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Towards Healthcare for All

From EPW:

Can we grasp an opportunity to provide health services to all Indians?

Sixty-five years after the Joseph Bhore Committee on health recommended that the State take full responsibility for providing preventive and curative services to all Indians, another opportunity to take a step in that direction is with us. The High Level Expert Group (HLEG) on Universal Health Coverage (UHC) for India, constituted by the Planning Commission, has offered a blueprint for introducing a National Health Package that would entitle all citizens to primary, secondary and tertiary care that is paid for by the state. This comes at a time when there is a momentum the world over – other than in the United States and China – to provide universal healthcare. India, which has one of the most indifferent records in the world in this area, must embark on the 10-year path laid out by the HLEG to move to universal care.

It does not require mention that the health status of India’s people is poor. There are economic, social and regional differences but the larger picture is one of high mortality (of infants, children and mothers), low life expectancy and high morbidity. Only nine out of 191 countries spend less than the 4.4% of total government expenditure that India now devotes to health. The limited volume and quality of public services has been driving people to private health services. These are booming, but the large out-of-pocket expenses on healthcare and drugs are imposing a heavy burden on patients. Such expenditure is estimated to push 30 million people a year into poverty. It is no wonder that what Indians increasingly fear is not falling ill but what they have to pay to get better. In recent years the centre has hit on insurance schemes like the Rashtriya Swasthya Bima Yojana (RSBY) and state governments on healthcare like the Aarogyasri programme of Andhra Pradesh. But the RSBY is ineffective because it is inadequate and Aarogyasri does not look beyond surgical care. Programmes like the Aarogyasri are also cash cows for insurance companies and corporate hospitals.

In a reversal of recent trends, the HLEG dares to ask the state to commit itself to providing “affordable, accountable, appropriate health services of assured quality…with the government being the guarantor and enabler, although not necessarily the only provider…” The committee makes recommendations in six important areas that are critical to realise the vision of UHC: (i) financing, (ii) service norms, (iii) human resources, (iv) community participation, (v) access to medicines, and (vi) management and institutional reforms. This, in effect, calls for a complete overhaul of the health sector and addresses in an integrated fashion all issues, from establishing the infrastructure necessary to create human resources in health, to building healthcare institutions, delineating protocols for treatment, providing medicines, and, of course finding the ­required financial resources. The state will finance the National Health Package, but the services themselves will be provided by public and private providers who would be contracted for the purpose. There is no place for insurance companies and there will be no user fees. The focus is on healthcare but the HLEG also gives due importance to the social determinants of health (such as nutrition).

The road map that the HLEG has laid out stretches to 2021-22. It has to be so since this is an ambitious plan to move from neglect to universal care. The big question, as always where it is a matter of state responsibility, is, “what will it cost and is it affordable?” There are, to be sure, many details to be filled, but in the vision of the committee UHC will require public spending on health to go from 1.2% of GDP today to 2.5% in 2017 and 3% in 2022. Considering the currently abysmally low level of outlays, this is not a huge increase to call for. And the committee rightly asks that this be financed from the general tax revenues and not from cesses.

A system of UHC in which the state and not the private sector plays a predominant role will have to cope with major opposition from business interests that have entrenched themselves in everything from diagnostics to drug manufacture to health insurance to healthcare. These interests will also benefit from state-driven UHC, but it will not be on their terms. It is the state which will dictate terms. A phased introduction of UHC with the stakeholders – the people – immediately benefiting from the change in direction offers the best chance of success. Political formations will also be foolish to ignore the gains they can reap from introducing a system of rational and free healthcare that people of all classes are desperate for. A second major challenge is that this is a package that is being recommended to the centre for implementation. Where do the states – the providers of public healthcare in the constitutional scheme of things – stand? A package that the states do not have the autonomy to design and implement is destined to fail. So a federally-designed programme is essential.

The challenges are many and the obstacles to implementation will not be minor. However, decent healthcare for every citizen is too important a matter to be delayed any longer by opposition of any kind. Will the United Progressive Alliance government be intelligent enough to pick up the blueprint that it has been offered?