Sudhanva Shetty Shetty
Writer, coffee-addict, likes folk music & long walks in the rain. Firmly believes that there's nothing more important in a democracy than a well-informed electorate.
The current NDA government has repeatedly professed that it is serious about providing universal healthcare – healthcare for all Indians.
Prime Minister Narendra Modi, in particular, was very vocal about this goal, reiterating numerous times that developing India’s crumbling healthcare sector would a top priority of his administration.
He stated that India could become a world leader in affordable healthcare, professed that India would soon have the “best healthcare system” in the world and announced intentions to ensure healthcare for all Indians.
As such, when the present government took office in 2014, there were high hopes of the health sector being given the attention it deserved.
But three years after the Prime Minister took office, there has been no impactful stride towards universal healthcare in India.
In July 2014, the Modi government announced the National Health Assurance Mission (NHAM), a plan to provide universal healthcare for all Indians in order to reduce the out-of-pocket spending on healthcare by the common man. A research group was constituted for preparing a comprehensive background paper for this purpose.
Eight months after it was announced, the ambitious NHAM was basically killed by the government due to budgetary concerns.
Then there was the National Health Policy (NHP), which envisioned the government as the biggest provider of healthcare in the country. It was approved by the Cabinet in March this year.
The NHP was widely criticised as it fell short in many areas, focussed mainly on revamping public hospitals, made hardly any stride towards making healthcare universal, and its impact was highly assumption-based and could be studied only in the long-term.
Broadly speaking, the state of Indian healthcare continues to deteriorate under Modi. For example, health spending, which the UN says should be at least 2.5% of GDP for a developing country like India, remains below 1.5% (in comparison, the US spends 8.3%, China 3%, and the global mean is 5.4%).
The percentage of people with any form of health insurance remains below 20% of the population and the majority of these people are well-to-do.
The persistent depravity that plagues the public health sector in India has meant that the private sector has dominated this scene. The private sector provides fair-quality services but at extremely high prices. Again, the brunt is borne by the lower-middle class and poor, who often avoid hospital visits out of fear of over-the-top expenditure.
Due to the lack of a concrete public health system, the private sector dominates healthcare in India, with about 70% of those with health insurance availing facilities by private service providers. (The 70% figure seems inclusive but its impression falls apart when you factor in that less than 20% of Indians have any form of health insurance in the first place.)
The NHP envisaged the government as the biggest buyer of healthcare services in the country. That meant every individual would ideally end up buying his or her healthcare services through the government unless and until he or she consciously chose to opt out and pay for private facilities.
This is by no means a critique of the free market. But when it comes to health, one must understand that not everybody can afford high prices for everything, from consultation to medicines to treatment. The private sector provides good service but at extremely high prices.
And as the government fails to produce a replacement for NHAM, private healthcare becomes the sole provider of quality service, forcing those who would rather avail public healthcare to opt for private healthcare.
This tragically increases the out-of-pocket healthcare expenditures by citizens. This preventable expenditure – called Catastrophic Health Expenditure (CHE) – disproportionately affects the poor over the middle-class or the rich. And as private healthcare providers broaden their rural outreach, poor and rural families continue to bear the brunt of rising CHE and health expenditure – costs that could be avoided and spent on children’s education or basic facilities had there been a reliant public health service in place.
Around 30% of the Indian people live below the international poverty line and many of these individuals refrain from hospital visits due to financial woes.
According to a 2011 study in The Lancet, 37.6% of low-income urban residents and 43.3% of low-income rural residents who did not seek care when ill listed financial hardship as the number-one reason.
By comparison, only 1.9% of the richest Indian urban residents and 21.1% of the richest rural residents who did not seek care when ill reported income as their primary constraint.
It is clear from these numbers that health and poverty are interrelated: the government can’t tackle one of the problems without confronting the other.
Partly because the other issues that India faces like government corruption, border disputes, religious tensions etc make universal healthcare seem less important.
Also, interest payments and entitlement liabilities have greatly constrained the government’s fiscal capacity to fund social programs such as healthcare.
The economic crises India faced in the early 1990s led to Indian policymakers placing a high priority on economic growth, opting to shift the priority of health. Therefore, health spending decreased over time. Health spending as a proportion of total government recurrent spending fell from 4.5% in 1985–86 to 3.3% in 2004–05.
It is currently below 1.5% and is still as insufficient as ever – something which even the government’s own Economic Survey lambasted.
Another reason why healthcare is not a major component of public debate is lack of media attention on the topic. Unlike in countries like the UK and USA where healthcare is not only a major aspect of political rhetoric but also a major driver of everyday news, Indian media rarely chooses to focus on healthcare as a legitimate topic.
This has led to ugly consequences, with the public mirroring the media to disregard the significance of healthcare.
Nearly one million Indians die every year due to inadequate healthcare facilities and close to 700 million citizens have no access to specialist care.
If the government were to increase government spending on healthcare from the current below-1.5% levels to UN-recommended 2.5%-levels, it would improve health conditions of millions of Indians.
A proper healthcare system is mandatory if India really wants to realise its global ambitions. It is clear that to cater to the needs of a growing population the government has to take a more active role, increase spending on healthcare, frame concrete policies and provide universal health insurance.
We can debate at length over which model the government must opt for: a single-payer system like in Canada or a multi-payer system like in Germany or a neo-Beveridge model like in the UK? But when the government expresses no legislative direction regarding universal healthcare, how can this debate be had?
Universal healthcare in India is not an impossibility: the Prime Minister has repeatedly said in the past that it was a priority for his administration.
It is high time that his administration treated it as a priority.
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