a public good and the need for a transformation from its current supply-induced-demand and commodified nature. If they had set this context for their discussion of primary healthcare and UHC, their suggestions and arguments would have carried appropriate weight towards developing a robust UHC for India. Another trap the authors fall into is that of locating primary healthcare only in the rural context, when there is a huge need to expand primary healthcare for urban settings also. The urban health mission was set up precisely for this, and has now been merged into a National Health Mission.

Similarly, the authors’ discussion on hospitals has contradictions. The authors are sceptical about the importance given to general hospitals like district and sub-district hospitals, and instead feel that there should be a larger focus on single specialty institutions which they call “focused healthcare factories”, as they are more cost-efficient. While their criticism of general hospitals is valid, the problem lies in the failure to establish a referral system with primary care as the gatekeeper, and not in the character of the general hospital. This failure leads to the lopsided and inefficient functioning of hospitals. Further, their suggestion to expand single specialty hospitals is not feasible, because there is a limit to how many cardiac hospitals or neurology hospitals or hernia surgery specialty hospitals can be set up, and be physically accessible to people. In their discussion on hospitals, the authors overlook the fact that in general hospitals or tertiary hospitals, more often than not, the super specialty centres are independent departments with their own buildings and equipment. Thus, for example, in KEM Hospital, Mumbai, while the main hospital deals with basic specialties the Cardio-Thoracic Centre, Orthopaedic Centre, Neurology and Nephrology Centres are separate entities in the same overall location. Similarly, some tertiary hospitals, like Nair Hospital in Mumbai, also have a separate building for Out Patient Departments so that there is no overcrowding in the main hospital. Even the All India Institute of Medical Sciences (AIIMS), Delhi has separate super specialty centres for Cardio-Thoracic, Neurology, Ophthalmology, Trauma services, etc.

The authors do make one very important point about setting up of AIIMS-like centres in various states. All states have their lead tertiary institutions, so the authorities should be strengthening them rather than setting up AIIMS in states, thereby dissipating the states’ existing human resources and weakening existing tertiary care institutions. If super specialty centres need to be created across states, it makes better sense to attach them to existing institutions or select district hospitals, so that physical access improves

To summarise

The first section of the book makes a strong pitch for primary healthcare and setting up of an integrated healthcare system but their suggestions for transformation fail due to a fragmented approach with different entities not necessarily integrated into an organised system of healthcare.

The second section has an interesting discussion on wastage, fraud and administrative errors in the healthcare system, referred to as “WaFEr”. The causes are a lack of transparency and accountability on the one hand, and lack of strong regulation and absence of ethics in medical practice. This section includes both private and public sectors while the first section focusses more on the public health system.

Examples of wastage, like irrational prescriptions, unnecessary diagnostic tests and procedures all contribute to the increasing burden of out-of-pocket spending on households, especially in the private sector. The authors suggest rightly that switching to generic prescriptions can substantially save resources. However, they fail to consider the experience of Tamil Nadu, Rajasthan and Kerala in drug procurement and distribution which has helped leverage three to four times the volume of drugs within the same budget [3]. Further, to resolve these issues, strong regulation and ethical practice are very critical and the authors could have focused more on this requirement.

The third section on “Health Technology” deals with the urgent need to use digital technology for electronic health records and prescription and for innovations like tele-medicine. The authors point out that despite the Ayushman Bharat Digital Health Mission, the use of information technology in the health sector has failed miserably, while succeeding in the financial sector. While the public health system has seen some progress, especially since Covid times; in the private health sector — where its use can bring in transparency and accountability — its use has been shunned.

The final section “Mission Possible”, brings together all the preceding discussions based on which the authors try to make suggestions to facilitate moving towards UHC. They look at payment mechanisms, private equity, public private initiatives etc. But their suggestions are fragmented and not helpful for an integrated and comprehensive healthcare system. In fact, the authors have devoted one full chapter to why India should not go the NHS way, and they veer towards a multi-level system which exists today with different classes served by different mechanisms. What is very interesting is that the authors have not even mentioned the Employees State Insurance Scheme and the Central Government Health Scheme as social insurance options; but in their final suggestions, they have indicated that the Railways healthcare system could offer a solution if upscaled to the larger population. The Railways have an employer-funded system of comprehensive and integrated primary, secondary and tertiary care for railway employees and their families, including pensioners.

The authors conclude with a strong pitch for primary healthcare to remain in the public sector and argue that its strengthening and universalisation would be the first step towards UHC.

Finally, while the overall structure of the book is good, and each section is summarised, the referencing could have been much more thorough. Many unsubstantiated statements are made throughout the text, as well as some errors, eg, on page 216, the UHC SDG is stated to be SDG 15, which actually is the one pertaining to Life on Land and protection of ecosystems. With more robust referencing, such errors could have been avoided. Nevertheless, this book is a useful contribution to the debate on UHC in India.