Healthy nation, wealthy nation
Healthcare schemes and policies must be inclusive—each fragment of our population must have its benefits
We are a global superpower in many aspects and are also moving up to become the fifth largest (2.5 trillion dollar) economy. India is also a preferred destination for medical tourism, but the government spending on health falls far short of expectation. We have been able to reach Mars, but are still struggling to reach a large number of children with life-saving vaccines. Our ranking on various health indicators is continuously sliding down and we are behind our less-developed neighbours – Sri Lanka, Nepal, and Bangladesh – on not just health indicators, but also on governmental fund allocation for health. The following areas require additional government assistance:
Out-of-Pocket Expenditure: The announcement of NHPS for the 50 crore population for secondary and tertiary care with Rs five lakh coverage does not include outpatient care. With NCDs accounting for more than 60 per cent of the disease burden, most of the expenditure incurred is on outdoor care. A recent NFHS survey shows that increasing number of patients, including the poor, are moving to the private sector due to the nonavailability of quality care in public hospitals.
Low increase in financial allocation to health: With the cost of healthcare spiralling out of control, the health expenditure continues to impoverish many Indians. In 1999-2000 an estimated 3.2 per cent of the population or 32.5 million were impoverished because of medical expenses, by 2014, the figure had risen to 94.44 million or 7.47 per cent of the population. Government expenditure on health as a percentage of the GDP was 1.3 per cent in 1990; it went down to 0.9 per cent by 2002. The government had committed to increasing it to 2 per cent in NHP 2002, but even in 2015, it was spending only about 1.2 per cent.
Strengthening public health system with adequate funds: The public health system in the country based on the Bhore Committee (1946), norms set in the 1983 policy and a cadre of ASHA workers and health managers at various levels, indicates that primary healthcare is still focussed on maternal-child health, communicable diseases and family planning. The vacuum created by the lack of expansion of primary healthcare in the public health system to deal with the ever-increasing non-communicable diseases is being filled by unregulated private sector growth both in rural and urban areas. The government has committed itself to establishing 150,000 health and wellness centres last year and more this year. There is little progress on the ground. The private sector needs to be integrated and brought into the mainstream, rather than being there just for the rich. The government must regulate the health sector on the lines of TRAI and provide funds to establish a regulatory authority for both public and private health. The budget does not allocate any funds to create an additional cadre of qualified hospital managers to be posted in all public hospitals. This would prevent recurrence of Gorakhpur like tragedies through the improved management of hospitals.
No mechanism to include health component in all policies: It is well known that 80-90 per cent of health is attributable to sectors other than health. There are many initiatives like Swachh Bharat Abhiyan, air pollution control measures and national nutrition mission announced in the Budget, but this will remain fragmented unless the Budget provides for setting up of a mechanism under the PMO or the Cabinet Committee to make sure that health is included in all policies affecting social determinants of health. For example, air pollution today accounts for 1.1 million deaths annually in India. Deaths related to PM2.5 have increased by 48 per cent since 1990. Similarly, deaths due to ozone have jumped by 148 per cent. Similarly, outbreaks of dengue and chikungunya have become an annual phenomenon because of the lack of action by other sectors.
Enhance State Governments' capacity in prioritising and implementing health initiatives: The budget does not take into account that health is a state subject and about two-thirds of health expenditure comes from the states' budget. Implementation of all health initiatives funded by the centre is done by the states. Moreover, the needs of states vary widely from state to state. Grouping the states in three or four groups helps, but does not meet their specific health needs. The current approach of developing models for the whole country in Delhi and then giving incentives to states to scale them up with little flexibility needs to be changed. The healthcare policy, planning and implementation should be steered by the states, not by central 'experts'.
Overall, there has been some increase with some new initiatives in the budget, but shows little deviation from the Centre pushing its agenda on states rather than building state capacity to reform the system. The Budget has made promises but there are several loopholes that must be addressed to fulfil BJP's election manifesto and the goals of NHP 2017.
(Dr Sanjiv Kumar is Director and Dr Sumesh Kumar is Professor, International Institute of Health Management Research, New Delhi. The views are strictly personal)