Breathe new life into public health. Far too many Indians rely on Baba Ramdev, Akshay Kumar

A marginal patient opts for private healthcare over govt services the moment it becomes affordable, despite the distrust. The goal should be to reverse this.

File photo | Ramdev addresses the media during the launch of 'Coronil', in Haridwar on 23 June 2020 | ANI

Media headlines and public discourse might not reflect it, but one of the most important policy priorities for India now and over the next decade is health. The immediate task, of course, is ensuring that we bring the pandemic under control within the next year. The longer term challenge is to create a health care and public health system that will form the basis of our future growth and development.

Public policies designed to bring about better health outcomes are desirable in and of themselves. But in the post-pandemic world, investment in health is important for an instrumental reason as well — to revive the Indian economy in the short-term and create a new engine of growth that the country desperately needs. Despite the beating the system has received due to the Covid-19 pandemic, the Indian healthcare sector has the potential and the opportunity to become a globally competitive hub for quality, affordable healthcare. The crisis is an opportunity for a comprehensive review of how India has approached its health policy, and lay the foundations for something that is a whole lot better. Over the next few weeks, this column will focus on new dimensions and angles in developing health policy for the future.

The trust deficit

A good place to start looking at reimagining India’s health policy is a comprehensive report published in August 2019 by FICCI and Ernst & Young. It draws attention to what is a mostly-overlooked aspect of health policy, especially in India — the issue of trust. Indeed, the distrust and mistrust are pervasive across our healthcare sector, corroding its capacity and undermining outcomes. While it is true that both public and private investment in health (1.3 per cent and around 2.3 per cent of GDP respectively) are low compared to other countries, high levels of distrust give us less bang for the bucks that we do spend. The interactions among patients, doctors, hospitals, labs, chemists, insurance companies and government officials are characterised by distrust, leading to more paperwork, wasted time, frustration, dissatisfaction and sometimes even violence.

Lack of trust is a more fundamental problem than lack of investment — more money can buy you more clinics and hospitals, but it can’t create trust.

The FICCI-EY report includes a nationwide survey of 1,000 individuals that finds that trust levels have dramatically dropped between 2016 and 2019. For instance, the percentage of respondents who believed that hospitals act in the patients’ best interests fell from 63 per cent to 39 per cent. Similarly, the percentage happy with their hospital experience fell from 78 per cent to 51 per cent. These figures are consistent with anecdotes we have heard from our friends or online, of doctors who order ‘unnecessary’ tests, hospitals who keep patients longer than ‘necessary’ and cumbersome bureaucratic procedures during admissions and discharge from hospitals.

But ask yourself what happened in the few years between 2016 and 2019 to warrant such a massive rise in distrust? Did India’s healthcare sector suddenly fall off the rails? There is little evidence that this is the case. The reason for the disproportionate increase in distrust lies elsewhere — in the overall climate of moral panic created by the proliferation of social media. The mechanism is clear — bad news and bad experiences, real or fake, spread faster, wider and create a most lasting impression than good ones. Few people tweet about the normal, mundane and satisfactory experience after visiting a doctor or a hospital. Even if they do, few will retweet them. A bad experience, however, soon develops wings on social media. Studies show “there is broad consensus that misinformation is highly prevalent on social media and tends to be more popular than accurate information, while its narrative often induces fear, anxiety and mistrust in institutions.”

A 2018 survey by GoQii, a fitness tracking product company, reportedly found that over 92.3 per cent of its presumably literate, middle-class users did not trust the healthcare system in India. Interestingly, they trusted Akshay Kumar, the movie star, and Baba Ramdev, the yoga guru and FMCG magnate, for health advice. (The survey was perhaps conducted before the movie star became the company’s brand ambassador).

Restoring trust

While it is possible for governments to work with social media platforms to tackle misinformation on a specific issue like Covid-19, it would be impossible to combat generalised spread of mistrust on the healthcare system. Yet the greater the prevalence of mistrust, the more difficult it will be to implement policy changes and reforms necessary to improve outcomes. Public attitudes against private hospitals, for instance, can oppose the public-private partnerships necessary to improve and expand government hospitals. Distrust in pharmaceutical companies can translate into support for price caps. Public health initiatives can meet with resistance. The same moral panics that valorise doctors and nurses one day can demonise them the very next.

To be sure, we do not know how to restore and increase trust in public institutions. It is unclear if we can address the trust problem in healthcare in isolation; but we can certainly attempt it. One way would be for government clinics and hospitals to set the market benchmarks in terms of quality and pricing. This calls for massive investments by both, Union and state governments, in upgrading government healthcare facilities to a level that the marginal middle-class patient would prefer to go to. Today, the marginal patient opts for private healthcare the moment it becomes affordable, despite the distrust. The goal of health policy should be to reverse this — to raise standards of public facilities so that they become the first preference. Another way would be for the government to create confidence in the rule of law — that insurers will pay promptly, that hospital bills will be settled even after the patient is discharged, that criminality and violence will be punished, and so on. Finally, technology, which promises to solve many of our healthcare challenges, must be more carefully considered before being deployed, lest it exacerbates distrust.

Nitin Pai is the director of the Takshashila Institution, an independent centre for research and education in public policy. Views are personal.