An air of anticipation and optimism greeted the formation and installation of the new government in 2014. A widely held view was that it would be much more decisive than the previous dispensation in providing some direction to public policy. Twenty months have passed and the initial sense of optimism has been replaced by a growing sense of frustration at the inability or unwillingness in providing leadership in key areas of public policy.
The health sector typifies the hands-off policy of the government in areas that impact welfare and livelihoods. There has been a singular lack of purpose in policymaking and its implementation in the health sector. The initial signals, especially the government’s widely publicised intent to provide “Health Assurance” to all, were promising. Many commentators assumed that it was the new government’s take on Universal Health Coverage (UHC). Now, in 2016, there has been no further explicit unpacking of the vision around “Health Assurance” or UHC. The former has remained an empty slogan, devoid of content or vision. This despite at least one high-level committee having been constituted in the early days of the present government to spell out its vision on ‘Health Assurance’. Its report, submitted more than a year ago, appears to have been given a quiet burial.
The draft of a new National Health Policy was unveiled over a year ago and public comments invited. The comments were compiled and the revised draft has been lying with the Ministry for the last four months. Media reports highlighted the government’s unhappiness with the policy draft especially after Niti Aayog’s rap on the Ministry of Health’s knuckles for not having privileged private sector participation in health provisions in the policy draft.Floundering programmes
In the past 20 months, several actions have fed growing concerns that there are clear attempts to move health policymaking in a particular direction. Two successive Union Budgets have slashed support to the health sector, and by more than 20 per cent. These cuts have brought programme implementation in already under-resourced areas to a virtual standstill. The HIV/AIDS and TB programmes are floundering, with a stock-out being reported for many essential medicines. Reports indicate that those who are responsible for the implementation of the National Health Mission (NHM) are frustrated and demoralised. Instead, proactive measures seem to have been initiated to scale up health insurance schemes, including the flagship Rashtriya Swasthya Bima Yojana (RSBY); the latter has been moved from the Ministry of Labour to Ministry of Health. So we have a greater emphasis on health insurance schemes, where provisioning of services is largely outsourced to private facilities on the one hand and a systematic under-resourcing of public provisioning of health services under the NHM on the other. Despite several conflicting announcements, there has been no progress in the roll-out of a “free medicines scheme” ensuring availability and free access to essential medicines in public facilities.
There have been vague assurances that some small incentives would be extended to States that initiate free medicine schemes, a far cry from the vision initially that promised Central funding for all such schemes. Amid conflicting statements, the only assurance that has held ground is on support to the availability of just 50 medicines. The actual implementation of even this grossly inadequate provision has not been spelt out. Interestingly, the National Pharmaceutical Pricing Authority was pulled up by the government when it attempted to bring in more medicines under price control.A particular vision
The inactivity in promoting public services and public oversight and progressive withdrawal of support to public services is part of a particular vision of UHC. Here, the role of publicly provided health services is replaced by outsourced services to the private sector. Insurance mechanisms and not public provisioning is the hallmark of this approach.
Concurrently, given that public financing is being reduced, what is being promised under UHC is basic and not comprehensive services. Even these basic services are largely reserved for primary levels of care, thus paving the way for an ever larger penetration of private facilities, especially in the hospital sector. Finally, as seen in the 2015 Budget, private health insurance is incentivised for the rich and a section of the middle class. While not made explicit, this is the vision of the government towards UHC. It is not a new vision but one that informs the implementation of UHC in a range of low- and middle-income countres that follow neo-liberal economic policies. The impact of such a vision has been uniformly negative in all countries that have implemented it. Unfortunately in India, especially in the health sector, we appear to believe in the merit of learning by repeating other people’s mistakes.
(Amit Sengupta is convener of the Jan Swasthya Abhiyan, the Indian chapter of the People’s Health Movement.)