India faces a severe healthcare crisis, with 95% of middle-class individuals underinsured and rising medical costs exacerbated by insufficient public healthcare expenditure. Dr. Mahboob Khan advocates for a radical overhaul of the healthcare system to ensure universal coverage, emphasizing community-managed care and better integration of health services. The document highlights the urgent need for regulatory reforms and improved healthcare accessibility while addressing the significant challenges posed by a growing population and inadequate medical workforce.

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If Indian Healthcare Insurance is covered to even half the population,
India’s ranking in the World will increase!
By Dr.Mahboob Khan Phd
Imagine India, If the Healthcare Insurance is covered to even half the
population, India’s ranking in the World will increase!
Government Regulation to curb sky-rocketing expenses of Private
Hospitals will be a Big Relief to the Rising Indian Middle Class!
India has double digit medical inflation. On the other hand, health cover
is not adequate, and even employers’ health cover is insufficient in many
cases, and individuals end up paying from their own pockets many a
times. And, even though the premiums for health insurance have
remained relatively stagnant, it has been mainly thanks to competition
among the insurers. According to the report: Over the last four years,
premiums of most insurers have increased only once – in 2014 – over
the previous year, reflecting a CAGR of 2.79% (for sum insured of Rs
2,00,000 and Rs 3,00,000) and 3.29% (for sum insured Rs 5,00,000 and
Rs 10,00,00).
95% of middle-class Indians do not have enough health insurance
The Big Picture
An increased appreciation of rapidly rising healthcare treatment costs
does not seem to have translated into Indian consumers being better
prepared. This is either because we, as consumers believe that we are a
genetically healthy bunch or are unaware of just how expensive medical
procedures have become. Around 95% of middle-class Indians do not
have enough health insurance to cover some of the most common
procedures and ailments in the country, according to a report by
BigDecisions.com, one of India’s leading personal finance advice
platforms. Surprisingly, consumers above 45 who are at higher risk of

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health problems and closer to retirement, are least prepared for
emergencies as they are under-insured by an average of 69%.
An increased appreciation of rapidly rising healthcare treatment costs
does not seem to have translated into Indian consumers being better
prepared. This is either because we, as consumers believe that we are a
genetically healthy bunch or are unaware of just how expensive medical
procedures have become. It is getting more expensive to treat some of
the most commonly occurring diseases in India. Amid an inflationary
environment in India for at least a decade, prices four years ago were not
exactly low. The fact that they have again risen, by double digits in some
cities, is noteworthy.It is clear that there is room for Indian prices to
increase further. We believe that current inflationary trends are likely to
continue for the foreseeable future. While it is no surprise that typical
treatment costs in the US are sometimes more than 10x what they are in
India, that they are more than twice as expensive in countries closer to
home such as Malaysia and Thailand, means Indians could soon be
paying more.95% of our users are not adequately insured, with 62% of
10,000 BigDecisions users having less than 50% of required health
cover. Consumers above 45 (with higher needs, typically higher incomes
and fewer years to retirement) are a high-risk group – they are the least
prepared for health emergencies as they are under-insured by an average
of 69%.
We make the case not only for more resources but for a radically new
architecture for India’s health-care system. India needs to adopt an
integrated national health-care system built around a strong public
primary care system with a clearly articulated supportive role for the
private and indigenous sectors. This system must address acute as well
as chronic health-care needs, offer choice of care that is rational,
accessible, and of good quality, support cashless service at point of
delivery, and ensure accountability through governance by a robust
regulatory framework. In the process, several major challenges will need
to be confronted, most notably the very low levels of public expenditure;
the poor regulation, rapid commercialization of and corruption in health

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care; and the fragmentation of governance of health care. Most
importantly, assuring universal health coverage will require the explicit
acknowledgment, by government and civil society, of health care as a
public good on par with education. Only a radical restructuring of the
health-care system that promotes health equity and eliminates
impoverishment due to out-of-pocket expenditures will assure health for
all Indians by 2022.
Translating this vision into action.
I. India’s healthcare priority should be to dramatically improve preventive
and primary care standards. Its facilities should be strengthened with
more personnel, increased capacity building, and rigorous monitoring,
all complemented with greater demand-side pressures. The primary
health center (PHC) and its subcenters should be trained to act as a
single-stop for all preventive and primary care services, and a gatekeeper
for all referral services. While this is notionally their mandate even
today, its compliance remains weak and these institutions have been
reduced to being maternal and child health centers. All the existing
national programs, including the village public health activities, should
be closely integrated into the PHC and brought under the control of its
medical officer. These facilities should be provided resources to equip
themselves with all the basic infrastructure and equipments and maintain
them in a clean and hospitable manner. Wherever the medical officer is
not appointed, a senior staff nurse should be entrusted the supervisory
responsibility.
II. The PHC would act as a nodal agency co-ordinating all preventive and
primary care activities – maternal and child health interventions, basic
OP services, normal deliveries, administration of national programs, and
coordination of village public health activities. This functional profile
demands the services of a public health manager, more than a trained
medical practitioner, much less one trained rigorously for more than five
years. A three-year course with a curriculum designed to accordingly
may be one way to also overcome the acute shortage of MBBS doctors
that leaves a large proportion of PHCs without any doctor.

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III. Given that less than fully qualified (LTFQ) providers, commonly called
quacks, are the point of first contact in nearly 80% of cases in rural
areas, no meaningful reform is complete without integrating them into
the mainstream. Their capacity building should involve continuous
trainings and a gradually phased pathway to formality. One approach
may be to offer a very basic preventive and primary care-focused course
curriculum as a certificate in primary care, to be acquired over a 4-6
month duration of distance learning. The entire coursework can be
provided on-line and through mobile phone apps, with the final
examinations too conducted online under strict monitoring. Once they
acquire the certification, these providers can be empanelled and used for
various preventive and primary care services offered by the government
in return for a fee.
IV. The secondary care institutions like the 30-100-bed community health
centers (CHCs) should be strengthened with all basic facilities and kept
very clean. Currently, they are the weakest part of India’s health care
system. These hospitals should contain round-the-clock doctors and be
equipped to handle basic surgeries including C-section deliveries.
Wherever resources are extremely scarce, staff from two CHCs can be
temporarily redeployed to run at least one full-fledged CHC. A mobile
team of anesthetists can be made available if required.
V. All tertiary care admissions, except in cases of emergencies, should
happen only through the primary care center and preferably the first
referral unit in the CHC. While this may be difficult to enforce, a variety
of different approaches may have to be adopted to gradually internalize
this approach among all the public and private stakeholders.
VI. It may be difficult to put the insurance genie back in the bottle. The next
best option is to consolidate all the public insurance schemes offered to
different categories of people under one umbrella, with a basic insurance
plan and different types of top-ups, including those which provide
premium care. Like in the continental Europe, the basic plan should be
community-rated, cover a very basic set of high-incidence catastrophic
medical conditions and no more, and have the same premium across
insurers within a region. Private insurers should also offer this basic plan

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and at the same terms. They would be allowed to differentiate based on
the top-ups and the quality of their services.
VII. The government, jointly with the private insurance agencies, should
negotiate the annual price schedules of care providers and diagnostic
services on a regional basis. This price schedule would be applicable for
all government and private insurance and for any other contracting of
services (like with CGHS). It would be a matter of debate as to whether
the fee schedule should become the price standard for all categories of
consumers as would be the case in a completely regulated market.
VIII. The public tertiary care facilities should be strengthened with more
facilities, greater cleanliness and responsiveness, and better
management. Since such institutions are only a handful in each state, the
state governments should take it up as a mission to bring them up to the
standards of the best private hospital in the region. Patients under public
insurance or being subsidized for their health care should be discouraged
from visiting tertiary care facilities for simple secondary care treatments.
Apart from providing affordable and accessible care for the poor, strong
public tertiary care facilities are essential to keep private providers
honest.
IX. In an environment where government hospitals are badly managed and
discourage even those who cannot afford private hospitals, allowing
insured citizens to choose their hospital is certain to further enfeeble
public facilities. In the circumstances, there may be only two options.
One, public insurance schemes can mandate that patients go to private
facilities only in case the same treatment is not available at the public
facility and on referral by the tertiary care facility (or on pre-
authorization by the TPA). Two, the personnel delivering the care in the
public facility should be incentivized with a share of the payments. It is
not clear as to which of the two alternatives may work and a light-touch
mix of both may be necessary.
X. Finally, districts should be allowed to innovate to implement the
components of this plan. The Government of India should offer a menu
of interventions to improve health care service delivery – electronic
medical records of all medical transactions in public facilities,
strengthening of the rogi kalyan samitis at the PHC level, initiatives to

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make public facilities more attractive for patients, integration of the
LTFQ care providers, rating of private providers and so on. The district
may commit to the implementation of a clearly defined action plan
consisting of some of these interventions and corresponding outcomes
and enter into a 3-5 year MoU with the state National Health Mission
Society. In return, the district should be encouraged with an incremental
share of the NHM allocations. This strategy should not be forced upon
all districts. In fact, only a handful of self-selected districts in each state
should experiment with it, and based on their learnings, the strategy
should be gradually expanded to cover others. Apart from closely
monitoring and refining the programs, the state and central governments
should encourage competition among those districts in the achievement
of their action plans.
Now, it would be impossible to implement all these components in a
one-size-fits-all mode across the country on a mission mode. It is just
too complex. For sure, many of these reforms would struggle to pass the
test of political acceptability and seriously strain the administrative
bandwidth for effective implementation. Greater program flexibility
would certainly lead to failures and scams. Dfferent parts of the country,
even parts of the state, will progress at different pace in implementation.
But given the enormity of the challenge, this may be the only way to
initiate a process which could, potentially, over a long time frame,
atleast stand a reasonable chance of getting us to the destination.
Not long ago, consumers could access health information about as easily
as they could access plutonium. This is changing rapidly in the
information age. As a result, consumers—rather than doctors,
government, insurers, hospitals, or healthcare companies—will own the
Healthcare Century. Any healthcare institution that ignores this trend
does so at its peril.Before the information age, consumers were almost
entirely beholden to their physicians for information about health and
disease. Now, consumers increasingly educate themselves using the
Internet to learn about their health, illnesses, and symptoms. Every day,
the patient-doctor relationship becomes more of a partnership as patients
come up the learning curve.Previously, the system kept you from your
test results until a doctor had time to interpret it for you. Now, mobile

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health innovations not only allow consumers and caregivers to obtain
more data about the body, they also making such data obtainable under
consumer control rather than under the control of the healthcare system.
Such real-time, self-gathered health data may help the informed
healthcare consumer keep doctors away.Until recently, patients were
asked to participate in clinical trials about which they knew very little.
They underwent therapies that they could not independently research.
Informed consent was not very truly informed, and patients were
expected to trust the system—a concession of power to experts who
might harbor biases or misaligned incentives. In the social media age,
consumers are taking back some of that power by tapping into online
communities and FDA clinical trial sites to gather additional
information.Pricing and performance opacity has long been the norm in
healthcare. Stories about the variation in what hospitals charge different
patients for the same treatment were once merely anecdotal. Consumers
now share their medical bills online, and healthcare pricing data is being
aggregated to create transparency for consumers. Similarly, consumers
share their performance reviews of doctors and hospitals.Consumers are
not only empowering themselves through information about health but
also by becoming participants in health innovation. Patient groups such
as the Cystic Fibrosis Foundation and Food Allergy Research &
Education directly fund and develop novel therapies that benefit patients
in partnership with industry. The 2010 Patient Protection and Affordable
Care Act established The Patient-Centered Outcomes Research Institute,
which enables patients to become directly involved in improving
healthcare research and outcomes.Information is power, and a tectonic
power shift is catalyzing a revolution in healthcare as information
becomes demystified and liberated to consumers. The Gutenberg press
liberated the printed word and the human mind, spawning an
unprecedented era of human progress. As consumers take control of the
future of healthcare, an unprecedented era of medical progress will soon
be upon us.

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How can you Ensure Healthcare Reforms When Statistics say the real
pictures. How to Fix Accountability of Doctors is also a major
challenge.
 There is just one doctor per 2000 people in India
 There is acute shortage of 64 lakh skilled human resource in the sector
 The physician density of India per 10,000 populations stands poorly at
6.5 against a global average of 14.2.
 The density of hospital beds per 10,000 populations, which stands at
nine against a global average of 30. doctors don’t want to serve rural
India. They are very averse about their posting in countryside areas.
maximum doctors in urban India are without the MBBS disagrees.
 Healthcare Insurance almost non-existent. Unlike in the US, ordinary
patients in India have no meaningful insurance to cover healthcare
expenses. Most have to pay the medical bill on their own, and an
increase in defensive medicine may affect these patients economically.
But it is also true that in the absence of any insurance oversight, and
without any government regulation, hospital expenses are skyrocketing
in India
 There are just 0.64 doctors and 1.44 nurses for 1,000 Indians. The ratio
halves for rural India with a large number of health personnel working in
urban areas. Although the number of health personnel has increased the
demand for medical treatment has also risen with improvement income
in recent years
 A comprehensive study found that defensive medicine may contribute
only 1-2% of the cost of US healthcare.
 Malpractice liability may have a moderate degree of deterrent effect in
countries with an effective regulatory system through medical council or
board that routinely uses disciplinary action to curb negligence and
unethical behaviour by doctors. Unfortunately, medical councils in India
have been riddled with incompetence and deep rooted corruption.
Disciplinary action against negligent or unethical doctors by medical
councils, which comprise only doctors, is almost non-existent in India.