Here comes an unhealthy fore

A Reuters report quotes two health ministry officials, saying that the Government of India has ordered a 20 percent budget cut in healthcare. The sobering report, dated 24 December, takes the wind out of the expectations created by Prime Minister Narendra Modi. For if there is any sector in India that should not be tapped to reduce budget deficit, it is healthcare. India has one of the world’s poorest healthcare systems. There are several ways to know why and how. One way is to meet the poor – urban and rural. Expenditure on health constitutes one of the biggest reasons for rural indebtedness. If you travel through villages to understand why indebted farmers commit suicide, the top reasons include: lack of irrigation, high cost of production, and emergency health expenditure. Survey after survey has shown that the costs of addressing a medical emergency leaves families in debts that takes years to repay. On several occasions, I have visited an indebted family after its sole breadwinner committed suicide. (This is why journalism draws comparisons with ambulance chasing.) Each family has its own account of hopelessness. But I’ve heard stories that can never reflect in any survey.

A major illness to a family member guarantees chronic indebtedness. For a poor farmer, the choice is: take a severely ill family member to an overcrowded government hospital without basic facilities, or to borrow money from whoever is willing to lend – and at whatever rates – to rush to a private clinic or a hospital. You can rest assured the private hospital will take the family for every rupee that it can borrow. On the whole, Indians spend more out of pocket for healthcare than most other countries of the world; WHO’s numbers show over 86 percent of the total money spent on healthcare in India in 2012 came from the pockets of the patient or his/her family. In simple terms, the government has told its citizens that when they need medical care, they are on their own; there is very little that the government will do to help them. The list of countries where this figure is lower is truly embarrassing for India – governments of Tajikistan, Vanuatu, Belarus and several countries of sub-Saharan Africa spend more than the Indian government proportionately (in terms of the government’s share of the total healthcare expenditure).

In South Asia, the governments of Sri Lanka (83 per cent) and Nepal (81.4 per cent) perform better than the Indian government. In the US, where healthcare has become such a major political issue, out-of-pocket expenditure accounted for only 20.7 per cent of the total healthcare expenditure. Take the example of Delhi. The last government hospital built here was 26 years ago, when the township of Rohini was built. The locality of Dwarka was built long after, and it has no government hospital. At the same time, private hospitals have mushroomed across Delhi – all at incredible subsidies, most eminently, of prime land, which they are given by the government at Re 1.

Yet these hospitals routinely refuse to entertain even the minimal quota of poor patients that they are legally required to serve in exchange of the subsidised land. No government, no political party has done anything to prevent this inequality. In fact, since the private hospitals have bled the public hospitals dry of talented doctors, most political leaders also go to private hospitals now. On every indicator, India’s healthcare system deserves intensive care from the political class. One of the indicators of a country’s development status is its expenditure on healthcare in comparison to its GDP. The US government spends more than 8 percent of its GDP on healthcare; the Chinese government spends more than 3 per cent. The Indian government – regardless of the party in power – has spent only around 1 per cent of its GDP in healthcare. Which explains why out-of-pocket expenses are the highest among populous nations.

Government after government, political party after political party has – over and over – done everything to hand over the healthcare to the private sector. Which amounts to saying that all the parties consider healthcare a low-priority area. From Atal Bihari Vajpayee to Manmohan Singh, Indian prime ministers have effectively told Indian citizens that their health is in the hand of private profiteers. Modi raised expectations with a slurry of promises; the BJP manifesto specifically mentioned out-of-pocket expenditure on health. Now, requirements of fiscal prudence are taking centre stage. So, if the Modi administration wanted to fix the economy before addressing sectors like health and education, it could have been forgiven for not increasing the health budget immediately, preferring to tweak and restructure existing spending, while firming up a plan for an overhaul. But to cut the already measly health budget by a fifth is tantamount to telling a patient in the intensive care unit that if he cannot pay for his treatment, his government does not consider his life and health worth investing in. This shows, in unambiguous terms, that the Modi government puts a very low priority on healthcare. It is an indication also that the Swachh Bharat Abhiyan is a public relations exercise. For if the government was as serious about sanitation as the fanfare showed, it would have reflected in the health budget, for sanitation is an element of health. The cut in health budget will be a reflection on Modi’s promise of development. Is economic development the only goal, the only definition of development? Are people supposed to earn better so that they can spend more on healthcare? What happens to those who are not benefitted by economic development? Is their health irrelevant? 

The 20 percent cut in the health budget, if it comes through indeed, will mean that Modi stands for the Nehruvian ideals of economic growth and modernisation that Upadhyay opposed ardently. In fact, a Modi will appear as a Manmohan Singh on steroids, standing for an even more violent and severe kind of modernisation and neo-liberalism. This cut will make longer the queues outside government hospitals, making the helpless more desperate. GOVERNANCE NOW