The Government of National Capital Territory of Delhi (GNCTD) announced on December 13, 2022, that 450 diagnostic tests will be available free of cost from January 1 next year, initially at mohalla clinics and then extended to government hospitals. The GNCTD operates 39 hospitals, 201 dispensaries, 31 polyclinics and 521 mohalla clinics.
The range of tests include those that are fairly routine (blood sugar or thyroid function) to those used for screening of cancers (such as Prostate-Specific Antigen) and even those for relatively less prevalent conditions (such as anti-tissue transglutaminase antibodies to diagnose celiac disease). There are currently 23 empanelled private diagnostic centres for this scheme.
An RTI response (to an application filed by The Indian Express) revealed that 1.04 lakh people got imaging tests such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans under the scheme in 2021, up from 52,000 in 2017 – a spectacular doubling in four years. What really are the import of these numbers?
The seemingly huge number in 2021 is likely a partial count of such imaging tests conducted in Delhi. The UK’s National Health Service (NHS) conducted 37.7 lakh MRI and PET scans (October 2020 to October 2021), for a population about three-and-a-half times more than that of Delhi. The number of computed tomography (CT) and MRI tests per 1,000 population in India was 36 compared to 53 in Brazil, 144 in the UK or 407 in the US.
Similarly, compared to 1,111 pathology tests per 1,000 population in India, Brazil conducts 5,924 tests and the US 20,958. Does this portend a huge unmet need that the GNCTD is trying to address? Seemingly, yes.
Applying the IPHS Lens
The National Health Mission (NHM), through the Indian Public Health Standards (IPHS), provides a standard list of diagnostics, in essential and desirable categories. It does allow for an expanded list though should any state government choose to provide more.
Interestingly, the currently available GNCTD list of 212 tests does not include the IPHS-mandated tests for common infectious conditions such as cholera, diphtheria or kala-azar. At the same time, it includes a wider array of tests for certain endocrinological conditions or other sophisticated tests. Unlike the IPHS, it does not categorise the list into essential and desirable tests.
What about the levels of healthcare services? The IPHS provides two distinct lists of services, including diagnostics: one for Health and Wellness Centres (HWC) and Primary Health Centres (PHC) and the other for Sub-District Hospitals (SDH) and District Hospitals (DH).
The GNCTD has decided to make the same set of diagnostics available at all levels, from mohalla clinics and dispensaries to well-equipped hospitals that serve as referral centres. The lack of a tiered approach (across primary/secondary/tertiary levels of institutions) in terms of provisioning of diagnostics may have contributed to the popularity of the scheme, underscored by burgeoning numbers, but points to inappropriate systems thinking in its approach to planning and provisioning of health services.
Diagnostics is Big Business
The announcement of 450 free medical tests led to a 2.61 percent decline in the share prices of a leading diagnostics chain (one of the big four) by the following afternoon. This scheme is largely delivered by contracting out tests to private diagnostics centres in Delhi. The diagnostics sector in India is growing at an annual CAGR (compound annual growth rate) of 11-12 per cent.
Nationally, the four largest chains account for only 6 percent of the market share and local laboratories have a 46 percent market share. Hospital-based laboratories account for the balance 48 percent of the market share. It is possible that schemes such as these may preferentially benefit local players rather than the big chains as the government contracts out tests at Central Government Health Services rates. The Indian market is expected to grow more around specialised tests that now account for about a quarter by volume but up to 45 percent by value; the GNCTD list does include a fair share of such tests.
Address the Fault Lines of Fragmented Health Services
Health services in Delhi have long been a story of a multiplicity of agencies (central, state and local bodies), and contestations over resources and jurisdictions. Epidemics such as cholera, plague, dengue, SARS and COVID-19 have generally been marked by technical coordination across agencies as well as proactive political leadership.
Organisation and delivery of ‘routine’ healthcare services are riddled with fragmentation and overlap across agencies and inter-agency conflicts. The weakening and marginalisation of municipal structures have not helped matters either.
Diagnostics are integral to a responsive healthcare system and account for a significant proportion of out-of-pocket expenditure. The emphasis should be on an assured minimum set of diagnostics appropriate to the level of care, that translates to initiation and continuation of appropriate treatment (based on accurate diagnosis).
Universal Health Coverage (UHC) calls for reaffirming the commitments to WHO’s primary healthcare approach. The current electoral shifts in Delhi have opened the doors for greater synergy between the municipal and state governments. Together they should aim for shaping primary health care services that are high quality, safe, comprehensive and integrated – and backed by a continuum across secondary and tertiary levels.
Rajib Dasgupta is currently Professor at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University and a former Deputy Health Officer with the Municipal Corporation of Delhi. Views are personal, and do not represent the stand of this publication.