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.
Receive Daily Updates
Recent Posts
Steve Ovett, the famous British middle-distance athlete, won the 800-metres gold medal at the Moscow Olympics of 1980. Just a few days later, he was about to win a 5,000-metres race at London’s Crystal Palace. Known for his burst of acceleration on the home stretch, he had supreme confidence in his ability to out-sprint rivals. With the final 100 metres remaining,
[wptelegram-join-channel link=”https://t.me/s/upsctree” text=”Join @upsctree on Telegram”]Ovett waved to the crowd and raised a hand in triumph. But he had celebrated a bit too early. At the finishing line, Ireland’s John Treacy edged past Ovett. For those few moments, Ovett had lost his sense of reality and ignored the possibility of a negative event.
This analogy works well for the India story and our policy failures , including during the ongoing covid pandemic. While we have never been as well prepared or had significant successes in terms of growth stability as Ovett did in his illustrious running career, we tend to celebrate too early. Indeed, we have done so many times before.
It is as if we’re convinced that India is destined for greater heights, come what may, and so we never run through the finish line. Do we and our policymakers suffer from a collective optimism bias, which, as the Nobel Prize winner Daniel Kahneman once wrote, “may well be the most significant of the cognitive biases”? The optimism bias arises from mistaken beliefs which form expectations that are better than the reality. It makes us underestimate chances of a negative outcome and ignore warnings repeatedly.
The Indian economy had a dream run for five years from 2003-04 to 2007-08, with an average annual growth rate of around 9%. Many believed that India was on its way to clocking consistent double-digit growth and comparisons with China were rife. It was conveniently overlooked that this output expansion had come mainly came from a few sectors: automobiles, telecom and business services.
Indians were made to believe that we could sprint without high-quality education, healthcare, infrastructure or banking sectors, which form the backbone of any stable economy. The plan was to build them as we went along, but then in the euphoria of short-term success, it got lost.
India’s exports of goods grew from $20 billion in 1990-91 to over $310 billion in 2019-20. Looking at these absolute figures it would seem as if India has arrived on the world stage. However, India’s share of global trade has moved up only marginally. Even now, the country accounts for less than 2% of the world’s goods exports.
More importantly, hidden behind this performance was the role played by one sector that should have never made it to India’s list of exports—refined petroleum. The share of refined petroleum exports in India’s goods exports increased from 1.4% in 1996-97 to over 18% in 2011-12.
An import-intensive sector with low labour intensity, exports of refined petroleum zoomed because of the then policy regime of a retail price ceiling on petroleum products in the domestic market. While we have done well in the export of services, our share is still less than 4% of world exports.
India seemed to emerge from the 2008 global financial crisis relatively unscathed. But, a temporary demand push had played a role in the revival—the incomes of many households, both rural and urban, had shot up. Fiscal stimulus to the rural economy and implementation of the Sixth Pay Commission scales had led to the salaries of around 20% of organized-sector employees jumping up. We celebrated, but once again, neither did we resolve the crisis brewing elsewhere in India’s banking sector, nor did we improve our capacity for healthcare or quality education.
Employment saw little economy-wide growth in our boom years. Manufacturing jobs, if anything, shrank. But we continued to celebrate. Youth flocked to low-productivity service-sector jobs, such as those in hotels and restaurants, security and other services. The dependence on such jobs on one hand and high-skilled services on the other was bound to make Indian society more unequal.
And then, there is agriculture, an elephant in the room. If and when farm-sector reforms get implemented, celebrations would once again be premature. The vast majority of India’s farmers have small plots of land, and though these farms are at least as productive as larger ones, net absolute incomes from small plots can only be meagre.
A further rise in farm productivity and consequent increase in supply, if not matched by a demand rise, especially with access to export markets, would result in downward pressure on market prices for farm produce and a further decline in the net incomes of small farmers.
We should learn from what John Treacy did right. He didn’t give up, and pushed for the finish line like it was his only chance at winning. Treacy had years of long-distance practice. The same goes for our economy. A long grind is required to build up its base before we can win and celebrate. And Ovett did not blame anyone for his loss. We play the blame game. Everyone else, right from China and the US to ‘greedy corporates’, seems to be responsible for our failures.
We have lowered absolute poverty levels and had technology-based successes like Aadhaar and digital access to public services. But there are no short cuts to good quality and adequate healthcare and education services. We must remain optimistic but stay firmly away from the optimism bias.
In the end, it is not about how we start, but how we finish. The disastrous second wave of covid and our inability to manage it is a ghastly reminder of this fact.