My prescription for India's health sector
The first two years of the National Democratic Alliance (NDA-2) government did see some positive changes like better immunization coverage, better drug price control for access to essential drugs, and a higher insurance cover for poor families, not to mention the Swachcha Bharat Mission. The government began with three good policy documents -- the National Health Assurance Mission (NHAM), the draft National Health Policy (NHP-2015) and the National AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) Mission 2014, but then the momentum was mysteriously lost.
The ambitious NHAM was probably shelved for financial constraints, though it has some connection with the new health insurance cover. The draft NHP is on the backburner, apparently because it ‘rather boldly’ optimises and defers state commitment on rights-based health care, something socialist groups would find a soft target.
The United Progressive Alliance government, through its flagship National Rural Health Mission (NRHM), mainly focused on mother and child care (in line with UN’s Millennium Development Goals) and attempted a revamp of peripheral health facilities. NRHM talked of a rights-based health care without its enactment. It covered some ground but corruption, shortage of medical personnel and a patently bureaucratic design maligned the mission.
The harsh reality of India is that about 60 percent specialist positions in rural and district hospitals continue to remain vacant. Health care is a state subject but policy, disease control programmes and regulation of medical education are central subjects. Yet the UPA could not reform the Medical Council of India (MCI) and the medical education sector. These problems still haunt us.
The UPA had appointed a committee for Universal Health Care (UHC) which recommended a rights-based UHC, raising tax-financed public health spending to at least 2.5 per cent of GDP from the chronic 1 per cent level, a medical college and better health infrastructure in each district and a universal health cover package for families.
However, the UPA shrank away from this, given the daunting personnel and finance implications. On health care the left leaning groups’ demands are: health care as a justiciable right, higher public spending on health of 2-3 per cent of GDP to start with and a UHC modelled on the National Health Service (NHS) of the United Kingdom.
NDA-2 has apparently attempted to break away from some of the socialistic scaffold of the UPA. Thus the draft NHP-2015 was rightly not keen on rights-based health care, deferring it till individual states were willing to take greater responsibility. The draft NHP2015 offered the following:
- Strengthen primary, secondary and tertiary care for rural and urban areas.
- Make available health human resources, including AYUSH and paramedics
- Attend to production and use of drugs, diagnostics, technology, equipment
- Provide a safety net for the below poverty line (BPL) population and ensure affordable services for above poverty line (APL) sections
- Strengthen public and charitable health care facilities without directly disadvantaging the private and corporate sector in health care
- Stimulate decentralization and good governance
- Encourage state level-fund-pools for free and affordable care
- Promote AYUSH
- Improve health determinants through better sanitation, occupational safety, de-addiction, pollution control and nutrition.
This is a good and pragmatic document, talking of affordable care instead of free care. However MCI reforms, expansion of health human resources to include paramedics and AYUSH and clear choice of UHC model should be part of this.
The NHAM, although preceding the NHP-2015, was a NHP-congruent action plan for strengthening universal primary care and protection from catastrophic health expenses by improving public hospitals and contracting public-private-partnerships (PPPs), if necessary, for tertiary care. Together this makes a good policy and action plan.
The modern liberal position abhors a welfare regime; yet it retains a variable role for the state in social sectors. Here are some defining lines for a liberal position on health sector reforms.
- Right to health is not the same as right to health care. A rights-based approach enjoins the state to provide all the way. This is the burdensome to the state and detrimental to the people and the health sector itself. We need to ensure health care, and not the burden of needless litigation. Health care is not a fundamental right in the Constitution, but part of the Directive Principles and rightly so.
- In a liberal democracy, rights come with responsibilities, and people need to participate and contribute for health services. State as a sole provider is an illiberal idea.
- Public health and free primary care are solemn duties of the any modern government. But free specialist care is another issue; it can be reserved for the poor, but others need to adequately contribute.
- Choice of care must remain with the family and citizen – public or private/charitable, formal-informal, primary care or hospitals, AYUSH or modern etc. A UHC is good only so far as it expands care but not when it thrusts a rigid frame with protocols, select technology and parasitic institutions on people. A fully tax-based UHC sooner or later becomes bureaucratic, cost- inefficient and burdensome. So, even if funds are available, contributory schemes are always preferable.
- We also need to steer clear of the American health care model guzzling 17 per cent of GDP, (half of which are public spend) and yet having all stakeholders dissatisfied. In much of Europe, the welfare state is spending about 30-50 per cent of taxes and 8-12 per cent of this goes into health care. These systems are facing problems of ageing citizens, chronic ailments, high-technology and human resource costs and now scores of migrants.
- In much of the remaining world, including India, this level of welfare is impossible due to low incomes and large populations. Even the United States and China could not do this. Besides, welfare state is a veiled problem rather than a solution, as it causes long term dependence of the individual on the state, and kills other institutions, initiatives and innovation. On the funds front, India can never reach levels of 8 per cent or even 4 per cent of GDP in health care in the near future. But if public funds and private expenditure are taken together, we are already spending 4 per cent of GDP on health. The issue then is transparent pre- payment systems and efficient utilization.
- There is need for a UHC but with better citizen participation and contribution; and PPPs are part of the solution. This is possible only with social health insurance systems prevailing in some European Union countries like Germany and France or even Singapore. These systems can be incrementally developed and improved, and they retain both provider and citizen control. Governments can and must share the costs for the poor families till they are poor, but the rest can be borne by middle and higher income groups.
- Since 70 per cent of health spend in India is already directly coming from citizens, this transition to prepayment is essential and logical; rather than following the tax route.
- India does have a public health care system -- thick and thin in various states -- and our first job is to reform and run it well. APL families must find our public hospitals attractive. So we have to improve facilities and introduce pre-paid contributory schemes for APL. For instance an APL family may choose to pay and enrol for the Maharashtra government’s Jeevandayi medicare scheme. Such state-fund-pools should continue to operate also for PPP hospitals. This will improve access and cost-efficiency. The new universal cover plan should therefore be attractive and open to the APL population with direct contribution, so that they can switch from the costly family mediclaim (private insurance). This is how we can expand common pool state health funds, and harness the erratic current private expenditure to more efficient use. This alone can give us a wider UHC for India with time.
Equity, access, quality, affordable cost, participation, informed choice of both healing system and provider are the important keywords for a liberal UHC. The NDA-2 government can rework the NHP-2015 (and NHAM) along these lines and start a new chapter of an India-relevant UHC.
