India's public healthcare system deserves a check-up
The existing health structure of India has an evolutionary history. India's health system can be divided into three distinct phases. The initial phase, 1947-1983, when healthcare initiatives were undertaken on two principles - none should be denied care despite the inability to pay, and it was the responsibility of the concerned state to provide healthcare to the people.
The second phase, 1983-2000, saw the first National Health Policy (NHP) of 1983 that articulated the need to inspire private initiative in healthcare services and an expansion of service for providing primary healthcare in rural areas.
During the decade following the 1983, NHP, an extensive programme of expansion of primary healthcare services was undertaken in the sixth and seventh Five Year Plan (FYP) and rural healthcare received particular attention. The third phase, post-2000, witnessed a further shift that affects the health sector in three essential ways. There was an increase in desire for utilisation of private sector resources to address public health goals. New avenues are generated for health financing due to the liberalisation of the insurance sector and change on the part of the state from being a provider to a financier of health services.
In the 1980s, medical care was open up for market expansion with many international players including the World Bank, getting interested in shaping this sector. The seventh Five Year Plan (1985-90) scaled up investment in family planning and opened up to private sector partnerships and NGOs under the enhanced pressure of neo-liberal policies.
The introduction of health sector reforms leads to cutbacks, private investments in public hospitals, purely techno-centric public health interventions and an introduction of user fees. There have been significant changes in the emergence of the middle class, demanding advance medical services. Medical bureaucracy supported this trend, professionals grown with a biomedical mindset has supported. Together they assisted the state in its neo-liberal policy shifts over the 1990s.
During eighth plan (1992-97) slogan of "health for all" was changed to "health for underprivileged", it reduced the comprehensiveness and talked about the privatisation of medical care. The conditionality imbibed in the reforms unfolded further over the ninth and tenth FYP results into an expansion of an unregulated growth of the subsidised medical market.
By promoting tertiary care and private insurances the reforms, in fact, squeeze providers of medical services for a majority. The introduction of user fee further marginalised the mass. In the late 1990s, despite improved economic growth rates and a flourishing middle class, it did not bother to provide national insurance system, health co-operatives, health cess or free services for the poor.
In the field of health, two important things happened in India in the year 2000. For the first time, the Indian government announced the National Population Policy (known as NPP 2000), and India became a signatory to commit to Millennium Development Goals. After two years, India announced the National Health Policy (2002) that reflects the concerns of Millennium Development Goals.
The NHP (2002) may be considered as the forerunner of NRHM which was to start from 2005. The guidelines of national population policy and national health policy documents focus on demographic achievements. This demographic obsession is the basis for turning National Rural Health Mission (NRHM) into medicalised health care rather than comprehensive PHC.
The National Health Bill, 2009 grants health as a fundamental human right and the 65th World Health Assembly in Geneva recognised universal health coverage as the urgent imperative for all nations to unite the advances in public health. Consequently, the now-defunct Planning Commission of India instituted a high-level expert group on universal health coverage in October 2010. The experts group gave its report in November 2011 and recommended Universal Health Coverage for India by 2022.
According to the current status of the national programmes, they only provide universal coverage on specific interventions like maternal ailments that result from less than 10 per cent of all mortalities.
Around 75 per cent of the communicable diseases are outside their purview, and only a limited number of non-communicable diseases were covered. As it stands, health will be recognised as a fundamental right only when three or more states request for it. Since health is a state subject, therefore, adoption by the respective states will be voluntary. The very objective of universal health coverage that hinges on portability will be defeated in the absence of uniform adoption across the nation.
The draft National Health Policy 2015 is being introduced almost 13 years after the last health policy was drafted. The new policy draft determines that the present concept of primary healthcare covers hardly 20 per cent of the health needs and accounts for hefty out-of-pocket expenditure which is considered as one of the major contributors to poverty. Although bringing down expenses has been listed among the major objectives of spending of the new proposed policy, it has no ideas on how to do it. It is silent, for example, on regulating the private healthcare sector.
After a gestation period of about two years that faced extensive public dictum and strident debate within the government, the policy finally emerged. Then the question arises how does the NHP 2017 propose to organise healthcare services? The answer stated was "health assurance". The policy document suggests government’s role as benefactor of healthcare services by stressing its role as a "strategic purchaser" of services. The overall prescriptions in the policy regarding insurance schemes that rely primarily on private sector provisioning in cases of secondary and tertiary level care are designed to strengthen the private sector further and denude the public sector.
The recommendation in the NHP 2017 to increase the government’s expenditure on health from the existing 1.15 per cent to 2.5 per cent of the GDP by 2025, finds no replication in the Union Budget 2018-19.
The share of NRHM in total expenditure has fallen further from 52 per cent (2015-16) to 44 per cent this year.
Within the NRHM, cuts were fairly radical for reproductive, and child healthcare and communicable diseases care but an increase in funds for strengthening health systems which are presumed to be for setting up the 1.5 lakh "health and wellness centres" as mentioned in the Budget speech. The allocation of 1,200 crores for 1.5 lakh wellness centres means an average of 80,000 per centre. Their effectiveness in the absence of a supportive infrastructure is questionable.
The government of India announced the launch of a comprehensive national health insurance scheme to cover 10 crore (100 million) families for treatment at secondary and tertiary health care centres. Insurance as a substitute for public health infrastructure can be counter-productive. First, it will expand space for the unregulated private sector which can inflate healthcare cost and hiked the insurance premiums which are to be borne by the state. Second, it will not make up for the absence of the public health infrastructure in underserved areas.
The huge out-of-pocket expenditure to avail healthcare services clearly indicates the unavailability of primary healthcare and low government spending on health service system. The announcement of world’s largest healthcare programme - the National Health Protection Scheme - a massive insurance scheme for 50 crore (500 million) of India’s poorest, sounds impressive. Conversely, what appeared less important was the promise of universal health coverage and what went utterly missing was health as a fundamental right.
The emphasis is shifting from public provisioning of services to merely ensuring universal access to services. While there is a lot that needs to be said about the shortcomings and directions for our health system, the aforementioned points have been the basic thematic rationale of the system that can respond to the needs of the majority.