Indian Railway Health Service : A Model for Universal Health Coverage | Economic and Political Weekly

2022-08-20 01:39:10 By : Mr. jack wang

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The Indian Railway Health Service is one of the largest and most widely spread medical service models in the country. It has, over time, established a health infrastructure network, with 125 hospitals, 586 polyclinics, 92 lock-up dispensaries in its sector, and 686 hospitals recognised in the private sector for medical treatment. It provides comprehensive healthcare not only to railway employees and their families but also retired employees. If the railway health model is redeveloped and recreated to achieve the goal of universal health coverage, it can not only continue to provide robust healthcare facilities but also deliver quality people-centred integrated care.

With the advent of the railways and the construction of railroads in India in the 19th and the early 20th centuries, issues around worker safety and solutions for the same became a common concern. During this period, while the introduction of this miraculous “big technology” continued to amaze rail passengers and employees alike, they often experienced its ghastly dangers as well. For instance, in 1881, there were 30 derailments in the Madras Presidency ­itself, along with incidents of collisions, fires in trains, defects to train wheels, among others (Jineesh 2021). These grim rea­lities sparked the development of a branch of medical practice termed “railway surgery” during the Victorian era. The railroads also connected different parts of the country and brought a huge number of people to remote, underdeveloped areas that lacked doctors and medical staff, further contributing to the development of these healthcare facilities.

In the “Train Doctors, A Detailed History of Railway Surgeons,” Robert Gillespie (2006) states: “Railway surgeons, nearly forgotten today, once formed the nucleus of a vast and innovative healthcare network.” As the number of railroads increased, railroad physicians and surgeons became essential in the healthcare system. According to Gillespie (2006):

Railroads initially relied on contracts with private doctors along their lines, but the huge number of visits soon made hiring dedicated railroad physicians a practical option. By the early 20th century, every major railroad listed full-time doctors on its payroll.

In a similar vein, the Indian Railways developed and consequently followed a “huge health directorate headed by a dire­ctor general of Railway Health Service (in Railway Board) with chief medical directors in every zone and chief medical superintendents in every division” (Debroy 2018).

A by-product of the British colonial rule, the Indian Railways, was inaugurated on 16 April 1853, when the first passenger train, carrying around 400 passengers, ran a stretch of just 33 kilometres (km). It was nationalised in 1951 and is now one of the largest railway systems in the world, covering a total route length of 66,687 km, of which 31.85% is double or multi-tracked. According to the Ministry of Railways, with a total of 7,325 stations, as well as 13,169 passenger trains and 8,479 goods trains operating each day, the Indian Railways carries approximately 1,250 million passengers (GoI 2021). The medical vertical of the Indian Railways, that is, the Indian Railway Health Service (IRHS), now renamed the IRHS, is an organised “Group A” service of the Government of India. Recruitment to the cadre is done through the Combined Medical Services Examination conducted by the Union Public Service Commission (UPSC).

Overview of the Indian Railway Health Service

In its nascent phase, the IRHS was not uniform—every station had arrangements that differed widely. In April 1954, E Somasekhar, the then chief medical officer of the Southern Railway, proposed a comprehensive plan on the organised expansion of the medical service for the railways. Since then, the railway health service has been continually exp­anding and developing. The 1962 report of the Railway ­Accident Enquiry Committee headed by H N Kunzru described the IRHS as “being second to none.”

The functions of the IRHS can be broadly divided into four parts: industrial and occupational health services; disaster management at the time of railway accidents; implementation of national health programmes over the railways; and implementation of food standards, sanitation, and safety over railways.

The IRHS is supposed to conduct a pre-recruitment medical examination of the candidates, and periodic examination of the employees, certification of injuries under the Workmen’s Compensation Act, invalidation of unfit employees, medical certification of employees in cases of sickness, emergency service to sick passengers, and basic awareness. The other major portion of its work includes providing free promotive, preventive, curative, and rehabilitative healthcare to current and ­retired employees and their dependents. Additionally, it oversees sanitation in the railway colonies and stations, monitors quality of water and food at the stations, and creates awareness about good health practices and vaccinations.

From the bottom-up, at the subdivisional or the peripheral level, the additional chief medical superintendent is in ch­arge; the divisional level is headed by the chief medical superintendent; the zonal level by the chief medical director; and the broad railway level by the executive director. The cadre is headed by a director general, railway health service, who ­reports to the Rail Bhavan in New Delhi.

IRHS and Universal Health Coverage

“Promoting and protecting health is essential to human welfare and sustained economic and social development” (WHO 2010). “Health for all” is necessary not only for a better quality of life but also for global peace and security. Health is indeed a political affair as governments try to fulfill the expectations of people.

Universal health coverage (UHC) was an approach by the World Health Organization (WHO) to “promote health for all (HFA).” However, this approach did not materialise due to various reasons. In 2005, a resolution was passed by the World Health Assembly urging countries to mandate UHC and HFA as soon as possible. Furthermore, with COVID-19 unravelling the fragile nature of the public healthcare sector as well as profiteering by private hospitals, there is a need and demand for a robust UHC apparatus in the post-pandemic world. So, UHC ­refers to the concept of equitable access to quality healthcare for all the citizens of the nation, irrespective of their income or social status, with minimal direct payments, as the government ensures these services.

According the WHO (nd), UHC means  ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Although Sustainable Development Goal (SDG) Target 3.8 is to achieve UHC by 2030, it is a concept rooted way back in the WHO Constitution of 1948, which voices health as an essential human right and commits to ensuring the highest achievable level of health for all. UHC covers three main dimensions: equity, fina­ncial risk protection, and quality service (World Bank 2021). The global report on tracking UHC, published by the WHO and World Bank (2017), stated that “an estimated 97 million people were impo­verished by healthcare expenditures at the $1.90-a-day poverty line in 2010, equivalent to 1.4% of the world’s population.”

UHC has been achieved by many of the high-income countries, but time and resources play an important role in securing it. For instance, Germany took nearly 118 years to achieve UHC, while Belgium took 64 years to protect 99% of its population against major and minor health risks. Middle-income countries like Thailand and Mexico that have been able to achieve UHC prove that it is not only the prerogative of rich countries. In fact, certain high-income countries, like the ­United States, have not been able to achieve UHC (IPH 2012).

In the Indian context, 55 million people were pushed into poverty due to having to fund their own healthcare ( Nagarajan 2018 ). In some cases, the health-seeking behaviour of many is adversely affected to avoid such impoverishment. The healthcare sector is one of the driving forces of employment generation. According to the Commission on Macroeconomics and Health (CMH), illness leads to financial losses for a country. Better health increases productivity and enhances the ability to earn more income, which, in return, potentially permits ­indi­viduals and societies to afford better nutrition and access to better healthcare. Reaching the “highest attainable standard of health” is critical for human well-being. In lieu of this and many other arguments, the National Health Policy, 2017, in its first objective talks about progressively achieving UHC in the country.

There are two major players—private and public—involved in healthcare provision in India. The basic amenities provided by the public sector are in the form of primary healthcare centres (PHC) and, to a limited extent, secondary and tertiary services. In contrast, private players place an emphasis on provi­ding care through secondary and tertiary facilities. Despite being one of the major outsourcing countries for medical professionals, India still lags behind in terms of quality and accessibility to healthcare. According to the Lancet’s Global Burden of Disease Study 2015, in terms of access and quality, India ranks 145 among 195 countries.

In 2011, nearly 31% of the Indian population lived in urban areas, and this proportion is constantly expanding (Lahariya et al 2016). At the same time, India is gradually witnessing a transition in disease epidemiology, with non-communicable diseases contributing nearly “two-thirds of total disease burden.” The health outcomes of the poor living in urban areas are not any better than those of the rural population. Fragmented healthcare service delivery, inadequate financing, poor infrastructure, insufficient coordination among the stakeholders, inadequate health workforce, and high level of inequities and inequalities are some of the key challenges of urban healthcare provision (Lahariya et al 2016). These are some of the reasons that policymakers attempted to address through the launch of the National Urban Health Mission (NUHM) as part of the overall National Health Mission (NHM) in 2013, in order to meet the healthcare needs in cities and towns.

This leads to the much-debated question of whether the ­Indian healthcare system is affordable and accessible to all. A 2012 McKinsey report analyses that “the urban rich access healthcare at a rate that is double that of the rural poor and 50 percent more than the national average” (Gudwani et al 2012). The Economic Survey 2018–19 reveals that affordability and accessibility to proper healthcare in rural areas is still a matter of concern, as compared to urban areas (GoI 2019). Gaps in infrastructure, lack of doctors, absenteeism, and poor quality of service are some of the reasons why the population chooses private healthcare facilities over the public system, leading to a high out-of-pocket expenditure (OOPE) on health. According to the National Health Accounts Estimates for India, 2015–16, India’s OOPE is very high at 60.6% of total health expenditure, in contrast to the United Kingdom (15.6%) and Thailand (12.5%) (GoI 2018). It was further reported that within a period of 10 years, from 2004 to 2014, the total OOPE per household rose from `3,855 to `4,955 (Ravi et al 2016).

In this context, several government health insurance schemes and reforms are aimed at providing comprehensive care to the population and protecting households against catastrophic exp­enditures. The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB–PMJAY), which was introduced by the government in March 2018, aims at providing health insurance of `5 lakh per year to 10 million vulnerable families, on the basis of the Socio Economic Caste Census of 2011. This would roughly include around 500 million Indians, that is, approximately 40% of the country ’ s population and is seen as the government ’ s first step towards achieving UHC (the AB–PMJAY and the path of UHC in India) (Angell et al 2019). The scheme has two components: the first one is to constitute 1,50,000 health and wellness centres (HWC) to cater to the primary healthcare needs of the people; and second is to provide financial protection for secondary and tertiary care to households covered by the scheme. The AB–PMJAY thus aims at empowerment and reasonable commitment towards the achievement of UHC. To augment the growth and quality of healthcare, UHC has ­become the primary model under the SDGs. The Rashtriya Swastha Bima Yojana (RSBY), the previous insurance-based scheme, also had a similar structure and framework as the ­AB–PMJAY, but failed to deliver on its primary objective of reducing out-of-pocket health expenditure.

Healthcare is a concept that is interlinked and interconnected to various other factors. Any policy that aims to achieve UHC for a huge populace like India, cannot be carried out in isolation; various elements come into play in implementing and sustaining a broad policy. Finance is one of the biggest obstacles in achieving UHC. The fact that the states have to bear 40% of the financing, as per the AB–PMJAY, adds to the burden of sourcing funds for states with high poverty levels. This is further exacerbated by the inability states to set their goods and services tax (GST) rates along with the central government’s obligation to keep a check on the fiscal deficit. Another important factor that acts as a hurdle in attaining UHC is the focus on only the “dem­and aspect” of healthcare. On the supply side, by 2030, India will requires 20.7 lakh doctors to reach a doctor population ratio of 1:1,000, which implies the need for a growth rate of 151% registered doctors in the country (Mishra and Kashyap 2020).

The inadequate rural health infrastructure also serves as a major challenge that needs attention. According to the WHO, there are merely nine beds per 10,000 population in India. In India, the delivery of healthcare facilities, being a state subject, rests with the states. Thus, the centre–state dynamics play an ­important role in its implementation. Corruption is another challenge that might hinder the proper operation and implementation of the scheme. In the case of the AB–PMJAY, there have been cases of fraud and impersonation registered with the ­police, with a large number of non-beneficiaries availing ins­urance benefits (Mishra and Kashyap 2020). Further, since the hospitalisation payments are in the form of reimbursements, there have been cases of no or delayed reimbursements adding to the misery of the poor (Mishra and Kashyap 2020).

In addition to these challenges, the scheme also faces issues in terms of integration with various state-run insurance programmes, resistance by states, budget allocation, private hospital empanelment, and services covered. Furthermore, the extent to which it can be expanded to the entire population as well as the time it will take for the same is questionable in the recent context.

The fundamental way in which a country can proceed tow­ards UHC is through promoting health equity, which ranges from universal access to health services and health protection. According to the World Health Report 2008, “Universal coverage is not, by itself, sufficient to ensure health for all and health equity—inequalities persist in countries with universal or near-universal coverage—but it provides the necessary foundation” (WHO 2008). People desire health facilities to be equitable; however, the root of inequality lies in various social issues that must be tackled via intersectoral and cross-governmental action. To advance health equity, certain actions need to be taken by the health sector, the basis of which lies in the universal coverage, that is, universal access to health services along with social health protection.

The IRHS mission statement is “total patient satisfaction, through humane approach and shared commitment of every single doctor and paramedic, to provide quality healthcare using modern and cost-effective techniques and technologies.” It provides promotive, preventative, curative, and rehabilitative healthcare to all its employees. This type of comprehensive and affordable healthcare for all (the employees) forms the basis of UHC.

The IRHS has a total of 125 railway hospitals, 586 polyclinics, as well as 133 hospitals recognised in the private sector for medical treatment. This adds up to a total of 13,963 beds for a population of 61,58,780, which means one bed for approximately 477 people (Indian Railways nd). This is well above the bed to population ratio of 1:1,000 recommended by the WHO. The Central Bureau of Health Intelligence (CBHI) regulates in-s­ervice training for the officers and staff working in various railway health institutions, for capacity building and human resource development in the health sector. For disaster management in the event of railway accidents, it is equipped with different types of accident relief medical equipment (ARME): 172 scale 1 equipment in medical vehicles, as part of accident relief trains; and 325 scale 2 equipment in boxes at specified stations. It has also provided India with some of the most efficient medical technologies. For example, the Southern Railway Headquarters Hospital has some of the best cardiologists and cardiac surgeons in the country, and the first cardiac bypass surgery of India was carried out there in 1975, followed by the corrective transposition of the great arteries surgery in 1979.

Health Infrastructure and Human Resources

In Table 1 (p 57), the railways health infrastructure, as per March 2019, has been dissected into various zones and tabulated (CBHI 2019). The table consists of the various dispensaries and hospitals along with the number of indoor beds allotted to each zone.

From Table 1, it is revealed that the Northern Railways has both the highest number of dispensaries and hospitals, while the Eastern Railways has the highest number of indoor beds. Although the healthcare sector often acts as an employment and revenue generator, it is criticised because of its skewed workforce. Despite human resources in the healthcare sector playing an important role in providing care and services, there is a lack of a qualified workforce in the healthcare system. The current doctor to population ratio in India is 1:1,456, while the nurse to population ratio is 1:475.14. In addition to this, 56.4% of health workers, which is nearly 1.4 million, are not qualified as per the demands of the cadre. This unqualified workforce is usually the first point of contact for the rural population and the poor as far as the ailment is concerned. In contrast, the healthcare professionals of the IRHS are selected through entrance examinations, which justify the quality of these health providers.

In Table 2, the human resour­ces engaged by the railway health sector are tabulated, revealing the entire universe of clinical staff appointed by the Indian Railways. The table indicates that the number of nurses employed is high across facilities. The number of pharmacists across different railway zones has also been ­tabulated.

An adequately skilled health workforce is required to ensure UHC. The WHO categorised India among “the 57 most severe crisis-facing countries” in terms of availability of human reso­urce for health (Karan et al 2019). The WHO recommends a threshold of 22.8 skilled health professionals per 10,000 population. In this context, the Indian healthcare sector faces a shortage of health workers. There exists a maldistribution of health workers across rural and urban settings, along with an alarmingly large unqualified health workforce. In many places, the first clinical point of contact with the community is these unqualified doctors. In contrast, as stated above, recruitment to the IRHS cadre is carried out by the UPSC, which determines capability and merit, and thus provision of comprehensive care and services.

The reports of the Expert Group on Indian Railways (2001) and the Committee for Mobilisation of Resources for Major Railway Projects and Restructuring of Railway Ministry and Railway Board (Debroy et al 2015)—also known as the Rakesh Mohan Committee and Bibek Debroy Committee, respectively—suggested outsourcing of health services, and ceasing to provide the same through the railway medical service. The committee suggested that provision of medical facilities is a “non-core” domain of railways and hence the focus given to health services should be reoriented to strengthen the core railway services instead (Expert Group on Indian Railways 2001).

However, the question arises whether it is viable to cease services at an existing hospital, when there already exists a shortage of hospitals in India. Literature shows that the bed occupancy ratio in a government hospital is around 95%, while the same ratio for railway hospitals is around 62%, thus revealing how railway hospitals are not optimally used ­(Debroy 2018).

The IRHS is also extremely cost-effective in terms of efficiency and range of health services it provides. According to the Health Directorate of the Railway Board, to cover the wide range of services, the railways spent `3,800 crore for medical, health, and other welfare services and `1,41,000 crore for ordinary working expenditure in 2018–19. The 2018–19 statistics suggest that the railways spent an average of `6,814 per beneficiary in that period (Indian Railways 2021). This, when viewed against outsourcing of health service to the private sector, proves to be more cost-efficient. The inherent issues ­related to the privatisation of healthcare remain, namely lag in reimbursement, hazard of overprescription of tests by the private hospitals, and failure to cover a wide range of health services.

Table 3 tabulates the performance statistics of the railway hospitals, which consist of multiple factors ranging from total outpatient and inpatient cases, to the number of surgeries conducted, number of new cases, etc, as given by the Indian Railways Annual Report and Accounts 2018–19 (GoI 2020).

Table 4 charts down the qualitative performances of the railway medical services including certain factors like morta­lity in hospitals, bed occupancy rate, and the number of patients referred to other hospitals for in-patient department (IPD) treatment. Table 5 tabulates the distinction between sanctioned employees and working employees of the Indian Railway Health Service. Table 6 compares certain other parameters between various healthcare models and railway models—like the scope of the model, the number of persons included annual cost, etc. This data shows the strong and robust system of railway medical services.

Table 7 tabulates the comparison between the National Health Service followed by the United Kingdom and the Railway medical model depending on certain factors like population covered, doctors, nurses, waiting times, and others.

Railway Model and Health Expenditure

So, if the railway model is extrapolated in India then the total health expenditure of India will be as follows:

The Indian Railways has, overtime, established a strong and robust infrastructure of hospitals and health units. With a dedicated clientele and a trained and well-qualified staff, it provides a comprehensive healthcare system. As seen in this paper, the railways provide an equitable health service that is cost-effective despite covering a wide range of services, and even includes disaster management such as in the event railway accidents. It has uniform policies and rules, with a wide scope for decentralisation. The doctors are recruited by the UPSC, ensuring the highest merit, while nurses and allied staff are selected through Railway Recruitment Boards. Most of the railway hospitals are located in important cities and have good land and infrastructure. Some of the railway hospitals are pioneers in certain specialties, for instance, the railway hospital in Perambur near Chennai was well known for cardiac services, and its doctors have established and worked in some of the best cardiac units in Chennai. During the COVID-19 pandemic, railway coaches served as level 1 COVID-19 care centres and aided in the provision of basic healthcare and quarantine facilities.

As outlined in this paper, railway hospitals in India have a legacy of over a century. The expectations and aspirations of railway employees, their families and pensioners from railway hospitals have also increased over time. Railway hospitals need to bring in professional management to continue to improve services. Furthermore, if the railway medical model is recreated to achieve UHC, it will not only be capable of providing robust healthcare facilities but also deliver quality people-centred integrated care. There is a long pending need to improve and strengthen the railway health service in this direction, and proper investments and innovative technological transformation can successfully address the provision of comprehensive care facilities.

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