Context

The forthcoming election is going to be an inflexion point for India’s health system story — how affordable, how accessible, how equal?

Divergent Approaches

• Though health is not a political priority as yet, two visions of the future health policy seem to be clearly emerging.

• One, espoused by the BJP — a centralised hospital insurance-driven health system designed on the Medicare model of the US.

• The other, of the Congress, calling for guaranteeing every citizen with access to essential health services, resembling the UK and the European model.

• Both these approaches are widely divergent and will profoundly impact the three pillars of the health system — access, quality and affordability.

Concerns

• Given India’s fragile economic system and multiple demands on it, notwithstanding India being the second-fastest growing economy, sustainability will be a major concern.

• The two thought streams, propounded by the BJP and the Congress, are embedded in and reflect two social value systems:

  • In the US, it is individual liberty and personal responsibility.

  • While Europe and countries like Japan are driven by ideas of social responsibility and state accountability.

US model

• The US confines itself to subsidised care for the poor and elderly, regulates stringently for quality and allows financial incentives like profits to encourage technological innovation.

• As a consequence, it has over 20 million of its population without access, despite spending 18 per cent of its GDP on health.

European Model

• The UK and Europe, on the other hand, believe in the principle of collective responsibility ensuring every individual’s inherent right to health and wellbeing, thereby making the state develop financial and regulatory systems that guarantee all individuals equal access to healthcare services and products.

• These countries spend an average of 10 per cent of the GDP on health with far better outcomes than the US.

Equality v/s liberty

• When India won independence from the British, we were driven by the European values of equality that got imposed onto a highly stratified social system.

• Some successes have been achieved in implementing affirmative action.

• Over the years, however, the economic and social models trended more along the values of individual liberty rather than social equality.

Degrading Health standards In India

• Disparities have widened to such an extent that latest data seems to suggest that 1 per cent of India’s population enjoys 70 per cent of its wealth.

• While an Indian is among the 10 richest of the world, we also account for the world’s poorest, over 36 per cent of children stunted due to chronic malnutrition, half of the population defecating in the open and nearly three-quarters without access to tap water.

• The rising burden of disease in India is but a reflection of such deprivation of essential and basic social goods and the wide inequalities cutting across regions, castes, gender and age.

Challenges in building sustainable healthy blocks

• Stacked against an incremental and systematic building of the health system blocks, in the manner that Thailand or Turkey did, are powerful lobbies of the health industry that support the narrow agenda of the hospital insurance programme.

• These lobbies have the support of US-based foundations and donors, World Bank, CII, FICCI, the medical associations and companies related to health insurance, data aggregating IT, medical devices etc.

• The public health approach that seeks to prioritise comprehensive primary care as an entitlement of every citizen is clearly numbed out and would require peoples’ movements and participation.

• This is critical as with the meagre resources of 1.1 per cent of GDP, choices are being made.

Conclusion

• No one would argue that hospital insurance is a wrong policy and that only primary care should be the focus.

• But a system hanging on hospitals without the foundation of primary care is a sure recipe for disaster as it is clearly unaffordable and unsustainable.

• Effective primary care not only reduces one-third of hospitalisation but by prioritising well being over sickness, it removes the causal factors to disease and illness.

• It is important to reiterate the importance of these issues as the last budget showed a 300 per cent increase for health insurance.

• With the revision of hospital rates, the cost of the health insurance programme will also double and continue to rise.

• In the absence of a commensurate increase in health budgets, the price will be paid by the large swathes of the poor and middle classes who desperately need good quality primary healthcare.

• Its absence is responsible for the proportionately higher number of premature deaths, one quarter of the global TB burden and a million dying just for want of clean air.