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Quality health care with public funds

Prabhat Jha
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Universal Health Insurance will free the current out-of-pocket spending on health and channel funds toward far more productive uses

TOLL OF TOBACCO:Data show that 1 million Indians die every year because of smoking. Above is a file photo of school students participating in an awareness campaign against smoking in Chennai.— PHOTO: S.THANTHONI
TOLL OF TOBACCO:Data show that 1 million Indians die every year because of smoking. Above is a file photo of school students participating in an awareness campaign against smoking in Chennai.— PHOTO: S.THANTHONI

Indians around the world are proud that India’s vibrant democracy has worked. Indians who voted for Prime Minister Narendra Modi as well as those who did not, aspire not only for better job opportunities, tolerance, fairness and a humble government, but also for better health-care services. Mr. Modi promised to bring about change. There are six practical steps that he could implement as Prime Minister to rapidly ensure better health for all Indians.

Tax-payer financed services

First, the government has an opportunity to issue a clarion call for universal health insurance (UHI). The government could declare a deadline before which most private spending can be replaced by taxpayer-financed health services. Can India afford this? Yes. India already spends about 6 per cent of its GDP on health care. But 80 per cent of this is out-of-pocket and drives over 40 million Indians below the poverty line every year. In addition, the quality of health care also differs. Ask any urban Indian of his/her experience in a private hospital and you will be told how he/ she paid too much only to get poor treatment or overtreatment, of dubious quality and with little respect. UHI should not be about insurance for the well-off, but instead prevent large expenses for the poor.

One of the main challenges is to raise revenue: VAT and other tax reforms can raise about 3 per cent of GDP, at least half of which should be used for the first phase of providing UHI. The second challenge is to regulate downward any growth in private indemnity insurance. UHI will free the current out-of-pocket spending and channel funds toward far more productive uses. A single-payer system is an example of enhancing the reach of health care through a wide range of private providers. It is also a fine way to weed out unscrupulous practices in the health-care system. Gujarat’s Chiranjeevi Yojana is one example of how private services can be delivered using public finance.

While strengthening the public health-care system, the government could concurrently adopt a few bold, high-impact interventions within three years to improve health care. In India, around 1.5 million children continue to die before their fifth birthday, mostly due to conditions that are avoidable. Thus, a second priority should be to include a rapid scale-up of the introduction of new vaccines against diarrhoea and pneumonia among children. These vaccines have made ear infections among children in the west less common. If they are used in India, perhaps the deaths of 2,00,000 children (between the ages of 1-59 months) can be avoided. While these new vaccines are much more expensive than they were in the past, they are certainly cost-effective. Novel delivery models, such as the one that the Union Health Minister Dr. Harsh Vardhan pioneered in Delhi for polio, must be tested and scaled to deliver vaccines to every doorstep.

The most feasible priority will be to reduce smoking. Smoking kills about 1 million Indians every year. The number of cases of tubercolosis has risen because of smoking. While all kinds of smoking are harmful, prolonged cigarette smoking has already been shown to rob Indians of a full decade of life on an average. All cigarettes must be taxed on their tobacco content and not length. The Asian Development Bank has found that tripling the tax rate can save about 8 million lives. Contrary to common misconception, this will not drive cigarette smokers toward bidis as the two markets are different. Finance Minister Arun Jaitley knows that the value of 1 million lives is far, far greater than the purported revenue made by the tobacco industry. More practically, tripling of the tax would yield another 0.3 per cent of GDP in revenue.

Preventing vascular deaths

A fourth priority should be to tackle adult vascular deaths — the leading cause of deaths in the country, killing over 1 million Indians between the ages of 30 and 69 per year. Data show that about two-thirds of people who die from such diseases suffered a heart attack or stroke earlier. In such patients, low-cost generic risk pills that combine aspirin with a statin drug in order to reduce cholesterol and lower blood pressure can reduce by two-thirds the chances of suffering another stroke or even dying. Low-cost treatments of acute heart attacks are also now possible. The vibrant Indian generic drug industry knows how to deliver high-quality drugs at low cost (and indeed was largely responsible for the major turnaround in HIV treatment in Africa). What is needed is a change in regulation that would allow any drug that has already shown to be effective to be packaged with other drugs, provided they have met the standards of manufacturing.

Controlling malaria

A fifth priority should be to control malaria. India has made substantial progress in reducing the number of cases of malaria and the number of deaths caused by the disease (although the official numbers of rural Indians dying from malaria remains underestimated). Specific measures need to be taken to prevent a big resurgence of malaria.

This would involve a change in the Indian malaria programme to a proper use of combination drugs. These treatments must be made widely available in rural areas, particularly in Odisha and the northeast. More pressingly, India can lead in fighting resistance to effective malaria drugs that are emerging from the Greater Mekong Region. This means that Foreign Minister Sushma Swaraj, who was earlier a capable Health Minister, must substantially boost India’s foreign aid to combat drug and insecticide-resistant malaria in Asia. India can contribute $100 million to a regional malaria fund, and establish a public-private partnership to provide subsidies to reputable drug manufacturers (many of whom are in India). This is not only good science and good economics, but also good politics. Leading malaria control in Asia will enhance India’s health profile in the region.

Finally, a major effort should be made to improve health reporting. The Census should be strengthened, expanded and paired with the economic census and other surveys. This new central information hub will help track and report on development and progress.

The most revered leaders around the world have been those who made health for all possible. Canadians rated Tommy Douglas, a provincial Premier as their most important citizen after he introduced UHI. England adopted the National Health Service, not when it was rich, but during the austere times following World War II. There are many obstacles to this but they need to be overcome. We hope that Mr. Modi will choose these practical steps to secure a healthier future for all Indians.

(Prabhat Jha is Director for the Centre for Global Health Research, New Delhi and Toronto.)

One priority of the government should be to include a rapid scale-up of the introduction of new vaccines against diarrhoea and pneumonia among children


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