Congress President Rahul Gandhi on Friday (15 March) lashed out at Prime Minister Narendra Modi’s flagship healthcare insurance scheme, Ayushman Bharat, which is world’s largest such initiative. He was interacting with medical professionals in Raipur, Chhattisgarh.

Gandhi told the audience that his party’s manifesto for upcoming Lok Sabha polls will promise a new right - healthcare for all. “We look towards including the Right to Health Care Act in our national manifesto that will guarantee minimum health care facilities to all Indians,” he said. It is pertinent to note here that Gandhi’s Congress didn’t contemplate introducing this right during its decade long rule when it erected its rights-based regime. It must also be pointed out these rights didn’t translate into reality after years of introduction (right to food), did tremendous harm (right to education), didn’t eradicate joblessness (right to employment) or put a premium on information which should’ve been openly available (right to information).

As Sir Humphrey would say, “Always dispose of the difficult bit in the title. Does less harm there than in the text.” It’s classic Congress approach of doing things. That’s how Nehru made us secular. That’s how Indira Gandhi removed garibi. That’s how Rajiv Gandhi built a bridge to digital age. That’s how Sonia Gandhi gave us the right to employment. No wonder, despite giving this right in 2009, these same folks shout from the rooftops, where the jobs are!

During the 2014 Lok Sabha election campaign, candidate Modi understood this mindset well. Calling for a bureaucratic shift, he declared, “What we need are not more new Acts – we need action.” That’s what has happened in last five years where we have seen work being done at unprecedented speed and scale as far as most of Modi’s pet projects are concerned.

Coming back to healthcare. Gandhi mentioned three things his party intends to do: introduce the right through an act; increase expenditure on health to around three per cent of the gross domestic product (GDP), and enhance and strengthen the number of doctors and the professionals to be trained in the country.

Gandhi’s colleagues, Rajeev Gowda who is part of Congress manifesto committee and former finance minister P. Chidambaram took to Twitter to elaborate on their party’s proposal.

1. Cost: Chidambaram said health expenditure will be increased to three percent gradually between 2019 to 2024 and not in one go in 2019 itself.

2. The right: Gowda said that the act will guarantee universal access to health services, including diagnostics and medicines for both outpatient care and hospitalisation. It will be done “through a network of public hospitals” as clarified by Chidambaram.

3. Infrastructure: Gowda said that focus will be health assurance not insurance. The goal is to: a) eliminate the out-of-pocket expenses that drive lakhs into poverty every year; b) make public hospitals the first choice for patients. Chidambaram tweeted saying the government will increase the number of doctors by establishing more medical colleges and providing more scholarships and loans to medical students.

Now, let’s discuss these issues one by one.

First, the cost. Congress is proposing to increase public health expenditure to three per cent of GDP but this is a 15-year old promise. When UPA came to power in 2004, it had planned to increase health expenditure as percentage of GDP to 2-3 per cent by 2009. It could only take it to 1.09 per cent - a figure which remained unchanged throughout its second term. This has marginally improved to 1.3 per cent by 2018-19. So, spare the cynics if they have hard time believing what the Congress is promising.

National Health Policy 2017 set the target to take public health spending to 2.5 per cent by 2025, and given the trend in spending increase by union health ministry in the last four years, the central government appears on course to meet this target.

Additionally, it should be underscored that post the 14th finance commission, the centre-state spend ratio has changed from 75:25 to 60:40, meaning that as far as expenditure is concerned, the states need to do the heavy lifting. So, Congress can start by increasing health expenditure in those states ruled by it rather than promising moon in the national manifesto. One would’ve taken its claims on health spending more seriously had it not promised a national farm loan waiver and a national minimum income costing trillions of rupees. Money doesn’t grow on trees. Ask Manmohan Singh.

Second, the right-based act. Congress wants to give health assurance not insurance. It wants to “guarantee universal access to health services, including diagnostics and medicines for both outpatient care and hospitalisation.” Sounds good. But here is news for it. Guaranteeing it on paper doesn’t necessarily translate it into healthcare on ground.

We know far too well what it did in the education sector. It guaranteed every student aged 6 to 14 the right to education. And forced the private sector to bear all the burden. In exchange, they were promised token reimbursement which either doesn’t come and if it comes, is almost always late. Result? Hundreds of budget schools which catered to lower middle class were forced to close down. Thousand others are facing threat of closure. Plus by exempting those institutions which are run by minorities, from this act, the market is distorted along religious lines.

Imagine, if such a right were to be given in health sector where any person can walk in to a private hospital and claim the right to be treated, at a highly subsidised rate, and then hospitals file paperwork and run after the government to get that token reimbursement. Imagine if you can’t even verify if the person who is coming in to get treated is really poor or not and if he is later found to be poor by the government, after he has been treated, hospital gets punished.

This is not some imaginary draconian scenario from a socialist utopia. It’s how the RTE act is being implemented in the country at the moment.

Compare it to the way Ayushman Bharat is structured. All the beneficiaries (over 10 crore families) have been identified and are being given e-cards. It hasn’t made it binding on private hospitals by law to admit anyone who comes in. Rather, the rates of reimbursement for different treatment are clearly defined and those in the private sector who feel comfortable with them can join in. Yes, most of the rates announced are on lower side but the upside offered to private hospitals, in exchange for joining under low rates, is in form of millions of new customers who would otherwise have gone to government hospitals. Instead of closing down hospitals, the scheme incentivises private sector to invest and scale up their operations.

Rahul Gandhi complained that the scheme is benefiting only the richest 10-15 businessmen. One wonders who he is referring to. Here, private insurance companies have limited role as barring four-five states, most have formed their own trusts, bypassing the private sector. In any case, even if insurance industry grows in India, how is that a bad thing, if it serves in providing critical healthcare to millions of poor. So far, over 15 lakh people have received the treatment free of cost. More than two crore have got their e-cards. But for Congress, it’s the colour of the cat that matters. It couldn’t care less if it can catch the mice or not. Helping 10 crore poor families has become secondary goal for it. No one should make a profit because Nehru said it’s a dirty word.

Now, what Ayushman Bharat would do is that it would initiate the process to kill the inefficient government hospitals by shifting customers from them to private ones (if they join the scheme). At the very least, the former would be less burdened. But the Congress mindset is to punish those who are making a profit even if they are getting things done better than the government.

This takes us to the third point. Infrastructure. Congress manifesto committee member Rajeev Gowda said that Congress will make public hospitals the first choice for patients. Guess what? They already are the first choice for patients. But not because they provide quality healthcare but because they are cheap and most patients can’t afford private ones even in tier 2 and tier 3 cities. And where will the doctors and hospitals come from to cater to millions of people? As of 2018, only six states in the country meet the modest WHO criteria of one doctor for 1,000 people.

Chidambaram says “the government will increase the number of doctors by establishing more medical colleges and providing more scholarships and loans to medical students.” If his party had done that during its more than five decades long rule, we wouldn’t be having this discussion. But scratch that. Even if Congress’ promise of taking public health expenditure to 3 per cent of GDP were to be implemented in one go, government hospitals won’t be capable of giving universal health “assurance” to all, neither in quantity nor in quality.

By incentivising the sector, we can serve many more number of people with a fraction of the amount that the Congress is proposing to pump into inefficient government hospital system. That’s what Ayushman Bharat is trying to do. Yes, some insurers are going to make a profit. Many private hospitals too. But who cares? Let thousands of them bloom. There is no nirvana for India in forcing government to be in business of running hospitals. As far as supply of doctors is concerned, more than increasing scholarships as Chidambaram is proposing, we need a liberalised medical education regime where opening and running private medical colleges is easy and free of license-raj. The competition will bring down costs and help in attracting more students to this profession than any government dole through scholarships will.

This is not to say Ayushman Bharat is perfect. Far from it. But it gets the basics right. Now, tweaking it regularly based on feedback from all stakeholders is all that is needed. Congress’ proposal is irrational, impractical and untenable. It should be thrown in the dustbin where it belongs.

Right To Healthcare

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