Health versus wealth

Poornima Joshi

Current deliberations in the Planning Commission about actualizing universal health care in the Twelfth Five Year Plan, have invited concerns. There has been a marked thrust on state-funded insurance as opposed to a genuine effort on the government’s part to rebuild public health systems, something that has been a globally time-tested system to ensure health for all.

The ongoing discussions are based on reports of the Planning Commission’s steering committee and High Level Expert Group (HLEG). The contentious theme in the definition of the Universal Health Care (UHC) coined by HLEG, excluding the promise of ensuring “affordable, accountable, appropriate health services of assured quality to all Indians”, states the role of government as a “guarantor and enabler” and not necessarily the “only provider” of health and related services.

The HLEG makes two critical recommendations that have raised objections from health experts and activists alike. A crucial recommendation that is being contested is the “purchase” of insurance schemes by the government. “Purchase of all health care services under the UHC system should be undertaken either directly by the central and state governments through their departments of health or by quasi-governmental autonomous agencies established for the purpose,” says the HLEG report. The other contentious suggestion is the proposed “contracting in” of the private sector. “Develop effective contracting-in guidelines with adequate checks and balances for the provision of health care by the formal private sector,” HLEG report adds.

At a seminar organized by the Council for Social Development in the Capital in July, health experts opposed this proposed roadmap towards UHC even when there was near unanimous approval of the proposal to raise health expenditure from the abysmally low, that is, 1.2 per cent of the GDP, to at least 2.5 per cent of the GDP by the end of the Twelfth Plan, and to at least 3 per cent of GDP by 2022.

According to Prof. Imrana Qadeer, formerly of the Centre of Social Medicine and Community Health (CSMCH) in JNU, improvement of health care has to be accompanied by enhancing the efficiency of public sector. “There is a need to go back to the Bhore committee and delve into economic and social structures in the country to if access to health care has to be universalised. We have to talk of equality not equity. The steering committee separates health from health services,” said Prof. Qadeer. “What do terms such as ‘contracting-in’ of the private sector mean when the corporate sector is actually leading reforms in the health sector?”

The HLEG envisages a “managed care” model with a thrust on an increase in government expenditure. By increasing public spending on drug procurement, availability of free essential medicines is to be ensured. General taxation, as per HLEG, is the principal source of health care financing – complemented by additional mandatory deductions for health care from salaried individuals and tax payers. It proposes introduction of specific purpose transfers to equalize the levels of per capita public spending on health across different states level of essential health care. Most importantly, the HLEG proposes universal and cashless access to an Essential Health Package (EHP) including essential medicines.

These ideas are further consolidated in the steering committee of the Planning Commission. “To begin with, core components of the EHP must include all the preventive, promotive, curative and rehabilitatory services in routine and emergency settings available under RCH and national health programmes,” says the steering committee report.

There are problems with this “packaged care” model, pointed out Dr Amit Sengupta of the Delhi Science Forum (DSF). How do you spend the money—do you use it to build a system or use it to provide UHC as a package? Who provides health care is important because fragmented provisioning of services does not allow for development of integrated health systems.

“Advancing the logic of fragmentation, an attempt is made to promote segregation of health systems into primary care by the public sector and tertiary care by the private sector. As the private sector grows to fill the vacuum, a loud noise is made about ‘catastrophic payments’. The state then steps in and asserts that a ‘minimum package’ would be ensured. The argument for this is lopsided because private sector, despite being a ‘partner’ in providing tertiary care, is then financed through public funds, that is, through ‘minimum packages’ ensured by the state,” said Dr Sengupta.

There is enough evidence, said Dr Sengupta, to prove that the best performing systems are those that are publicly financed and provisioned. “Public provisioning needs to be located in a range of other social protection measures while public financing has to be located in a progressive taxation system that is premised on the notion of equity.”

Clearly, it will take far more than insurance packages to ensure health for all. Time-tested global models in Cuba, Costa Rica and neighbouring Sri Lanka prove that the government has to necessarily be the “provider” and not just a “guarantor” to actualize universal health care.