For the first time in living memory, and deviating from the usual passing references, healthcare was accorded a place of importance in the provisions of the 2018-19 budget. The FM proudly announced the introduction of “the world’s largest government related healthcare programme” the National Health Protection Scheme (NHPS). Ten crore families would get a Rs 5 lakh cover for secondary and tertiary care. This increased the amount under the Rashtriya Swasthiya Bima Yojna (RSBY), which itself has been a failure, by more than 16 times. Calculated even at a very modest premium, of Rs 1200 per family where the oldest person is 35 years old, this works out to Rs 12000 crores. It will increase when the elderly are factored in. The inclination to applaud was short-lived as reality sunk in.
A study reported in the international journal Social Science Medicine, reported that the RSBY scheme had little or no impact on the out-of-pocket expenditure of patients; it continues to cripple households.
The grandiose plan makes no reference to neglected primary healthcare and this will continue to contribute to the failure of any such scheme. The country has 27000 PHCs; by its own admission the MOHFW in its 2016 report admits to a shortfall of 22% in PHCs. More realistic estimates indicate that the country needs around 80000 PHCs. Those that do exist function at an apologetic level. 80% of specialist posts are vacant; 40% do not have ambulances to transport critically ill patients to higher centers.
Many lack in basic amenities like water and electricity. In any healthcare system, it is the level of primary care that determines the final status of the health of the nation. This is sadly ignored in the budget. One cannot expect private enterprise to invest in rural or primary healthcare as private health care will always operate on a for profit basis.
The World Bank in collaboration with the MoHFW and NITI AYOG released the “Performance in Health Outcomes Index”, a composite index which assessed the overall performance in states on a comparative scale. Health being a state subject, each state has its own unique method of handling this sector. As a result, huge disparities are observed between Indian states in public health. For example, in Kerala, the infant mortality rate is 12 per thousand live births whereas, in Assam, the number is as high as 56. One third of the states registered a reduction in their health indices, and the MOHFW has announced incentives under the National Health Mission which will be linked to performance on the index. How this will fit in with the proposed insurance scheme remains a muddled matter.
Information unearthed under the RTI has revealed gross misuse of funds in the Maharashtra Chief Ministers Relief Fund for healthcare. Funds have been granted for dead patients; funds released twice for the same ailment; income status has been fudged and justified on the grounds that the authority issuing the certificates has no way of verifying the income status of the applicant. As a result funds have been granted for people classified as economically weaker section in spite of owning large tracts of land and multiple flats.
The disease burden in India to a significant extent comes from lack of clean drinking water, inadequate sanitation and malnutrition. 35% of deaths are related to malnutrition, TB, lack of neonatal care and respiratory infection. These, if picked up early can easily be treated at the PHCs at out-patient level. I fail to understand how insurance cover will help such patients. What is needed most urgently is funding for basic healthcare facilities so as to reduce the numbers who end up needing secondary and tertiary care. Countries like Brazil, Japan, China and Sri Lanka have demonstrated outcomes in the form of reduced disease burden, lengthening life expectancies, 33% fall in emergencies and hospitalization, and avoiding preventable morbidity.
Funding this grand scheme will require an annual outlay of Rs 50,000.00 crores and will cover only hospitalisation. It is unclear how this will be met, as there will be a considerable shortfall even with all the financial gymnastics like the health and education cess, LTCG tax and other features of the budget. The cost is proposed to be shared between the Centre and the state on a 60/40 basis. Some states particularly the southern states, already have their own schemes which have shown considerable success. Are they expected to abandon their schemes, and adopt the insurance proposal?
There can be no two ways about it; the key to the healthcare issues in India lies in resolving the deficiencies at the PHC level. Hoping to resolve the issue by increasing the current government spending of 1.1% to 2.5% by 2025 merely creates a pipe dream. Abdicating responsibilities by shifting them onto insurance and private healthcare cannot solve the problem. The NPPA survey of four major private hospitals showed that drugs, consumables and diagnostics accounted for 46%of a hospital bill with a mark-up of 1737% on the profit margin. This is in contrast to the attending doctors’ fees which accounted for about 12% of the bill. Yet it is the medical professional that bears the brunt of the criticism and faces the flak. Unnecessary investigation, overtreatment and excessive use of ICU facilities all add to the patients’ misery. Attempts to regulate private healthcare has failed. States (including Goa) have either not adopted the Clinical Establishments Act or failed to implement it.
If better standards of healthcare are to become a reality in India, the emphasis must shift from secondary and tertiary care to the primary care level; from specialist to generalist care and from private to public healthcare. The state must accept its role of service provider in primary care and not that of a financier.
(The author is a founder member of the Voluntary Health Association of Goa).
