Affordable and good health care – wherever it comes from – should be the only guiding principle.
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). 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 achieve universal health care, instead 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, we 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.
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The United Nations has shaped so much of global co-operation and regulation that we wouldn’t recognise our world today without the UN’s pervasive role in it. So many small details of our lives – such as postage and copyright laws – are subject to international co-operation nurtured by the UN.
In its 75th year, however, the UN is in a difficult moment as the world faces climate crisis, a global pandemic, great power competition, trade wars, economic depression and a wider breakdown in international co-operation.
Still, the UN has faced tough times before – over many decades during the Cold War, the Security Council was crippled by deep tensions between the US and the Soviet Union. The UN is not as sidelined or divided today as it was then. However, as the relationship between China and the US sours, the achievements of global co-operation are being eroded.
The way in which people speak about the UN often implies a level of coherence and bureaucratic independence that the UN rarely possesses. A failure of the UN is normally better understood as a failure of international co-operation.
We see this recently in the UN’s inability to deal with crises from the ethnic cleansing of the Rohingya Muslims in Myanmar, to civil conflict in Syria, and the failure of the Security Council to adopt a COVID-19 resolution calling for ceasefires in conflict zones and a co-operative international response to the pandemic.
The UN administration is not primarily to blame for these failures; rather, the problem is the great powers – in the case of COVID-19, China and the US – refusing to co-operate.
Where states fail to agree, the UN is powerless to act.
Marking the 75th anniversary of the official formation of the UN, when 50 founding nations signed the UN Charter on June 26, 1945, we look at some of its key triumphs and resounding failures.
Five successes
1. Peacekeeping
The United Nations was created with the goal of being a collective security organisation. The UN Charter establishes that the use of force is only lawful either in self-defence or if authorised by the UN Security Council. The Security Council’s five permanent members, being China, US, UK, Russia and France, can veto any such resolution.
The UN’s consistent role in seeking to manage conflict is one of its greatest successes.
A key component of this role is peacekeeping. The UN under its second secretary-general, the Swedish statesman Dag Hammarskjöld – who was posthumously awarded the Nobel Peace prize after he died in a suspicious plane crash – created the concept of peacekeeping. Hammarskjöld was responding to the 1956 Suez Crisis, in which the US opposed the invasion of Egypt by its allies Israel, France and the UK.
UN peacekeeping missions involve the use of impartial and armed UN forces, drawn from member states, to stabilise fragile situations. “The essence of peacekeeping is the use of soldiers as a catalyst for peace rather than as the instruments of war,” said then UN Secretary-General Javier Pérez de Cuéllar, when the forces won the 1988 Nobel Peace Prize following missions in conflict zones in the Middle East, Africa, Asia, Central America and Europe.
However, peacekeeping also counts among the UN’s major failures.
2. Law of the Sea
Negotiated between 1973 and 1982, the UN Convention on the Law of the Sea (UNCLOS) set up the current international law of the seas. It defines states’ rights and creates concepts such as exclusive economic zones, as well as procedures for the settling of disputes, new arrangements for governing deep sea bed mining, and importantly, new provisions for the protection of marine resources and ocean conservation.
Mostly, countries have abided by the convention. There are various disputes that China has over the East and South China Seas which present a conflict between power and law, in that although UNCLOS creates mechanisms for resolving disputes, a powerful state isn’t necessarily going to submit to those mechanisms.
Secondly, on the conservation front, although UNCLOS is a huge step forward, it has failed to adequately protect oceans that are outside any state’s control. Ocean ecosystems have been dramatically transformed through overfishing. This is an ecological catastrophe that UNCLOS has slowed, but failed to address comprehensively.
3. Decolonisation
The idea of racial equality and of a people’s right to self-determination was discussed in the wake of World War I and rejected. After World War II, however, those principles were endorsed within the UN system, and the Trusteeship Council, which monitored the process of decolonisation, was one of the initial bodies of the UN.
Although many national independence movements only won liberation through bloody conflicts, the UN has overseen a process of decolonisation that has transformed international politics. In 1945, around one third of the world’s population lived under colonial rule. Today, there are less than 2 million people living in colonies.
When it comes to the world’s First Nations, however, the UN generally has done little to address their concerns, aside from the non-binding UN Declaration on the Rights of Indigenous Peoples of 2007.
4. Human rights
The Human Rights Declaration of 1948 for the first time set out fundamental human rights to be universally protected, recognising that the “inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world”.
Since 1948, 10 human rights treaties have been adopted – including conventions on the rights of children and migrant workers, and against torture and discrimination based on gender and race – each monitored by its own committee of independent experts.
The language of human rights has created a new framework for thinking about the relationship between the individual, the state and the international system. Although some people would prefer that political movements focus on ‘liberation’ rather than ‘rights’, the idea of human rights has made the individual person a focus of national and international attention.
5. Free trade
Depending on your politics, you might view the World Trade Organisation as a huge success, or a huge failure.
The WTO creates a near-binding system of international trade law with a clear and efficient dispute resolution process.
The majority Australian consensus is that the WTO is a success because it has been good for Australian famers especially, through its winding back of subsidies and tariffs.
However, the WTO enabled an era of globalisation which is now politically controversial.
Recently, the US has sought to disrupt the system. In addition to the trade war with China, the Trump Administration has also refused to appoint tribunal members to the WTO’s Appellate Body, so it has crippled the dispute resolution process. Of course, the Trump Administration is not the first to take issue with China’s trade strategies, which include subsidises for ‘State Owned Enterprises’ and demands that foreign firms transfer intellectual property in exchange for market access.
The existence of the UN has created a forum where nations can discuss new problems, and climate change is one of them. The Intergovernmental Panel on Climate Change (IPCC) was set up in 1988 to assess climate science and provide policymakers with assessments and options. In 1992, the UN Framework Convention on Climate Change created a permanent forum for negotiations.
However, despite an international scientific body in the IPCC, and 165 signatory nations to the climate treaty, global greenhouse gas emissions have continued to increase.
Under the Paris Agreement, even if every country meets its greenhouse gas emission targets we are still on track for ‘dangerous warming’. Yet, no major country is even on track to meet its targets; while emissions will probably decline this year as a result of COVID-19, atmospheric concentrations of greenhouse gases will still increase.
This illustrates a core conundrum of the UN in that it opens the possibility of global cooperation, but is unable to constrain states from pursuing their narrowly conceived self-interests. Deep co-operation remains challenging.
Five failures of the UN
1. Peacekeeping
During the Bosnian War, Dutch peacekeeping forces stationed in the town of Srebrenica, declared a ‘safe area’ by the UN in 1993, failed in 1995 to stop the massacre of more than 8000 Muslim men and boys by Bosnian Serb forces. This is one of the most widely discussed examples of the failures of international peacekeeping operations.
On the massacre’s 10th anniversary, then UN Secretary General Kofi Annan wrote that the UN had “made serious errors of judgement, rooted in a philosophy of impartiality”, contributing to a mass murder that would “haunt our history forever”.
If you look at some of the other infamous failures of peacekeeping missions – in places such as Rwanda, Somalia and Angola – it is the limited powers given to peacekeeping operations that have resulted in those failures.
2. The invasion of Iraq
The invasion of Iraq by the US in 2003, which was unlawful and without Security Council authorisation, reflects the fact that the UN is has very limited capacity to constrain the actions of great powers.
The Security Council designers created the veto power so that any of the five permanent members could reject a Council resolution, so in that way it is programmed to fail when a great power really wants to do something that the international community generally condemns.
In the case of the Iraq invasion, the US didn’t veto a resolution, but rather sought authorisation that it did not get. The UN, if you go by the idea of collective security, should have responded by defending Iraq against this unlawful use of force.
The invasion proved a humanitarian disaster with the loss of more than 400,000 lives, and many believe that it led to the emergence of the terrorist Islamic State.
3. Refugee crises
The UN brokered the 1951 Refugee Convention to address the plight of people displaced in Europe due to World War II; years later, the 1967 Protocol removed time and geographical restrictions so that the Convention can now apply universally (although many countries in Asia have refused to sign it, owing in part to its Eurocentric origins).
Despite these treaties, and the work of the UN High Commission for Refugees, there is somewhere between 30 and 40 million refugees, many of them, such as many Palestinians, living for decades outside their homelands. This is in addition to more than 40 million people displaced within their own countries.
While for a long time refugee numbers were reducing, in recent years, particularly driven by the Syrian conflict, there have been increases in the number of people being displaced.
During the COVID-19 crisis, boatloads of Rohingya refugees were turned away by port after port. This tragedy has echoes of pre-World War II when ships of Jewish refugees fleeing Nazi Germany were refused entry by multiple countries.
And as a catastrophe of a different kind looms, there is no international framework in place for responding to people who will be displaced by rising seas and other effects of climate change.
4. Conflicts without end
Across the world, there is a shopping list of unresolved civil conflicts and disputed territories.
Palestine and Kashmir are two of the longest-running failures of the UN to resolve disputed lands. More recent, ongoing conflicts include the civil wars in Syria and Yemen.
The common denominator of unresolved conflicts is either division among the great powers, or a lack of international interest due to the geopolitical stakes not being sufficiently high. For instance, the inaction during the Rwandan civil war in the 1990s was not due to a division among great powers, but rather a lack of political will to engage.
In Syria, by contrast, Russia and the US have opposing interests and back opposing sides: Russia backs the government of the Syrian dictator Bashar al-Assad, whereas the US does not.
5. Acting like it’s 1945
The UN is increasingly out of step with the reality of geopolitics today.
The permanent members of the Security Council reflect the division of power internationally at the end of World War II. The continuing exclusion of Germany, Japan, and rising powers such as India and Indonesia, reflects the failure to reflect the changing balance of power.
Also, bodies such as the IMF and the World Bank, which are part of the UN system, continue to be dominated by the West. In response, China has created potential rival institutions such as the Asian Infrastructure Investment Bank.
Western domination of UN institutions undermines their credibility. However, a more fundamental problem is that institutions designed in 1945 are a poor fit with the systemic global challenges – of which climate change is foremost – that we face today.