Health as national agenda
Civil society must fuel nationalism for quality healthcare to all citizens – even today, medical expense remains steep and largely inaccessible
The recently-concluded general elections lacked talk on healthcare for people, even though health and education form the basis for any kind of social development. Unfortunately, both have been pushed to oblivion in election campaigns which were essentially centred on evoking emotion and sentiment. This is a very sad reflection of our political scenario. Even the representatives of the most marginalised sections of society, who are the worst affected due to poor state support on these two core issues, have failed to highlight these concerns.
In the last about two decades, our country has moved ahead in advanced healthcare. But much of it has developed in the private sector because of which, access is limited to only those in the high-income group of our population. Focus on health tourism in healthcare provides opportunities to the rich and affluent from abroad to avail advanced healthcare in India at a cost lower than what is available in their countries. These policies, however, leave a vast majority of our population devoid of access to quality healthcare.
Inequalities in healthcare are a global issue but they are worse in developing countries. In 2017, nearly 50 per cent of the world's total population did not have access to quality essential services that protect and promote their health. Around 800 million people were spending 10 per cent of their household budget on out of pocket health expenses. As a result, 100 million people were being pushed into extreme poverty every year. In our country, out-of-pocket expenditure by households constitutes 63 per cent of Total Health Expenditure (THE). Due to this, 6.3 crore people are being pushed below the poverty line every year. The share of out of pocket expenditure on healthcare as a proportion of total household monthly per capita spending is 6.9 per cent in rural areas and 5.5 per cent in urban areas. This is considered to be catastrophic expenditure.
According to the National Sample Survey Office's (NSSO's) 71st report on 'Health in India', India accounts for a relatively large share of the world's disease burden. Lack of access to food, education, safe drinking water, sanitation, shelter, declining control over land and its resources by the already marginalised sections and falling opportunities for employment further add to disease burden. There has also been an epidemiological transition from communicable diseases to non-communicable diseases.
Public spending on health in our country is only around 1.1 per cent of its GDP (2015-16). As high as 86 per cent of the rural population and 82 per cent of the urban population are not covered under any scheme of health expenditure support. Ayushman Bharat provides coverage only for indoor care whereas about 70 per cent expenditure is incurred on outpatient care. The scheme excludes a major part of the low-income group population. Rural households primarily depended on their 'household income/savings' (68 per cent) and on 'borrowings' (25 per cent); urban households relied much more on their 'income/saving' (75 per cent) for financing expenditure on hospitalisation than on 'borrowings' (only 18 per cent). About 60 per cent people took treatment without any medical advice. This was primarily attributed to 'financial constraints' (57 per cent in rural, 68 per cent in urban). Out of the total medical expenditure, around 72 per cent in rural and 68 per cent in urban areas was made for purchasing 'medicine' for non-hospitalised treatment.
The National Health Accounts (NHA) estimate for 2014-15 shows that Government Health Expenditure (GHE) per person per year is just Rs 1,108. According to NHA, THE for the same period worked out to Rs 3,286 per person. Of this, out-of-pocket expenditure was Rs 2,394, constituting 63 per cent of THE. The Centre:State share in total public expenditure on health was 31:69 in 2015-16.
India is one among 193 countries who have signed the agenda for Sustainable Development Goals (SDGs) launched by a UN Summit in New York in 2015. Goal 3 of SDGs solely focuses on health. It comprises 13 targets which include, no poverty, zero hunger, good health and well-being for people, quality education, gender equality, clean water and sanitation etc. Some important targets to be achieved by 2030 include maternal mortality ratio to less than 70 per 100,000 live births, end preventable deaths of new-born and children under 5 years of age, reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. It also envisions to end the epidemics of AIDS, Tuberculosis, Malaria and neglected tropical diseases and combat Hepatitis, water-borne diseases and other communicable diseases. This demands national strategies and programmes to achieve universal healthcare and access to safe, effective, quality and affordable essential medicines and vaccines for all. This requires 5-6 per cent of public spending of GDP. Since our public health spending is around 1.1 per cent only, meeting these targets appears difficult. According to SDG Index and Dashboards Report, 2018, India's ranking in SDG is 112. In comparison, other South Asian countries barring Pakistan have better performances. Their rankings are Pakistan: 126, Sri Lanka: 89, Nepal: 102, Bangladesh: 111, Bhutan: 83, China: 54. In SDG on health, India ranks 143 out of 188 countries.
NITI Ayog has been assigned the task of taking steps to achieve SDG targets. There is a need to involve various stakeholders for implementing these. Health is a state subject in India but health policy decisions are guided by the Centre. Therefore, the government should come out with all details on the steps taken to date. Global experience shows that better results are achieved by a State's direct spending on health. There is a need to immediately increase public health spending to 3 per cent of GDP and increase it to 5 per cent to be able to meet the SDG requirements on health.
In a multi-country consultative workshop to assess the progress on implementation of health and health-related sustainable development goals, it was observed that the Low- and Medium-Income countries (LMICs) need special assistance to meet these goals. It is to be ensured that these goals should not meet the fate of the Alma Ata declaration signed in 1978. The Alma Ata declaration had envisioned health for all by the year 2000. India too was a signatory. But the targets were never achieved. We cannot lose time; effective measures need to be taken for not only the points mentioned in target 3 of SDGs – other related targets need to be equally fulfilled if desired results are to be achieved. A special focus has to be laid on gender equality as women are by and large greater sufferers in the pursuit of better health. Maternal and child healthcare have to be given priority.
Since out of pocket expenditure on health is one of the major causes of impoverishment, families send children for labour to support their everyday needs. There are reports that some families mortgage their children to meet healthcare needs. Income disparities have to be reduced. Steps have to be taken for economic reforms targetted at working people's needs for appropriate remuneration. Ensuring job and food security alongside curtailing prices of essential commodities is essential in assisting low-income groups. Growth has to be made inclusive so that its gains can be translated to deprived sections. Goal no. 4 stresses on quality education. This can be fulfilled only through an education policy with an increase in public spending on education. Right to Education should apply to all levels of education. Steps need to be taken for the promotion of good climate.
Goal no. 16 is emphatic on peace and justice as conflicts are leading to reversals in SDG progress. The countries that are facing armed conflicts and civil wars, more so those in the category of low-income countries, are finding it difficult to meet health objectives. India is the second biggest buyer of arms. Our spending on defence is adversely impacting spending on health and education. To reverse this trend, it is pertinent to hold mutual dialogue with neighbours and sort pending issues.
It is time people come forward to demand the effective implementation of SDG targets on health. Health has to be made a national agenda by society.
(The author is Co-President, International Physicians for the Prevention of Nuclear War (IPPNW) and Senior Vice President, Indian Doctors for Peace and Development (IDPD), among other engagements)