By G. Srinivasan
After the Union Budget 2018-19 unveiled the twin initiatives on the country’s proverbially rickety health segment—reinforcing the wobbly primary health center (PHC) edifice through a network of 1.5 lakh health and wellness centers and extending an annual hospitalisation cover of five lakh of rupees for 100 million poor families under the National Health Protection Scheme (NHPS), there was an outrageous onslaught across the political and academic divides. The principal and incontrovertible facet of the volley of vituperative reactions revolved around the ubiquitous ground reality of the non-functioning of PHCs, particularly in rural areas, where their activities need to work in clockwork precision to provide primary care to those in dire need.
Most of the political parties, when they were in power either in the states or at the Centre, hardly did anything to repair this unwholesome situation, though they are vigorously launching a fusillade of their fire-power of fret and fury, arguing that the insurance cover to indigent masses is like putting the cart before the horse! Joining the chorus to lend weight and credence are the academics and media fraternity without bothering to highlight how the budget also proposed to extend fiscal support to PHCs that had morphed into health and wellness centres under the new National Health Policy (NHP) 2017.
It needs to be recalled that for a country widely credited to have the benefit of demographic dividends with a robust youthful workforce it took 15 long years to unveil the new national health policy last year since the formulation of one in 2002. This indifference to maintain the youth in the pink of health so that the nation’s human capital could verily be converted into productive assets for the economy was palpable. India expends just 1.4 per cent of gross domestic product (GDP) on health, compared to 3.1 per cent in China, even as the huge revenue expenditure run by both the states and the Centre invariably drew their funds out of massive borrowings and taking even from whatever they set apart for capital expenditure in building infrastructure, physical as well as social. One need not go anywhere to realize that most advanced countries resolved decades ago that it makes eminent economic, political and moral sense to give a basic level of care for all denizens rather than giving everyone the choice of the most modern medical treatments, whatever the cost. That is why for all its costly operations over the years the National Health System (NHS) pioneered by Britain in the post-War period is still working with warts and all, ably underpinned by dedicated team of medical personnel and care givers of a welfare state in the face of tightening budgetary constraints and health-providers blues.
But India has neither evolved a pro-people health policy down the decades nor made adequate allocations in the federal and sub-national budgets to beef up the basic health infrastructure so that basic health care is assured to all. All the 2018-19 General Budget has to give to primary care is a pittance of 1,500 crore of rupees for transforming 1.5 lakh health and wellness centres. What irks level-headed people is the government’s unclear stance on basic health priorities that is the need of the hour with a proliferation of both communicable and non-communicable diseases. Whether one is a poor residing in the bucolic part or in urban conurbation, the fact of the matter is that strange forms of communicable diseases do break out due to our abject inability to ensure solid waste disposal and letting the living areas a breeding ground for medicine-immune bacterial proliferation and through the modern life-style practices that cause non-communicable diseases like diabetes, depression and heart ailments to an increasing number of people. So on both primary, secondary and tertiary levels the pressure on the extant health system is enormous warranting a gargantuan amount of resources.
With the government not doing enough to ensure that the PHCs or their morphed health and wellness centres get the funding they need to take the task head on, its second strategy of extending insurance cover to the poorest households will not cut the ice. This is obviously so because healthcare providers are paid for services rather than for outcomes. So they suggest a spate of tests, prescribe pills and do surgical interventions with impunity. All these providers of services would obtain the hospitalisation costs of their beneficiaries through ‘strategic purchasing’ from public and private hospitals. This entails a well-thought-through strategy of provisions that would be covered, adoption of standard clinical guidelines for diagnostic tests and treatments suitable for different diseases, setting and monitoring of cost and quality norms and measuring health outcomes and cost-effectiveness, according to Public Health Foundation of India president K.Srinath Reddy.
Whether such a preparatory groundwork is under way before the scaling up of insurance to cover all the targeted people to ease their ‘catastrophic expenditure incurred on hospitalization’ is not spelt out by the authorities, busy as they remain with spreading the sparse resources thinly on a host of popular schemes without ensuring how the operational snafus could be surmounted in a scheme of this size and dimension. There is also the expressed fear and worry that insurance as a substitute for a solid public health infrastructure may not do, especially when there is a heightened participation from the unregulated private sector that might unobtrusively shoot up health care cost and hike premiums. In a situation where any free service is, given the tendency to exploit without bothering about bringing down the overall quality of services to those who are really in need of care, cannot also be lost sight of.
It is also not clear whether Central and state health departments or their outfits have put in place plans to foster the capacity for competent purchasing of services in fulfilling their vision for providing health insurance to millions from a diverse range of providers. This is all the more crucial because pruned outlays for the National Health Mission and pigeonholing of its urban part genuinely provoke apprehensions about primary care delivery through the health and wellness centres that are to be run by a team of a mid-level provider (with a degree in nursing, AYUSH or community health and trained in primary healthcare and public health) as well as frontline health workers like auxiliary nurse midwives and ASHAs.
At the end of the day, the announcement of the health scheme, though derided as being politically a tactical gain to the NDA government like what farm loan waivers and MNERGA to the UPA, can still be a real breather to the poor provided the authorities come forward to demonstrate their commitments to the avowed cause by tying up all the loose ends and without being apathetic to the imperative follow-up action on the ground. (IPA Service)