Healthcare needs of the poor require urgent attention

Leave aside the semantics, both the Congress and the BJP promised in their manifestos to lower out of pocket expenditure on healthcare that pushes a large number of Indians over the poverty line.

When UPA-I came to power in 2004, the first National Advisory Committee prepared a report to demonstrate how the staggering out of pocket expenditure on health was the biggest contributing factor for a significant rise in the poverty level.

Eight out of ten years of UPA rule, the government took several steps, but much more needs to be done if the health scenario has to be altered. There are some successes like a big drop in the infant and maternal mortality rates. The government intervention focused on reproductive and child health, improved institutional deliveries and tackled vector-borne and communicable diseases like malaria and tuberculosis.

Over the last decade, India underwent a demographic shift with large scale migration from rural to urban areas. As per the 2001 census report, more than 30 per cent of Indian populace was urban, which is projected to exceed 40 per cent by 2030. But public sector health care facilities have not increased correspondingly, leading to a major growth in private health care business.

Indian health system now face the challenges of high rates of non-communicable and mental diseases and continuing threats of communicable diseases. In the absence of adequate epidemiological records, the burden for most of the diseases is unknown. “For instance we do not know the prevalence of rheumatic heart disease in poor rural India,” said Yogesh Jain, a paediatrician at Bilaspur-based Jan Swasthya Sahyog, a non-governmental organisation associated with public health.

About one and half years back, prime minister Manmohan Singh announced universal health care from the ramparts of the Red Fort. The Prime Minister’s Office and the union health ministry drafted a Rs 20,000 crore scheme to provide free medicines at government run health facilities that would have been the first step in reducing out of pocket spending on health.

“Out of pocket payments represent about 69 per cent of the total health expenditure – a common cause for impoverishment,” said Asheena Khalakdina at the World Health Organisation. They come from non-reimbursable fees (or hospital or medical cost) which a patient or family is paying directly to health practitioners or suppliers, without intervention of a third party.

India was ranked as having one of the world’s highest average out of pocket expenditure (74.4 per cent in 2011). It accounts for an average increase in poverty by as much as 3.6 and 2.9 per cent for rural and urban India respectively in 2009.

Better and effective

This is where Singh’s grandiose scheme on universal healthcare was supposed to chip in as it aimed to cover 52 per cent of the population by providing better health care and free medicines at public sector units. The scheme, however, did not take off because of objections from the Planning Commission that raised queries on the private sector’s role.

“Engaging with the large private sector is one of the key issues,” noted Khalakdina. Also the decision to set up a central procurement agency for drug purchase was taken late.
In their manifestos, both the Congress and the BJP have promised to look into this. While Congress manifesto talks about “universal and quality healthcare” and “right to health”, BJP Party harps on a “universal health care that is not only accessible and affordable, but also effective, and reduces the out of pocket spending for the common man.”

“The out of pocket expenditure on healthcare will not come down unless there is insurance cover for OPD expenses as 70 per cent of expenses are on drugs and diagnostics,” Jain said. “We need a clear road map and not election-time claims. The public financing has to go up with strong focus on primary care, rather than subsidising secondary or tertiary care,” explains K Srinath Reddy, president of Public Health Foundation of India. The existing central health insurance system (Rashtriya Swasthyo Bima Yojna) does just that as it pays for hospital stay and surgeries.

“RSBY has led to unnecessary surgeries in many states. Even if the patient visits a doctor with flu, doctors admit the person because of RSBY,” said A K Shivkumar, a consultant to the UNICEF. “Putting more resources into health, however, doesn’t always translate into better outcomes. Evidence shows that we need cashless access to health services at all points of delivery,” Poonam Khetrapal Singh, the regional director for WHO South East Asia pointed out in a recent article in the British Medical Journal.

The Planning Commission proposed piloting several projects on universal health coverage at the district level to demonstrate comparative advantages and costs of different approaches to UHC. The outcome of these projects will determine the private sector’s role in achieving universal health coverage in the next 10-15 years. Many want a Right to Health legislation, which Congress has promised in its manifesto.

“There is also a need to remove unnecessary taxes by the Central and the state government, which add nearly 30 per cent to the cost of health care,” said cardiac surgeon Devi Shetty. The task ahead for the new government would not be easy as several tricky issues ranging from availability of manpower to centralised procurement of drugs have to be tackled to ease out the pressure felt by the common man. The million dollar question is whether these health issues will get sufficient priority from the next government.