Universal healthcare awaits a final Sonia push to move forward

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Initially it was thought as one of the ideas that would aid the Congress-led UPA government to tide over the 2014 Parliamentary election. The universal health coverage, pursued enthusiastically by the Union health ministry faced roadblocks from the Planning Commission. However, the Sonia Gandhi-led National Advisory Council now has come forward to give a push to the UHC, which remained a pipe dream for millions of Indians six decades after Independence.

The idea of healthcare for all embedded first in the Joseph Bhore Committee Report of 1946, which was established by the British government to improve the public health and later in the Col S S Sokhey panel report of 1948. The second was a sub-committee on national health which gave its input to the National Planning Committee chaired by Jawaharlal Nehru. Two national health policies in 1983 and 2002 and several international declarations to which India is a party, advocated  the same.
Still, precious little happened on the ground. Inadequate availability and reach of healthcare centres, unequal access, poor-quality and costly healthcare services created a social divide. The per capita public spend on health was grossly insufficient.

As a consequence, the proportion of private out-of-pocket expenses (69 per cent) is among the highest in the world. The UHC seeks to cut down on the private expense on health by half in the next 10 years by promoting public spending on health.

Two features of private out-of-pocket expenditure have important implications for universal health coverage. One, the bulk of private out-of-pocket expenditure (74 per cent) is incurred on out-patient treatment and not on hospital care. And two, medicines account for 72 per cent of the total private out-of-pocket expenditure. Clearly, any system of UHC would cover for both in-patient and out-patient care and absolve individuals of having to pay for medicines and diagnostics as well.

A sub-committee on health at the NAC last week informed the powerful advisory body that financial protection against medical expenditures in India was far from universal at the moment with only a small proportion of the population having adequate medical insurance coverage.

Having to borrow in order to finance health has become a major cause of impoverishment, which was highlighted even by the then NAC during the UPA-I regime. Limited investments in public provision of healthcare has resulted in (i) short supply of reliable and affordable services, high inefficiency and poor compliance to quality standards; and (ii) citizens getting low value-for-money in both public and private sectors as a dominant and unregulated private sector systematically exploits the ignorance and helplessness of citizens.

More public expenditure

Both NAC and a high level expert group earlier constituted by the Planning Commission suggested increasing public expenditure on health, which is around 1.04 per cent of GDP. This is one of the lowest in the world. The National Common Minimum Programme of UPA-I made a commitment to increase public spending on health to 2.5-3 per cent of GDP over 5-7 years. It remained unfulfilled. NAC has now reiterated the same. But allocations for health over the first two years of the 12th plan period (around Rs. 50,165 crore or an average of Rs 25,000 crore a year) was not encouraging.

If the planned allocation of Rs 2,68,551 crore over the five-year period has to be fulfilled, this will require the Central government to allocate at least Rs 70,000 crores a year over the next three years of the plan. Whether the government will be in a financial position to do so is yet to be seen.

As the first step, NAC has recommended that the states should implement up to three UHC projects in districts using resources available with the “incentive pool” of the national health mission. Free availability of medicines, spending close to 70 per cent of resources on primary healthcare, absence of any user fee and giving local bodies flexibility in designing their own UHC models would be some of the components of these pilot projects.

The NAC suggested creation of a National Health Regulatory and Development Authority (NHRDA) as an autonomous and statutory body to oversee and support state governments to ensure standard quality care. But the achievement under the Clinical Establishment Act, 2010 – the first overarching central legislation that covers both public and private service providers across the country – is dismal with only four states adopting the legislation and none implementing it fully. Among other things, the Act is mandated to register clinical establishments and medical service centres and create a national database of the centres. It was also meant to formulate norms for infrastructure and human resources for healthcare service centres, and enforce the standards.

Special emphasis, said the NAC, was needed to be given for the rural and marginalised people including those living in urban slums. Urban health, especially of the poor, remained a neglected area. The recently-approved Rs 22,500 crore National Urban Health Mission (NUHM) may lead to improvement of basic health services to urban citizens in 779 towns and cities with a population of over 50,000.

Some of the recommendations match with suggestions given by the Planning Commission's high level expert panel. But whether the NAC recommendations would have the same fate as the other panel or whether the presence of Congress president would make any difference to the government, remains to be seen.