Extracted from Wada Na Tod Abhiyan‘s “Citizens’ Report on the “Four Years of the NDA Government, 2014-18: Promises & Reality”
The past four years provide a grim picture of neglect of public health by the government and further, a disdain towards policies that promote welfare. The period has seen several outbreaks of infectious diseases such as dengue and chikungunya, often reaching epidemic proportions in many parts of the country. The epidemics have laid bare the inability of the country’s health systems to protect people’s health. Yet successive budgets presented by the Central government have strengthened the perception that this government is ideologically committed to reducing public expenditure on welfare and public services. The period also saw examples of extreme failure to provide healthcare of acceptable quality both in the Public and Private sectors. The failure of public services was epitomised by the horrendous report of deaths of hundreds of children in a hospital in Gorakhpur, which lies in the constituency of the Chief Minister of UP. Yet we were informed from the ramparts of the Red Fort that the children who died in Gorakhpur’s hospital were victims of a ‘natural calamity’.
Rudolph Virchow, the 19th century German pathologist had famously remarked “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.” A nation that is prepared to accept this calamity as ‘natural’ is truly cursed. That the deaths occurred in the parliamentary constituency of the CM of UP compounds the enormity of the crime. For a crime it is, when callous disregard for the well-being and welfare of the most vulnerable, results in the loss of lives that could have been saved. Possibly it is the enormity of the crime that has triggered the massive cover up mounted by the government, both in Lucknow and Delhi, which has involved the incarceration of Dr.Kafeel who was made a scapegoat though evidence clearly suggested that he had been instrumental in preventing a greater calamity.
Simultaneously, several reports of gross misconduct and overcharging came to light in some of the elite private hospitals, such as Fortis and Max.
‘Fiscal discipline’ versus people’s health
The bogey of ‘fiscal discipline’ has been repeatedly raised to restrict public financing of the health sector. Within months of assuming office, in end 2014, the government signaled its intentions clearly by slashing 20% of committed central funds to the health sector. The Union budget of 2015-16 continued in the same vein and effected 5.7% cut in total allocation to the health sector. Since then the budget for health has either stagnated or has been slashed in the case of crucial sectors.
The 2016-17 budget provided indications that the government intends to continue with its policy of promoting ‘managed care’ where publicly provided services are progressively starved of resources and even public funded services are increasingly outsourced to the private sector. Overall, allocation to the Ministry of Health and Family Welfare (MoH&FW) saw a marginal increase from 32,819 crores in the Revised Estimates (RE) for 2015- 16 to Rs.37,061crores. After adjusting for inflation this represented a mere 5% per capita increase. Even the grossly understated ambition of the (then)draft National Health Policy was to increase healthcare expenditure to 2.5% of GDP. This would require a doubling of current expenditure and even simple mathematics would indicate that this would entail a 25-30% per capita increase in allocation every year, if the target of 2.5% of GDP spending on healthcare is to be achieved in the next five years.
While the Union Budget of 2015-’16 effected a 5.7% cut in total allocation to the health sector, the 2016-’17 budget allowed a marginal rise of just 5% when adjusted for inflation and there was a similar marginal increase in the 2017-’18 budget. In fact, the sum allocated in the 2017-’18 budget was less than the 2011-’12 allocation when adjusted for inflation.
What is particularly worrying is that the trend of starving the National Health Mission (NHM) of funds continues. Allocation for the NHM saw an insignificant rise – from Rs.19,135.37crore in 2015-16 year to Rs.19,437 for 2016-17. Given the impact of inflation and population increase this actually represents a 6-7% decrease, per capita, in allocation for the NHM. The underfunding of the NHM should be read in the light of the draft National Health Policy’s comment that “Strengthening health systems for providing comprehensive care required higher levels of investment and human resources than were made available. The budget received [for the National Rural Health Mission] and the expenditure thereunder was only about 40% of what was envisaged for a full revitalization in the NRHM Framework”. In the medicines sector we have further indications that the government is planning to further liberalise regulations. It is understood that the government is actively considering the Niti Aayog’s recommendation that regulation of drug prices should be delinked from the National List of Essential Medicines and that the National Pharmaceutical Pricing Authority in its present form should be wound up. Reports leaked in the Press also provide evidence that the Government has assured US Companies that it would not issue compulsory licenses to bring down the costs of exorbitantly priced patented medicines being sold by multinational corporations.
A positive step taken by the government was the order to ban 348 irrational combinations of drugs in 2014. This order was however overturned by the Delhi High Court and subsequently upheld by the Supreme Court in 2018.
Obsession with insurance schemes which don’t work
In its 2014 manifesto the BJP had promised that “the overarching goal of healthcare would be to provide, ‘health assurance’ to all Indians…”. That “health assurance” in the BJP’s lexicon is synonymous with health insurance and public-private partnership was made clear within weeks of assuming office by the then health minister, Dr.Harsh Vardhan. In one of his first interactions with the media, Dr.HarshVardhan said that “the government would work to provide ‘health insurance coverage for all through a national insurance policy for health”. Dr.HarshVardhan, echoing the BJP’s core philosophy also said that that he is “not in favour of taxpayers’ money being used to push a one-size- fits-all health policy”. In other words the BJP made it clear, right from the time it assumed office, that it would not expand public services and would instead roll out the red carpet for private providers of health care.
In contrast to the clear and deliberate intent to choke financial resources available to public healthservices through the National Health Mission, is the headline declaration in the 2016 budget speech of the H’ble Finance Minister that the public funded health insurance scheme would be expanded. As we shall see later, the National Health Protection Scheme, announced in 2018 seeks to do just that.
The government’s obsession with the promotion of insurance based care (which involves public funding but outsourcing of over 80% of services to the private sector) need to be examined in the context of mounting evidence that existing national and state health insurance schemes have failed to rein incatastrophic health expenditure incurred by the poor. The latest NSSO data indicates that the penetration of such insurance schemes is just 13% in rural areas and 12% in urban areas.
The problem lies not only with inadequate coverage but also with the way the system is milked by unscrupulous private providers for financial gains. These schemes, largely implemented through partnerships with private providers, have been indicted in several states for defrauding the system of hundreds of crores by performing unnecessary surgeries (for example a huge rise inunnecessary uterus removal operations) and for not contributing to better health outcomes.
Gap between rhetoric and delivery
This government’s approach to welfare services is characterized by a basic lack of honesty and a huge gap between rhetoric and delivery. Thus, for example, the 2016-17 budget, announced with considerable fanfare a plan to set up 3,000 Jan Aushadhi shops, which would sell medicines by generic names at fair prices. A closer look at the budget papers show that the scheme has been allocated a mere 35 crores in the 2016-17 budget. Even the centrally funded health insurance scheme (renamed the ‘Rashtriya Swasthya Suraksha Yojana’) received an allocation of only 1,500 crores in the 2016-17 budget. 1,500 crores to cover a population of 120 crores is a crude joke and lays bare the hypocrisy implicit in even schemes that the government tom-toms as one of its key priorities.
The impact of these policies started being felt within months of the election of the new government. The NHM’s activities faltered in many states and in some states it stuttered to a standstill. Serious shortages of consumables and human resources surfaced, with widely reported periodic stock-outs of medicines for the HIV and TB programmes. ￼￼￼
A vision based on aggressive privatisation
The government’s approach to health care is driven by neoliberal economics which seeks to promote private provision of hitherto public services and an overall withdrawal of the government from financing or providing public services. India’s health system is one of the most privatised in the world and public expenditure is one of the lowest. Yet the unstated game plan of the BJP Government is to cap public expenditure at a minimum level and at the same time, through public policy measures, encourage the growth of private providers.
The parliamentary committee report about the working of the Medical Council of India (MCI), released in 2014, pointed to high levels of corruption that permeates private practice and medical education. The Government continues is in its desperate bid to suppress the murky details of the ‘Vyapam’ scam in the BJP ruled state of MP.The scam involves corruption at the highest levels of the bureaucratic and political structures in the state, who have connived to make a mockery of medical education. Yet the government refuses to address the twin problems that fuel corruption in the health sector – the unbridled growth of private medical colleges (nationally the number of seats in private colleges has grown from less than 10 percent to around 50 percent in the last quarter of a century) and the rapid expansion of unregulated private medical care. While the government sheds crocodile tears about the state of the MCI and proposes various reforms, the new regulations legitimize the ownership of medical colleges by profit making companies, thus clearing the way for medical education to become a commercial enterprise.
National Health Policy
In 2017 the Union Cabinet approved the National Health Policy, finally adopting a plan that has been in the drafting stage for more than a year and a half. The 2017 policy admits that “growing incidences of catastrophic expenditure due to health care costs” are estimated to be “one of the major contributors to poverty”.
The National Health Policy 2017 has actually rolled back promises in two significant areas. The policy proposes that the government undertake an increase in health expenditure as a percentage of GDP from the existing 1.15 percent to 2.5 percent by 2025. The draft policy released in 2015 had promised that this will be achieved by 2020. Even if this is achieved, it will be half of what the World Health Organisation recommends as optimum public spending on health.
The National Health Policy 2017 has also retreated from tentative claims that the government had started making that healthcare would be made a justiciable right. The policy now says: “The policy therefore advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realising healthcare as a right in the future”.
The policy also falls short on ambition with other targets. The document says that the target that life expectancy at birth should be 70 years will be achieved in 2025. This future target is less than what both Sri Lanka and Bangladesh have already achieved.The policy has set targets that mortality for children below the age of five should be brought down to 23 deaths per 1,000 live births and that neonatal mortality should be brought down to 16 deaths per 1,000 live births, both to be achieved by 2025. These rates would still be more than twice of what Sri Lanka has already achieved – 9.8 for mortality of children under five years and 5.4 for neonatal mortality. Clearly, the National Health Policy’s targets are a decade or more behind what our South Asian neighbours have already achieved.
How does the National Health Policy propose to organise healthcare services? The answer lies in the oft-repeated term in the document: “health assurance”. The government’s role as provider of healthcare services is repeatedly qualified by emphasising its role as a “strategic purchaser” of services.While the policy claims that the priority would be to “purchase” services from public facilities and not-for-profit private facilities, it also foresees purchasing from for-profit private facilities.
Critiques of a public sector-led model to provide healthcare point out that private providers need to be harnessed and given dominant roles if healthcare needs to be universalised in India. But private facilities barely exist in underserved areas where the gap in healthcare services is the worst.This raises the more important question of whether there is a plan to progressively strengthen public services. The overall prescriptions in the policy regarding insurance schemes that rely largely on private sector provisioning in cases of secondary and tertiary level care are designed to further strengthen the private sector and denude the public sector.
Till now, the discourse on outsourcing care to the private sector was confined to secondary and tertiary services or hospital-based care. But the new policy now says: “for achieving the objective of having fully functional primary healthcare facilities – especially in urban areas to reach underserved populations and on a fee basis for middle class populations, government would collaborate with the private sector for operationalizing such health and wellness centres to provide a larger package of comprehensive primary health care across the country. Partnerships that address specific gaps in public services: these would inter alia include diagnostics services, ambulance services, safe blood services, rehabilitative services, palliative services, mental health care, tele-medicine services, managing of rare and orphan diseases.”
This is what is being attempted even in the face of public protests in several states such as Rajasthan, Madhya Pradesh, Chhattisgarh and Uttar Pradesh. The 2017 policy thus puts its stamp of approval on opening up primary healthcare services to the private sector as an additional avenue for them to make profits. The 2017 policy, contrary to claims about it made in Parliament, is part of the same vision that reduces the government’s investment in welfare and opens up public services to private actors.
National health protection scheme
The big-ticket promise of a National Health Protection Scheme (NHPS) announced in the 2018 Budget speech, euphemistically termed as ‘Modicare’ by critics and supporters alike and officially as ‘Ayushman Bharat’, appears to signal a clear intention of the current government. The basic contour of the scheme is that of an insurance scheme for those seeking hospital based care, which would provide coverage of upto Rs.5 lakhs to 10 crore families. The sense of disbelief among people who follow the health sector, merits some examination.
A similar promise was made in 2016, albeit with much less fanfare –to cover a similar population as envisaged under the NHPS with Rs.1 lakh annual limit. The five times increase in the upper limit is actually not very significant as most claims are settled at a level below Rs.1 lakh. Nothing really changed in the past two years – the scheme distributed a paltry Rs.456 crores in 2016-17 and allocated just Rs.1,000crores in 2017-18. These numbers pale into insignificance when compared to the Rs.10,000 crores per year projected by the government and a perhaps more realistic figure of Rs.20,000 crores to Rs.50,000 crores projected by the insurance industry and public health practitioners. Will the naysayers be proved wrong this time? Presumably time will tell.
It would be prudent however to recall that public funded health insurance schemes have been around for more than a decade in India, since the launch of the Congress Government’s Arogyashri scheme in the then Andhra Pradesh, and similar schemes now extend to many states and also includes a national scheme. While claimed to cover a third of the country’s population, latest surveys still find that coverage (not disbursal of benefits) stands at 11-12 percent of the population. Will it be different this time? We don’t have evidence either way to even start making an educated guess.
Will the NHPS, if rolled out adequately,lead to access to comprehensive healthcare services for those who need them the most? Actually the scheme is not designed to do so. It seeks to cover a package of hospital care packages. In reality hospital care, though financially the most catastrophic for families in the immediate sense,consumes a fraction of out of pocket expenses on healthcare. A much larger burden is posed by illnesses that do not require hospitalization or are not covered by the insurance package. A study of Arogyashri claimed that the scheme covered only 4% of illnesses and yet consumed a quarter of the state’s health budget.
Will a mega insurance scheme revive the moribund public system? Actually, going by past experience, insurance schemes are designed to do the contrary as they essentially involve outsourcing of hospital care to the private hospital sector. For the latter a Rs.10,000 plus payout is a bonanza but it comes at a cost. The public system gets further squeezed while the natural proclivity of an unregulated private sector towards ethical malpractices and over charging comes into play. A functioning public sector is a national asset; a burgeoning private hospital sector may well be a national calamity. Most critics of the NHPS will be happy to be proved wrong. Unfortunately on current evidence there appears to be little cause for optimism.