Affordable and good health care – wherever it comes from – should be the only guiding principle.
Let the choice remain with the people.
Thankfully, the National Health Policy (NHP) 2017 has been approved and uploaded. It will be useful to get some details of the Indian health system right before we assess the policy.
Health is a fundamental right (right to life) but health care is a directive principle of state policy. Health care is a state subject and state governments are, therefore, responsible for administration and regulatory functions. Medical education, drugs and disease control programmes are central subjects. The states also devolve care to local bodies. Many states have separate departments for medical education, health care and food and drugs regulation.
After the Second World War, many European Union and western nations built their health care systems either on the German sickness fund model or socialised medicine of the Soviet Union. The Indian attempt (Bhore Commission 1943) for a full state-led-health care in India along the United Kingdom’s National Health Service (UK-NHS) model failed for lack of funds, requiring something like 6-8 per cent of gross domestic product (GDP). Hence, India could develop only weak health facilities and made way for private urban health facilities that later spread in many rural areas. Today, the private health sector has more than 60 per cent share of the health sector; part of this being non-profit facilities. However, some states do not have a developed private health sector (the north-eastern states, Odisha etc). Thus the national cast for a mixed sector was laid long back.
The current national health spend is about 4 per cent of GDP (OECD median spend is about 10 per cent of GDP), of which about 1 per cent is the share of the centre and states, while the remaining 3 per cent is out of pocket private expenditure. The presence of private insurance (pre-paid, risk pooling) is hardly 3-10 per cent of this out of pocket expenditure, even in the better off states. Hence, we have unexpected catastrophic out of pocket private expenditure that drives poor families into debt and distress.
The Indian health system is deeply divided along tribal-rural-urban lines. The eastern, northern, north-eastern and central Indian states (except Jammu and Kashmir, Punjab, Delhi, West Bengal) have poorly developed public/private health systems, while the western and southern Indian states are better-equipped.
The Indian health care model is also divided by pathies. Ayurveda, Yoga, Unani, Siddha, Homeopathy (AYUSH) systems are stymied by the dominant modern medicine; the AYUSH sector gets a miniscule share of public or private funds. The health system is a doctor-centric model. Other cadres are weak, underpaid, often untrained and doing paltry jobs. The Medical Council of India (MCI, a regulatory body) and the Indian Medical Association (IMA, an association of doctors) dominate other pathies or paramedics. The emergence of super-specialties has further thickened the doctor-centric model. This has both cost and distribution implications.
India has a double burden – both infective diseases (like tuberculosis) and non-communicable diseases (diabetes, cancer and heart disease). The increasing life expectancy brings complex and long drawn illnesses that entail skilled care, technology and costs. Most OECD countries are worried about this life-expectancy-led cost implications combined with dwindling working age group. The Indian health system also faces the problems of child and maternal mortality and malnutrition both in childhood and adult life.
A major problem is the declining quality and affordability of medical education and the paucity of trained nurses and paramedics. Issues about AYUSH doctors using modern medicine, ubiquitous quacks (in the northern and north-eastern states) are neglected issues. The health system is layered as primary, secondary and tertiary (specialty) care, but the latter is dominating the private sector, entailing high cost and deprivations.
India is the global hub for low-cost pharmaceutical industry, but drug prices are still exploitative. The neglect of ‘health-determinants’ of water safety, sanitation and waste management, pollution, occupational hazards, tobacco and addictions continue to increase ill-health.
In short, affordable and quality health care for all is still a distant and elusive dream.
The NHP 2017 offers some tangible corrections for the situation outlined above, like raising the allocation for health to 2.5 per cent of GDP, improving hospital bed availability, reforms in medical and paramedic education, strategic purchasing of private care for poor families/underserved areas through public-private-partnerships (PPPs), management of determinants, control/elimination of communicable and non-communicable diseases. Addressing issues relating to mental health, tele-medicine, health information, medical research, control of quality and cost of drugs/implants and diagnostics, regulation of the health care sector, mainstreaming and enhancement of AYUSH, priority to good quality and accessible primary care (which gets two-thirds allocation of funds) more than secondary tertiary care are some inescapable features of any NHP. Strengthening public facilities and making them accountable for quality of care is another welcome declaration but is often wishful thinking.
However, NHP 2017 misses or errs on the following important issues:
One, reliance on the tax-route alone to raise public allocation to 2.5 per cent of GDP from the current level of 1 per cent by 2025 is just postponing the problem. A 2 per cent allocation is required right now to fill empty posts (30 per cent to 60 per cent of posts of doctors are vacant) and ensure the payment of Seventh Central Pay Commission rates to the health-medical establishment.
A better option would have been to harness middle class out of pocket private expenditure/private funds through social insurance mechanisms/state-funded health insurance schemes in place of family mediclaim policies or asking insurance companies to float affordable group insurance schemes. The political correctness of sticking to tax-funded single payer health care like the NHS (which is now nearly bankrupt) and timidity about user fees for paying classes will take us nowhere. This will not only not achieve universal health care, but will burden the country with a bureaucratic, high-cost, top-down and inefficient system. In short, it is just doubling of the current health system with all its shortcomings.
The minimum commitment should be 6 per cent of GDP and that can come only with harnessing out of pocket private expenditure. Tax funded systems are too few in the world and barely afloat. The social health insurance models, like in Thailand, South Korea and Singapore could have been helpful and also work like regulator of private sector to ensure value for out of pocket private expenditure.
Two, the national medical commission that the NHP 2017 speaks of will bring more bureaucratic blocks, more centralisation of human resource policies due to national entrance (NEET) and exit tests. The MCI is malfunctioning and the government could have disciplined these elements in 2015. Instead, we are taking a wrong lane. Medical education cannot be reformed with PG NEET or exit tests. NHP 2017 misses this point completely.
Third, NHP 2017 is mute on the rural doctors’ course, but talks of bridge courses and substitutes. Hence the human resource gaps may haunt us in most of northern and eastern India.
However, the redeeming feature of NHP 2017 is its resistance to making health care as a justiciable fundamental right. Liberals have long argued about role of state in health care – how and how much. A rights-based approach entails the state to provide all the way, which is detrimental to the state, the people and the health sector itself. NHP 2017 takes a pragmatic middle way for essential primary care and averting catastrophic expenditures rather than force another conflict on ‘denial of rights’.
Leaving this single bright spot in NHP 2017, I think it is a missed opportunity. Affordable and good health care – wherever it comes from – should be the only guiding principle. Let the choice remain with the people.