Unhealthy signs in health sector

If health is wealth, are we spending sufficiently to maintain the basic health needs for millions of citizens in the world's fifth biggest economy, as our politicos make braggadocio with little qualms? In his Independence Day speech delivered with fervent zest, Prime Minister Narendra Modi declared the world's largest government-funded healthcare programme. It is designed to provide insurance coverage of five lakh rupees per family annually, benefitting more than 100 million poor families in a country having more than one billion population. The indefatigable Prime Minister inaugurated the first healthcare and wellness centre under Ayushman Bharat Yojana in Bijapur (Chhattisgarh) on August 14, a day prior to his unveiling of the big scheme, billed as Modicare, from the ramparts of Red Fort.

Essentially, Ayushman Bharat (also hailed as the National Health Protection scheme) has twin tasks. Firstly, fostering a network of health and wellness centres across the vast country of continental size, supplanting the well-nigh moribund primary health centres. Secondly, extending insurance coverage to 40 per cent of India's population by degrees, i.e., the most deprived, for secondary and tertiary care, including hospitalisation costs. Even as several states have their own state health insurance schemes, how far the new scheme would subsume the extant ones or help those who have been left untouched by it has not been adequately amplified.

Be that as it may, the 2017-18 Economic Survey said that the total expenditure by the government (Central and States combined) on health as a percentage of gross domestic product (GDP) has increased from 1.2 per cent in 2013-14 to 1.4 per cent in 2017-18 (i.e., from the last year of the UPA government to the first four years of the NDA government). The National Health Policy 2017 of the NDA government foresees raising government health spending by 1.1 per cent to 2.5 per cent by 2025 in a time-bound manner while aiming at augmenting state health sector spending to more than 8 per cent of their budget by 2020. With states not worried over addressing basic issues such as primary health and education as the cost of election campaign seems too big a task in hand, it would be ambitious to expect them in drawing enhanced outlays on health, particularly when the state-run medical institutions are in a parlous state ushering even the poor patients to private hospitals and physicians.

Though the healthcare in the country comprises both public and private sectors, the private sector provides nearly 80 per cent of outpatient care and about 60 per cent of inpatient care, according to the latest report on the assessment of entities engaged in health and allied sector by the Public Accounts Committee (PAC). Interestingly, the PAC, which studied an earlier report of the Comptroller and Auditor General of India (CAG) on the issue, found that although there was expansion of the private healthcare expenditure by more than 35,000 crore rupees and 39,000 crore rupees during 2012-13 and 2013-14 respectively, the number of corporate assesses in the categories viz., medical professionals, nursing homes, and speciality hospitals had actually declined in 2012-13. It then increased marginally in 2013-14, revealing the extent of suppression of income and non-filing of returns, making abundant use of available exemptions and loopholes in the statute.

The PAC report also took cognizance of the referral fees disbursed to doctors by private hospitals, nursing homes, and diagnostics centres for referring patients and payments made on account of advertising expenses by the medical practitioners; however such expenditure has been claimed disallowed and unethical as per the directives of the Central Board of Direct Taxes (CBDT) and the Indian Medical Council (Professional conduct, etiquettes and ethics) Regulations, 2002 read with Homeopathic Practitioners (Professional Conduct, Etiquette & Code of Ethics) Regulations, respectively. Despite the directives in place explicitly, such benefits are still being distributed, though, in other forms, the committee said wryly. Hence, the committee pertinently suggests that such expenses being pertained to the promotion of business be allowed to be incurred from the profits after tax of the hospitals/pharmaceuticals, allied industries, and practicing doctors. Also, these should be made taxable in the hands of the beneficiaries.

A cognate issue flagged off by the PAC is that the fees charged by health professionals, private hospitals, nursing homes, medical clinics, medical colleges, diagnostic centres, pathological labs, and medical supply stores for their services are mostly received in cash, which is a high-risk area with potential for evasion of tax. Demonetisation of high denomination notes had not brought the best result in desisting these categories of service providers from taking cash, and now digitalisation of the economy would be ill-served if the authorities do not crack the whip to nip these nefarious practices from persisting any further. This way they would provide immense relief to legions of patients, who find paying their medical expenses a gargantuan task.

Yet another CAG report, tabled in Parliament in the monsoon session, on Pradhan Mantri Swasthya Suraksha Yojana (designed to rectify the imbalances in the availability of tertiary healthcare and improving the quality of medical education in the country by establishing institutions of eminence) found inadequacies in planning, financial management, setting up of new AIIMS, and refurbishment of existing state Government Medical Colleges and Institutions (GMCIs).

Illustrating financial management problems, the CAG report cited that six new AIIMS in Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur, and Rishikesh were holding an unutilised balance of Rs 1,264.71 crore, with Rs 393.53 crore for civil works and Rs 437.28 crore for procurement of equipment, lying unspent with the executing agencies. Four GMCIs (BJMC-Ahmedabad, BMCRI- Bangalore, NIMS-Hyderabad, and RIMS-Ranchi) diverted Rs 26.71 crore for other purposes.

Together, the PAC report and the latest CAG report touch only the tiny specks of a welter of problems plaguing the healthcare industry. They are unfortunately compounded by the apathy of the authorities, who could not fathom the depth of the health crisis that the nation would be facing if bitter medicines are not prescribed forthwith. There is no magic wand or silver bullet to cure many a malady, but promises regarding the health sector for the underserved would be defeated if the best reports, being with the government, are not taken on a serious note and acted upon without further loss of time. IPA

(The author is a

commentator on economic issues. Views expressed are strictly personal)