India's 'NHS': Modicare - the huge medical experiment
India's version of the NHS, fondly known as Modicare, is a health experiment like no other, helping 1.3 billion people.
Tuesday 3 July 2018 13:35, UK
How do you provide healthcare to 1.3 billion people?
It is a question that puts the foundation of the NHS, meeting the needs of a mere 60 million souls, in perspective.
The Indian government thinks it has found an answer as it attempts to close the gap between its economic progress and the health of its citizens.
Nye Bevan, founder of the NHS, said it would be the envy of the world - but given a choice, India has rejected the free-at-the-point of use model.
Instead, it will this year introduce a national health insurance scheme to cover half a billion people in what has been described as the greatest healthcare project ever attempted.
Ayushman Bharat, colloquially known as "Modicare" after Prime Minister Narendra Modi, will provide the 100 million poorest households with cover for advanced treatments such as surgery and cancer care.
It will provide more generous cover than the state insurance schemes that operate in some parts of India, and if successful has the potential to improve the health prospects of 500 million people.
While the Indian constitution guarantees free treatment for all, the government spends just over 1% of GDP on health (in the UK we spend just under 8%) and that only goes so far.
Primary care, some diagnostic procedures and maternity services are available at government-run hospitals and clinics, but state facilities are overwhelmed, access is patchy and beyond the reach of many rural communities.
So 70% of all healthcare in India is provided privately and paid for out of patients' own pockets. In reality, that means quality of care is dependent on how much money you have.
For millions of Indians living in yawning poverty it is a luxury they cannot afford, and healthcare outcomes are still poor.
A baby born in India today does have a greater chance of surviving and living longer than any previous generation.
Infant mortality is 35 of every 1,000 births, a dramatic reduction from 165/1,000 in 1960, and life expectancy is 69, up almost three decades in 60 years, but this progress is relative.
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Both figures are below the global average and well behind China and Brazil.
The limitations of publicly funding were clear at a district hospital we visited outside Delhi. It costs one rupee - just over a penny - to register at Sanjay Nagar-Ghaziabad Hospital, and after that care is free, up to a point.
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They see 600 new patients a day and the general physicians on duty are overwhelmed. Each examination, diagnosis and prescription takes little more than a couple of minutes, all with the next patient looking on from the doorway.
Many patients have diseases that have been all but eradicated in the west, such as tuberculosis and malaria; a legacy of poor sanitation and low take-up of vaccination programs, which health workers blame on a lack of education and awareness.
Staff are proud of the quality of care they offer, including being able to offer free food to mothers in the maternity ward for the first time, but the limitations are obvious.
Some welcomed the potential of Modicare. Surgeon Dr Akilesh Mohan, who conducts about 20 abdominal surgeries every week, told us it could cover the R400 (about £5) the hospital charges for each operation.
"This project has the potential to have a huge impact on the poorest people if it is implemented properly," he said.
For an idea of whether the insurance scheme might work we travelled south to Bangalore, to the largest heart hospital in the world.
Narayana Health was founded by Dr Devi Shetty, a heart surgeon who trained in the NHS and was Mother Theresa's personal physician.
He runs a private health empire that includes 24 hospitals in India and one in the Cayman Islands, and believes the combination of cheap health insurance and private healthcare is the best way of reaching the poorest.
He helped devise an insurance scheme for rural workers in Karnataka State that he says has funded 1.3 million operations.
Around half of the operations at his Bangalore hospital are funded by these state schemes, or a charitable foundation, with the work effectively subsidised by paying patients.
Around 30 heart surgeries a day take place in 15 operating theatres. Senior surgeons go from patient to patient for the key part of each operation.
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It is a production line system that has helped drive down the cost of each operation to less than $1,500 (£1,140) per patient.
"Healthcare is an $8 trillion global industry, but it helps just 50% of the people on the planet," Dr Shetty says. "To reach the other 50% cannot cost another $8 trillion because there isn't the money, so we have to find a cheaper way.
"Technology allows us to do that. In this country we have to pay, but we are going to be the first country on earth to dissociate healthcare from affluence.
"We will show that the quality of health you have does not need to depend on how much money you have.
"There are around one billion Indians with a mobile phone. If we take around half a dollar a month/week from every subscriber we would have enough to cover hundreds of operations for every one of those one billion people."
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Dr Shetty is evangelical about the potential of the micro-insurance model, and the role of the private sector in driving down the cost of care.
Others are not so convinced. Campaigners and opposition groups are suspicious of Mr Modi's political motives - he faces a general election next year - and believe basic public health is a greater priority.
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Dr Sylvia Karapagam spent six years working in the NHS before returning to India to practise and research public health.
"There is absolutely no evidence that a country like India can afford this Ayushman Bharat or Modicare scheme," she says.
"The focus should be on providing better public health, and dealing with communicable diseases like tuberculosis, malaria and so on that are preventable.
"The private sector has absolutely no interest in dealing with any of these conditions."
In Sanjay Camp, a Delhi slum, the basics of everyday life are plainly a greater priority than basic healthcare.
Twice a day, the city council delivers clean drinking water and the children sent to collect it swarm all over the tanker filling drums and barrels through brightly coloured hoses.
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But there is a middle-class India too, a burgeoning generation enjoying greater wealth than their parents but at greater risk from the diseases of affluence and longevity, such as diabetes and cancer.
These twin healthcare burdens are a challenge to dwarf the foundation of the NHS, and a reminder of the good fortune enjoyed by the 40 or so nations on Earth with developed, state-funded healthcare systems.
If Modicare is a success, it may be the model for rest of the developing world.
:: On Wednesday, you can watch a special hour-long live debate on the future of the NHS presented by Dermot Murnaghan on Sky News.
