New India Manifesto – Chapter 1 : National Healthcare System
Only 70% of Indians, according to a 2021 NITI Aayog report, have access to public health insurance or voluntary private health insurance. The coverage amount is too less for public insurance schemes such as Pradhan Mantri Jan Arogya Yojana. A 40-crore population is not covered under any health insurance scheme and is referred to as the missing middle who lacks any financial backing for healthcare treatment. Approximately 55 million Indians are pushed into poverty each year due to high out-of-pocket health expenses, according to a March 2022 WHO report.
In India, there are 58 per cent of hospitals that are privately owned with higher treatment costs, and 81 per cent of the doctors work there. According to the Indian Journal of Public Health, India will need 2.07 million doctors by 2030. There are many shortcomings in the infrastructure and workforce of the healthcare sector.
Doctors operate on humans regularly, and the public cannot expect empathy or compassion from every doctor. They are often under direct or indirect pressure to generate more revenue, leading to unnecessary tests and high-cost medical procedures in private hospitals. Converting normal delivery chances to Cesarean section due to greed is an example of how certain doctors manipulate the healthcare system.
Pharma companies bribe many doctors to get more sales of high-priced medicines, and many doctors in public hospitals directly demand bribes from patients for various operations. Doctors are also working under high mental pressure and long working hours. So, leaving healthcare to the private sector and the government staying as a spectator will be damaging for poor people.
Seventy-five per cent of hospitals are established in metro cities where only less than twenty-seven per cent of the population resides.
India’s private healthcare system is the foremost option for the majority population and is not affordable for commoners. People in India are more worried about the cost they will incur during treatment than the illness itself. Many of the population fear hospitals as they expect huge bills from private hospitals that will shake the foundation of such families.
The majority population in India is worried about these questions if they become sick: can they afford treatment, will their family look after them, and is there a chance to live another day? Parents expect children to look after them when they are old. A larger population of new-generation youngsters will choose an independent path, freeing themselves from their parents’ medical liabilities and responsibilities.
A solution to all these problems is to bring 75 per cent of India’s total healthcare system under the government’s control, ensuring that healthcare is accessible to all. A free healthcare system without a spending cap that cares for ill people is essential in India.
National Healthcare System
National Healthcare System is a model that provides free healthcare to 140 crore Indians irrespective of caste, race, ethnicity, gender, economic status and religion. A national-level authority will be created to control all public hospitals in India. The state government will control all hospitals within a state, whereas the central government will decide the rules and regulations. The central government will provide all hospitals with legal, technological and regulatory frameworks. All existing public hospitals will continue the ownership structure as of now. However, new hospitals will be built based on a joint partnership where the investment amount decides ownership. Even if the central government has a higher share, it is the responsibility of the state government to run it.
NHS requires massive funding, and some methods to create long-term funds to meet its expenses are provided here.
A. Government Tools
Long-term Government Promissory Notes and G-Sec Bonds can be used to raise money for building hospitals.
More than annual budgetary allocation is required to meet the required funding to build new and takeover existing hospitals. So, the government should take loans from multilateral agencies to develop hospitals.
B. New GST
Introducing GST for all products, including doctors’ private practice and private clinics, is required to increase tax revenue. Therefore, every small business should be brought under the GST net, from food to vegetable businesses. All producers, including farmers, will also have to pay GST for their produces.
C. 18 per cent GST on Religions and Other Organisations
Introducing an 18 per cent tax on the income of all religious institutions, charitable organisations, and non-governmental organisations is compulsory to increase tax revenue.
D. Hospital Tourism
Foreigners can get affordable treatment in India at a particular cost from public hospitals, which is an additional income.
E. Premium Facilities
By offering private AC rooms and other facilities such as TV inside hospitals, willing people who want such facilities can be charged an extra amount.
F. Customised Private Surgeries
Hospitals can charge the total amount for treatments like bariatric surgery and will also be a source of income.
G. Crowdfunding for Costly Medicines
There are certain medicines and specific treatments that are so expensive. It will be a huge burden if the government allocates an amount from its pool for such medication. For example, Zolgensma per dose cost is 18 crores, and spending such a large amount for one person is not feasible for the continued existence of the healthcare system. So, the government will create crowdfunding platforms and actively encourage people to donate to a pool to buy such medicines. Crowdfunding will be used to raise money for the working of the National Healthcare System.
State government should establish each hospital as a separate entity, thereby ensuring accountability from each hospital. There will be a board for each hospital that should regularly provide ways to increase revenue and cut expenses. Every quarter the expenses and funding requirements for each hospital will be published, and people of that locality will be asked to provide donations to ensure that the healthcare system is a success. Asking for donations by the hospital authorities from the people of their locality can generate considerable income.
I. Medical College
Start a medical college for every multi-speciality hospital, bringing revenue from student fees. In addition, nurse’s and doctor’s internship periods can be used in cost cutting of hospitals.
J. Income Tax
Everyone in the workforce should provide 1000 rupees annually as part of income tax, including labourers, farmers and everyone in the organised and unorganised sectors of the workforce. It should be implemented one year after the establishment of the National Employment System to ensure that the workforce is placed under the digital system before implementing this taxation system. 1 lakh+ crore rupees can be collected from the public by implementing this tax effectively.
Health should be transferred from the state list to the concurrent list in the Indian constitution. Only constitutional change can ensure that the national healthcare system is implemented.
Colour, economic status, caste, and religion are all influencing factors in the treatment received by the patient. Doctors and nurses are not social scientists and are not politically correct in their behaviours, thereby clearly displaying bias towards others. The government creating a hospital code of conduct for doctors, nurses, and hospital management will ensure that everyone works within that framework. It will also ensure that if a patient breaches the code of conduct, action can be taken against them. Since the government bears all the bills of patients, bureaucratic individual accountability will be enforced for hospital staff. They will be forced to work for the poorest and richest people alike. Once the NHS is implemented, the healthcare system will become free and accessible to the general population, and treatment of every severe disease, from chemotherapy for cancer to kidney dialysis for kidney failure, can be free for everyone.
Nationalised Labour Guild of Nurses
Fresher Nurses should get at least one-third or one-fourth of fresher doctors’ salaries. The salary difference is more than 10x in the current healthcare system in India. Most private hospitals severely underpay their nursing staff and pay very high for doctors. Creating nationalised labour guild will end discrimination faced by nurses. Government can introduce contracting from nationalised guilds. Private hospitals can continue paying what they already pay via the guild. However, the basic salary changes and government fixed hourly billing salary should be introduced only after 50 per cent of the healthcare sector comes under public control. Or else the immediate cost increase of treatments will be unbearable for patients.
The government should introduce a common website code for all hospitals, including public and private hospitals and small clinics. Only the domain name changes for each website. Expecting each hospital to comply with government decisions and waiting till they comply is a cumbersome process. If the government allocates a website and a login system for which they will pay, the government can ensure they comply with the necessary rules. If any options on the website are not filled, the government can easily find out which hospital is not following the rules. The hospital website will be connected with inventory listing and service listing.
B. Service Listing
The hospital website will have a service listing. The price range of various surgeries will be mentioned, and the lowest payment to highest payment charged for surgeries will be noted. It will ensure that every private hospital’s details are regularly published and updated, ensuring competition among them to provide at affordable rates. In addition, consultation fees of various doctors and all other service fee details should be made public.
C. Inventory Listing
Hospitals should publish the selling price of medicines and other medical items required for operation, ensuring their charges come under public scrutiny. As a result, the cost of medicines will decrease drastically as comparisons can be made between various companies and hospitals.
D. Healthcare GST
One per cent GST should be charged on the healthcare services currently exempt under GST.
E. CCTV Backup
CCTV recording should be made compulsory inside hospitals, and huge fines and penalties should be imposed for compliance failure. Hard disks should not be rewritten for three years. All CCTV hard disks should be stored in a separate room inside the hospital for three years. From GST evasion to medical negligence can be analysed from hard drives.
F. Offline Data Maintenance
Patient information should be maintained forever. Paper trail maintenance can be limited to 2 years. Digital backup of all the patient data should be stored on the hard disk and maintained by hospitals. Two hard disks of the same data should be maintained for additional storage security.
Patient data should not be leaked to the public; no information should be publicly available. Privacy rights will be enforced, and any leakage of patient medical history should be considered a severely punishable offence with imprisonment. The access will be limited to law enforcement agencies.
G. Health ID
Currently, health ID is based on a registration system, and the penetration of ID is minimal. Allot a unique id number to all individuals with an Aadhar card. Health ID should be automatically generated based on Aadhar number, and everyone should be sent a copy to their Aadhar address. ID details should be confidential, and only limited data should be added to medical history, ensuring privacy is maintained even if the online database is breached. If law enforcement wants the complete data, they must physically visit each hospital.
H. Redacted Listing
We have seen that people visit only certain hospitals and refer only to specific doctors for a particular operation. Some doctors are hailed as experts in that particular operation, and such experts are rare in India. The most important aspect is that some doctors’ success cannot be replicated in other hospitals or by other doctors. Such skilled doctors know how to act in hundreds of scenarios of different patients.
The redacted listing aims to create a national database accessible to all doctors nationwide. This database includes information about various medical procedures, medical history and operation notes of patients. The patient’s privacy should be maintained, and the following rules should be followed.
- No personal details such as name, address or anything that directly reveals the person’s identity will be added to the redacted listing.
- No location details and hospital names should be added.
- No time and date details of the operation will be available. If two dates are required to mention a particular procedure, they will be noted based on the two changed dates by maintaining the exact gap between dates.
The redacted listing should be made compulsory for all significant operations in hospitals. In addition, there will be a website and login system by which hospitals can add and update a particular patient record. A unique number will be generated to the health id, added to the patient data, and recorded in the patient’s offline database. This unique id will be used to enter the redacted listing for that case, as it removes any other digital trail connected to the person. The only identity record will be available at the hospital where surgery occurs. Once the details are entered, the website will mask all details of who entered data and whose data is entered. The remaining data will be publicly available to all doctors in India for reference. The database is free and is accessible only to doctors all over India.
Suppose another hospital doctor wants further details of the patient’s medical case. In that case, they can communicate and request with the intermediary national-level board, which will connect with the doctor or hospital that operated the patient.
Faulty treatment and cluelessness about what to perform in a situation have resulted in many deaths which are covered up. Redacted listing and the information doctors can derive from this portal will help them treat patients more effectively and reduce the death rate. In addition, thousands of surgeries performed in different scenarios will be available to all doctors nationwide. Doctors with low quality and skillsets will be exposed as the government can cross-check the database with its regulatory authorities. Such doctors can be asked to be reskilled by the government.
I. Nationalisation of Hospitals
The government should release a notification displaying interest in the takeover and request that hospitals submit their bids. The government should consider large hospitals, multi-speciality and super speciality for takeover. Small hospitals should be considered for takeover only if there is enough land area to extend. Government should take over only by paying the entire property and structure values and not based on the hospital’s revenue.
Most private hospitals are started by corporations, and the wealthy intend to make money at a rate they cannot get from other businesses. Compulsory changes introduced to hospitals will ensure their greed is regulated. The government must compulsorily enforce Nationalised Labour Guild of Nurses and the significant changes mentioned above.
Hospitals, as an essential service, should not be allowed to shut down. If any hospital is protesting against these compulsory changes and shutting down, they should be warned of takeover by the government against their will. In case of a seizure, they will be paid the market value of hospitals.
At least seventy-five per cent of all large hospitals should be nationalised in the short term. If hospitals are greedy and want to continue exploiting patients, cap the amount on each surgery or procedure.
Convert existing state-run smaller hospitals with land facilities to multi-speciality hospitals. The Target is to have one multi-speciality public hospital for at least 1,00,000 population.
If any loss-making small hospitals are interested in selling, the government should immediately buy such hospitals. Then, it can be run as smaller hospitals with basic facilities. However, there is no need for takeover attempts as the government can build many small hospitals in a short period if required. Therefore, what is really needed is large hospitals with multiple services and not smaller clinics.
Modernise all smaller public hospitals with the new changes, ensuring people prefer public hospitals over private ones.
J. First Come, First Serve Appointment System.
Building new hospitals is possible only long term and takes many years. So, during the semi-nationalisation of the healthcare industry, the appointment system should be enforced, thereby reducing corruption in healthcare service delivery to the masses.
Whoever applies first in a hospital will get served first in terms of surgeries or other procedures; circumventing it is difficult as there is a national-level health id that all hospitals will use. All probabilities of corruption in providing favouritism by bypassing this first come, first serve rule should be contained. People below 5 lakh annual income should be provided with this first, which can be extended to all later.
The appointment system should continue even after healthcare is made free and accessible to all, thereby ensuring a systematic and professional approach in providing health services. Furthermore, the time of the doctor and patient can be saved if it is properly implemented, as each slot is marked.
Government Paid Insurance and Private Healthcare
Money-making is the intention of most private hospitals, and they will circumvent laws to make excessive profits by exploiting others’ vulnerabilities. Expecting them to be reasonable in their charges will never work. If the government pays health insurance for the public, private hospitals will continue exploiting patients by rapidly increasing treatment costs. This will increase the cost of health insurance regularly at rates that become unbearable for the government. Overtreatment of patients and fraud will become common if the private sector controls the nation’s healthcare.
Small private clinics and hospitals in rural areas are less greedy than larger hospitals. Small hospitals in rural areas charge according to rural demand and the income of people with low incomes. However, multi-speciality hospitals do not work on that rule. They get patients from rural and urban places due to facilities and different treatments. Even if a multi-speciality is in a semi-urban area, the charges for various treatments will be so high. Moreover, no private party will be interested in establishing large village hospitals.
If government control 75 per cent of the healthcare sector, then the government can ensure that healthcare is accessible to rural and urban population.
Doctors Mindset Change
In private hospitals, doctors are becoming business-minded as increasing profits is the primary agenda of private hospitals. Therefore, they deal with patients and treat them with a money mindset. However, if the government controls a significant share of the healthcare sector, doctors are no longer required to lie or trick patients. Instead, doctors will be more compassionate towards patients, ensuring only necessary procedures are applied. This new mindset of doctors will be beneficial for patients.
Quality Control and Fight Against Corruption
Every hospital should work as a private organisation with client satisfaction prioritised over employee satisfaction. Hospital boards should be set up for every hospital. The board will submit a report of any discrimination, financial irregularities or employee misconduct to higher healthcare authorities. If any board is corrupt and is proven, they will be removed immediately. All nurses’ and doctors’ jobs are annual renewable contract-based, ensuring they maintain integrity throughout their careers. The board will be responsible for any equipment damage or any other issue inside the hospital, providing a regulatory framework for every hospital. Any theft of medical items by hospital staff or sale of items at low price to private hospitals should be severely punished. If any corruption by board members is proven, their assets will be confiscated, and they will be punished rigorously.
National Healthcare System is Not a Freebie but a Welfare Measure
Do not consider National Healthcare System as a freebie programme of the government. People are contributing through GST, indirect taxes, and other taxation measures and the fund is used to make healthcare free and accessible. So, people indirectly contribute to creating an initiative that works for their welfare. It is the right of the public to claim accessible healthcare for themselves, and the right to free treatment should become a legal right in India.
Wallet Payment Exchange System and National Healthcare System Payment
The hospital services can be delivered for free, and the government bears the burden without the patient knowing the actual cost of treatment. The problem is that when something is provided for free or is subsidised, they consider it a birthright and do not feel accountable to the system. The people working for a public hospital can be made responsible by implementing bureaucratic individual accountability. But at the same time, the clients of the hospital, i.e. the patients, also should be accountable to the system. Their loyalty to the state can be thoroughly established by implementing WPES for patients in hospitals.
When someone in public does not provide a GST bill while selling a random item, the buyer will feel guilty about buying such a product and report the evasion to the GST department. They will know that this GST revenue is needed to run a free healthcare system which benefits them also. The benefit accrued via WPES will be permanently added to one’s profile and stand as a constant reminder of what the nation has provided for their welfare. So, people will respond positively to the taxation system if WPES is correctly implemented for running the national healthcare system. People will realise that the taxes they pay for agricultural products, industrial products and services are not wasted and is effectively returned to them via employment opportunities, public education and healthcare.
Even for a slight case of tax evasion, severe penalties can be imposed, and such actions can be justified by highlighting the spending on these social welfare initiatives. There will be inner guilt in people if they evade taxes or if they see others evade taxes when the government is spending via healthcare for people. A commitment to a national cause will rise among the commoner in which paying taxes is considered essential in maintaining social welfare initiatives.
Implementation of WPES in National Healthcare System
For all ailments and issues, including minor ones, consultation is free in hospitals under NHS, and paper prescriptions can be made to a local pharmacy, ensuring pharmacies are not affected by the national healthcare system. Pharma companies need to make profits from medicines to ensure that it is reinvested in research and development of new drugs. So in the case of outpatients, medications that need to be taken immediately will be given from the hospital for free, whereas the medicines prescribed for one week should be bought outside from any pharmacy for minor ailments. The doctor will not recommend any particular pharmacy, and the recommended medicine record will be maintained in the hospital database to ensure that pharmacies are not engaging in conspiracy and corruption activities. All other issues covered by a normal health insurance scheme which includes hospitalisation, will be provided for free under NHS. So whenever hospitalisation is required, the entire cost of treatment will be taken care of by the government, including the room rent and all medicines.
There will be a special provision for senior citizens requiring daily medications. Based on the distance from the hospital, a senior citizen will be allocated a nearby hospital where they can collect medicines for one month or two weeks together after a check-up. Doctors will independently verify that the person requires certain medications, and any doctor attempting to create fake beneficiaries to make money will be punished.
Every Indian will automatically receive 1000 rupees in a WPES wallet linked with Health ID, which can be redeemed at public hospitals.
The patient or family members of the patient on behalf of the patient can request via NHS-regulated hospitals for approval of additional funds above 1000 rupees to WPES. An authority at the central level of NHS will approve each patient’s request, and funds will be added to WPES and redeemed at the hospital billing section. The amount requested can be any amount. Once the requested amount is transferred and settled, the account will be recharged again for 1000 rupees minimum balance. So whatever amount a person claims, it will be recharged to a minimum wallet balance of 1000 rupees once it reduces from 1000 rupees.
This 1000-rupee wallet balance is also used for flagging discrepancies and rooting out corruption. Any amount over 1000 rupees used in one stretch will be cross-checked to ensure that corruption is not involved.
Another method of regulating corruption is by creating a section in WPES where the total claims of a person are listed. In this section, the total amount received by the person to date will be mentioned.
All patients visiting a specific public hospital should also disclose whether any family member works in the hospital they visit. The system will thoroughly cross-check all such claims.
Central-level NHS authority will have a separate division to check fraud, like the insurance claim checking process. It ensures that fake surgeries are caught, and some doctors and hospital management may engage in greed by selling the materials meant to be used in surgery outside the hospitals to make money.
Every public hospital will have a special fund set aside for exceptional circumstances. For example, in emergencies such as accidents, the hospital will use the fund to perform operations. Once the patient’s identity is known using the WPES system, the amount will be paid again by the patient using the health id number, and after the payment, the initial amount used from the special fund will be reversed.
OCI holders, non-remitting NRIs expecting citizenship of other countries, NRIs possessing PR of different countries and foreigners will be excluded from free healthcare, and they must pay for every service public hospitals provide.
Cosmetic surgeries and other luxury facilities, such as spacious hospital rooms with extra facilities, are also paid services for all.
WPES is not involved in the paid services, and the patient directly pays to hospital based on the rates fixed for each treatment or each service under the NHS payment.
Special Note: This is the first chapter of the book New India Manifesto by Blessen T. Sam. The concepts introduced in this book are unique, and referencing the book and the author is appreciated. Support the hard work of the author to modernise India by purchasing a print copy of the book from Amazon or Flipkart. For research collaborations, contact the author at email@example.com.