A Planning Commission draft document has made proposals that fail to reflect the case for expanding and improving public-funded medical services and reining in private operators
In the health sector, the buzz these days is all about Universal Health Care (UHC). While health activists see in it potential to ensure access to quality health care for common citizens, commercial bodies seem to be eyeing the huge scope for profit from sickness, in a field already characterised by large scale commercialisation and imbalance of information between providers and users.
The concept of UHC gained ground in developing nations after Thailand and Brazil took significant steps towards this goal. These steps were based on political commitment, tax-based financing, strong public health systems and regulation of the entire health sector. In India, in 2010 the Planning Commission instituted a High Level Expert Group (HLEG) led by Dr. Srinath Reddy. The report of this group, which sketched a basic framework for UHC in India, was submitted to the Planning Commission in late 2011.
Dangerous shift in policy
In July this year the Planning Commission formulated its draft chapter on health for the upcoming 12th Five Year plan. Key elements of this draft chapter portend a dangerous shift in the development of health-care services in India. Despite certain positive recommendations, several suggestions in it provoke deep concern:
The draft chapter projects merely 1.58 per cent of GDP as public health expenditure by the end of the 12th plan, which is significantly less than the overall norm of five per cent suggested by the World Health Organisation, or the 2.5 per cent suggested by the HLEG and Planning Commission’s own steering committee, or even the 2-3 per cent suggested by UPA-I in its common minimum programme. It further recommends that 60 per cent of this increased amount must come from State governments, which have far lower capacity to hike revenues, while the share of the Central government would be conditional on contribution from the States. In a country that is already among the lowest spending on public health in the world, these financial limitations and conditions would render the notion of universal health care a mirage.
Flawed model
Another deeply problematic suggestion in the chapter is for the development of a “Managed Care” model of health-care provision. The foremost example of managed care today is the United States, which has among the highest per capita expenditures on health, yet the worst health indicators among Organisation for Economic Co-operation and Development (OECD) countries. In a managed care system, large networks (in the Indian situation these are mostly controlled by corporate hospitals) would be invited to compete for public funds and provide different sets of services. Patients will need to buy these services, which would be provided in separate packages, thereby fragmenting the health system and compromising quality and continuity of health care. International experience shows that the range of services covered in managed care situations tends to contract over time and providers compromise on quality to cut costs; “free services” become more limited, and failure to pay “top up” payments and premiums lead to patients being routinely denied more expensive procedures.
Public health institutions will be forced to compete with private providers, and public facilities which are unable to compete in market-like conditions would be “starved of funds” and their staff may be “rationalised.” “Corporatisation” of public health services would imply that public health facilities would be induced to function more and more like private facilities, working according to the logic of the market rather than public health logic.
Public health provisioning would be limited to a highly constricted ‘Essential Health Package’ (EHP) consisting of basic reproductive and child health services and preventive-promotive activities. The broader range of health services, including general outpatient care and all forms of hospital care would essentially be reserved for the commercialised private sector, with predictable negative consequences for public health development.
A weakened public sector would further reduce the government’s ability to regulate the private sector, costs and irrationality are likely to skyrocket and large groups of people would be denied quality health care. The draft chapter is muted on mechanisms for regulating the commercialised private medical sector and ensuring patients rights.
The Planning Commission further contradicts its own HLEG and even the opinion expressed by its steering committee, and proposes a countrywide expansion of Rashtriya Swasthya Bima Yojana (RSBY) type insurance-based coverage. This flies in the face of global evidence that commercial insurance cannot be an appropriate financing mechanism for universal health care, and sweeps aside civil society evaluations which show inadequate health-care coverage and a wide range of problems with the RSBY scheme.
Public-centred UHC framework
In short, the key proposals in the draft chapter point towards semi-privatisation of public health facilities, along with expanded public funds being given to the private sector and commercial insurance without consideration to public health logic. Combined with the overall limited scale of public funds proposed to be allocated, this set of proposals would seriously limit the much-needed expansion of the public health system, while bringing the health sector under the sway of corporate hospital-led networks, in other words, “UHC — Private, Limited.”
The Planning Commission draft chapter fails to reflect the rich debate on UHC initiated by civil society organisations and academic institutions. It interprets selectively the views of the HLEG and consultative groups and committees, established to guide formulation of the plan.
Even the Union Health Ministry is reportedly unhappy with this document. The chapter seems intent on ignoring public health arguments and evidence from diverse sources, and instead seems in favour of promoting discredited neo-liberal prescriptions. Its loudest cheerleader is likely to be the corporate health sector, which has an eye on the pie of public financing, especially in these times of recession.
If the government is serious about UHC, there is no alternative to strengthening and expanding the public health system while making it more accountable, regulating and rationalising the private medical sector; and, dedicating much more resources to public health. The chapter on health for the next Five Year plan will accordingly need to be rewritten. The health of the people is a fundamental right which should not be auctioned at the altar of private profit.
(Rakhal Gaitonde works with the Society for Community Health Awareness Research and Action and Abhay Shukla is with Support for Advocacy and Training to Health Initiatives. Both are actively involved in the medico friend circle and Jan Swasthya Abhiyan.)
After reading all the above comments, I'm unable to understand why do
people want to be dependent on govt rather than be self reliant. They
don't want more reliance but more dependency.Yet they think they have
more compassion than people presenting a different view. Why do they
hate people becoming self reliant.
Universalizing health care is a big challenge given, the country's population size and character of country's economy. UHC requires huge fundings, physical as well as human infrastructure, institutions and so on.given Govts overall responsibility to drive the country, it is correct to harness,the already mobilized capabilites and the potentials in the pvt sector through a cohesive mechanisms to ensure balanced development in the health sector.
I too disagree with Satish. It is not slavery when you are getting the best of services at an affordable cost, it is in fact freedom that you will experience -in this case as a benefactor of good health- by availing such facilities. Please read up on the meanings of the two words and their differences before commenting arbitrarily.
@ Satish & @ Werner: It is a sad fact in India, that the no. of people thinking like Mr Satish is quite huge, esp. among the so called "educated elite". That this attitude amount to denial of the basic privileges of humanity is true, but huge efforts to make such people understand this, and stop the privatisation of healthcare, paid by unsupervised govt machinery. As it is, the people are too poor to pay any more for healthcare, as the total amount spent on health, at 6% GDP(5% privately paid + govt spending of 1%) shows us. So unless govt steps in with radically more funding, and also beefs up the govt health system, India will remain a bad country for its poor citizens.
Satish: In a nation where millions of lives, particularly those of children and infants
are lost because of lack of adequate healthcare, your comment is nothing else but
cynical. Having lived for years in the West, I can tell you that market forces don't
get anything done! In the healthcare sector, free market rules do not apply as
informed decisions are difficult to make and the bigger players have underhand
methods to scuttle free markets working, e.g. notice how low-cost generic drug
makers still do not have enough market penetration in India, even though these
are Indian manufacturers and provide medicines to most of the developing world.
Good quality education and healthcare ought to be fundamental rights if a nation
wishes to move forward. The right to make unlimited amount of profits is not
sacred nor necessary either!
India needs a Shinawatra-style healthcare reform. For all his corruption, he
deserves laurels for lifting millions out of poverty.
@ Satish: So you mean it means slavery? In Europe public healthcare is part of our way of freedom - not slavery.
Health cannot be a fundamental right. The Govt. of the day will strive to ensure public health, but each individual citizen must be responsible for their own health to a large extent. Govt. can only facilitate this, by providing awareness of good sanitation and nutrition practices and also by making sure hospitals are available and contagious diseases are brought under control. It is not rational to expect the Govt. to take care of EVERYTHING. That is the failed socialist model which resulted in the collapse of USSR.
As stated by the author, we are indeed treading on dangerous lines. The
recommendations of the HLEG on UHC was laudable, however the draft report from
the planning commissions seems to have some serious omissions and revisions of
stated framework. The private healthcare sector when coupled with the private
health insurance organizations vying for public funds is a structure that needs
significant scrutiny. Commercial organizations driven by free market principles
cannot be trusted to deliver equitable, quality and un-compromised access to life
saving services. Further more its proved globally that the most successful UHC
models adopted are the ones lead by the state (Canada, UK) with the assistance of
private sector. The current recommendations of the planning commission only
stands to benefit intense privatization of a sector that is already quite unregulated
leaving the masses in jeopardy.
A lot of valid concerns, but also some gaps in conceptual clarity. I
agree with the case being made for increased public expenditure on
health, and the right to full access to essential package of health
services (EPHS) to ALL, irrespective of their ability to pay for it.
The EPHS need not be as constricted as the article fears; basically
what can be included depends on the country's resources, disease
burden and priority interventions. I don't agree with the view that
insurance or managed care are bad models per se. RSBY is a publicly
financed insurance model, not a "commercial" insurance system. It
can help separate the financing from provision of health care, unlike
the inefficient approach of the Government trying to own and operate
its facilities. Public financing with private provision can free up
Government capacity for stewardship functions, i.e., focus on
regulating the private sector, rather than trying to manage its own
hospitals.
Government has been saying that Public health care infrastructure is not enough. A case in point Andhra Pradesh government has spent Rs 2500 Crores for its flagship heath care program, AROGYASRI. With this huge money how many hospitals and infrastructure can be developed. This program resulted in mushrooming of super specialty hospitals.
The key word here is accountability. this is huge dilemma. Public health is prone to nepotism and corruption that prevents adequate care delivery. Will the private public partnership control the corruption and ensure smoother delivery? Remains to be seen. I suspect this document reflects the frustrations with control of nepotism and corruption in the public sector. While the private sector operates without controls is also linked to corruption, there may be some more semblance of accountability with the partnership. What is required is independence of the sector and bold decision making as in the NHS of previous generation. What a pity that the proposal for NHS roll out for India was vetoed.
The govt does not have a responsibility to provide healthcare to people. The only responsibility of the govt is enforce the law of the land (i.e, constitution) and protect the freedom of the people and to enforce contracts. If people think that health care is a right what they are proposing is nothing but slavery. You don't have right to somebody's else services. If you think you have right to somebody's else services that is nothing but slavery. It is only free markets which provide all the goods and services at the minimum price possible. Support freedom not slavery.
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