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Public Health Matters! Does it?

Posted by: Manish Thakur
Associate Professor, Public Policy and Management, IIM Calcutta
Apr 20, 2015

In December 2014, the Ministry of Health and Family Welfare placed the draft of National Health Policy 2015 (NHP hereafter) in the public domain for comments, suggestions and inputs (http://www.mohfw.nic.in/showfile.php?lid=3014). Somehow, this draft has not been able to generate the type of public debate that one witnesses in some other policy arenas. Barring few newspaper articles and some sporadic commentaries in the media, NHP remains ensconced in the website of the ministry while public attention veers around black money, coal scam, spectrum auction and the like. In the hullabaloo around smart cities, bullet trains and ‘make in India’, we appear to have relegated to the backburner one of the foremost policy challenges that we as a nation face. In fact, the Budget 2015 has gone for a lower allocation to health when compared to the last year. Our consistent indifference to public health, and the relative neglect of allied social development issues,has led to a situation when we fare worse than Nepal on some of the public health parameters let alone Sri Lanka and Bangladesh.

Even otherwise, the talk of universal healthcare sounds vacuous given the paltry public expenditure on health.The Government spending on healthcare in India is only 1.04% of the GDP which is about 4 % of total Government expenditure, and less than 30% of total health spending. True, the public health expenditure rose briskly in the first years of the National Rural Health Mission (NRHM), but at the peak of its performance, it started stagnating at about 1.04 % of the GDP. Besides, the budget received and the expenditure thereunder was only about 40% of what was envisaged for a full re-vitalization in the NRHM Framework.This has had a telling effect on health infrastructure and health care services.

Forget the developed world; we are far behind Brazil and China in terms of availability of health infrastructure. There are just seven hospital beds per 10, 000 populationin India compared to 23 in Brazil and 38 in China. The similar gaps exist in terms of availability of healthcare professionals as well. Lack of equitable access to affordable and quality healthcare remains the defining feature of the public health system in the country. The UNICEF figures reveal that an estimated 12.7 lakh children die (21 per cent of child deaths in the world) every year before completing five years of age. Likewise, around 50, 000 women die every year during pregnancy.

It is part of the received wisdom that high public investment in health care is one of the most efficient ways of ameliorating inequities in access to health care. Experiences from countries like Brazil clearly demonstrate that there is no escape from the national commitment to higher public expenditures for assured health care. Yet, even the NHP, 2002 target of 2% of the GDP as public expenditure has not been met so far. Moreover, the NHP 2015 proposes ‘a potentially achievable target of raising public health expenditure to 2.5 % of the GDP’ citing ‘the financial capacity of the country to provide this amount and the institutional capacity to utilize the increased funding in an effective manner’. This is sheer travesty of the lofty goal for ‘health in all’. 4 % of the GDP as public expenditure on health is the minimum that any sensible observer of the health scene expected from the NHP 2015. In a country where over 63 million persons slide into poverty every year due to health care costs alone, and where out of pocket expenses meet seventy per cent of the health care costs, only a universal health care can provide the financial protection for the vast majority of people. One has to be emphatic in asserting that the failure to attain minimum levels of public health expenditure remains the single most important constraint on the affordability and quality of health care in India. Our failure to expand healthcare workforce, and build health infrastructure, limited capacity building, and the reluctance to provide for regular employment to healthcare professionals have cumulatively affected the health service delivery. A suboptimal financial support invariably leads to feeble regulatory and management functions and constrains the much-needed expansion of the public health services.

Sadly though, rather than offering a concrete roadmap for enhancing public expenditure on health, the NHP obfuscates the real issue by talking about the Right to Health as a fundamental right. Going for a justiciable right is not the panacea for all the ills plaguing the healthcare system, something that we have learnt from the experience of the Right to Education. In fact, there is no running away from the task of huge public allocation to health in order to offer a modicum of universal health services to all our citizens. The idea of health cess on the lines of education cess can very well be an additional source of increased revenue flow to the health sector.

In a related vein, the NEH makes all types of right noises to regulate the private healthcare sector but offers little by way of a concrete institutional-legal framework to do so. Passing an act in a haphazard fashion is no regulation. The private sector in health is increasingly turning into a congeries of unscrupulous operator not only fleecing the poor and vulnerable patients but also trying to make money out of various government schemes where public provisioning of private health services is involved. There have been reports of the gross misuse of the RashtriyaSwasthyaBimaYojana where private service providers have gone for unnecessary surgical procedures to inflate the insurance claims. As of now, only 17 per cent of Indians are covered under any health insurance. Imagine the future scenario once the insurance cover gets enlarged and the private healthcare thugs are allowed to operate with impunity.

A policy document is not merely a statement of pious intentions of the government of the day. Not only does it need to have an-built implementation framework drawing upon learning from the past but also needs to put forth a holistic institutional designidentifying administrative reforms, delineating governance structures and anticipating future challenges. It is laudable that the National Health Policy 2015 explicitly declares the ‘determination of the Government to leverage economic growth to achieve health outcomes’ and reiterates ‘an explicit acknowledgement that better health contributes immensely to improved productivity as well as to equity’.It has a lofty vision of assuring‘universal availability of free, comprehensive primary health care services, as an entitlement, for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable and non-communicable diseases in the population’.It also does a commendable job of cataloguing past failures in terms of sub-critical human resource deployment, weak logistics and inadequate infrastructure. It rightfully gestures towards an integrative framework recognising the centrality of the social determinants of health.

Yet, in its totality, the document turns out to be a mish-mash of incongruent future goals and the past failings and achievements. It is not merely a question of lack of detailed attention to such important issues as the public provision of finance, appropriate regulatory framework for the private healthcare sector, human resource policies for the capacity building at all levels, the augmentation of service delivery of the existing healthcare institutions, accountability structures and the new political compact between the Centre and the states for better governance and effective healthcare outcomes. What is sorely missing is the firm conviction that universal health care is an invaluable and practicable public good and not a starry-eyed policy vision. Like any other public good, an equitable access to healthcare services is very much a function of the state capacity.

Article by: Manish Thakur
Associate Professor, Public Policy and Management, IIM Calcutta

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