In Conversation: Nachiket Mor, Visiting Scientist, The Banyan Academy of Leadership in Mental Health

September 6, 2021

Nachiket Mor - Reimagining India’s Health System - The Lancet Citizens’ Commission
Nachiket Mor has a PhD in Economics from the University of Pennsylvania. His work is focused on the design of national and regional health systems. He is a Visiting Scientist at The Banyan Academy of Leadership in Mental Health, and a Senior Research Fellow at the Centre for Information Technology and Public Policy at IIIT Bangalore.

Nachiket Mor: With its ability to improve general quality of life and enhance a country’s growth potential, Universal Health Care is an important goal globally. While many countries have made significant headway towards this, India’s journey has unfortunately been rather slow. The persisting high disease burden, widespread malnutrition, low public spending, catastrophically high out-of -pocket expenditure, all point towards the fact that we have a long way to go towards UHC. The devastation caused by the two waves of Covid, only served to highlight the immediacy of reforms needed. 

Nachiket Mor: Any discussion of the pathways that India needs to take towards UHC needs a clear understanding of how it is to be financed. Questions around financing can tell us how much money is available in the system, how this money is raised and how it is utilised. Each of these questions are critical in deciding our course towards UHC. It ultimately helps determine who has access to how much and what kind of health.

The financing workstream, which I coordinate, is basically trying to answer two broad, connected questions. Firstly, we ask, how can we get more money for health? Currently 63% of India’s health spending is out of pocket. The objective is to instead have a larger share of our health be funded by taxes or insurance premiums and gradually reduce OOPE to almost zero. For this, we start by asking exactly how much is needed for UHC in India? Are states already spending enough? If not, how much is really needed? We have a team that is working on answering these questions through models and simulations.

With a spending of 0.5-1.5% of GSDP, state contribution to healthcare is very low indeed. And as we move to richer states, contrary to what one may expect, we see the share of health expenditure either stagnating or even declining. Despite the rather obvious issues our health systems face, why are states so reluctant to spend more? How can states be persuaded to increase allocations to health? How both states and citizens can be convinced to politically prioritize healthcare, is another critical question that we are trying to answer.

With government spending being low and rather slow to pick up, it is also important to look at what insurance premiums can do in the interim. Commercial insurance in India, while small, is growing rather fast. However, the current form of insurance India has-indemnity contracts- do little to either financially protect customers or improve their health outcomes. As commercial insurance continues to grow, we ask if they can be regulated to align them more with our UHC goals? Can the current indemnity contracts be replaced with products that integrate financial protection and health outcomes? Here we also try to see if and how a restructured commercial insurance segment can build capabilities that can ultimately be picked up by the state to accelerate the move to UHC.

Secondly, we ask, how can we get more health for the money? Government spending, while low, still accounts for nearly a third of India’s total health expenditure. It is then, important that these funds are optimally utilized. However, available evidence on the utilization of these funds points towards rather skewed priorities (for instance, excessive spending on C-section in place of pre-natal check-ups and care) and poorly performing government insurance pools (including India’s mandatory social health insurance- ESIC), effectively providing neither good health outcomes nor financial protection. A crucial question that we then try to answer is, how can government spending be reformed to ensure people get the most benefits out of the limited resources available? Creating better structures for fund utilization, in addition to getting people the most out of existing funds, could also provide states the much-needed incentives to spend more. 

Out of pocket spending forms the largest share of our health spending and this could continueto be the case for another couple of years till pooled finances take over. This would mean that it is critical for us to think of ways to help people get the most out of what they are spending. Are there ways to steer people away from unnecessary specialised care and towards more primary care? How can the debilitating impacts of spending at the point of consumption be reduced? These are yet another important set of questions that the financing workstream is trying to answer.

Nachiket Mor: Right from the Bhore committee, we as a nation have acknowledged the need for reform in India’s health system and the urgency with which these reforms are needed. We have since then had multiple commissions that have laid out different recommendations towards health system reform. Unfortunately, a lot still remains to be changed. The Lancet citizens’ commission is building on the decades’ worth of expertise and knowledge put together by these various commissions. With experts from different backgrounds and its interactions with the different system stakeholders, the commission is also working with a strong acknowledgement of what is needed and what the system is capable of. By not looking at government as the sole pillar upon which health reforms rest and acknowledging the strengths of the different, previously overlooked, stakeholders, the commission hopes to make headway into developing a more viable and practical pathway towards UH.