Towards a healthy India

Frankness and honesty, two admirable features of the 12th Plan’s Approach Paper, are unfortunately not sufficient to address the many shortcomings in guaranteeing health security to Indians. Imbedded in the subtext of the Approach Paper is an inexplicable reluctance, if not lack of courage, to embrace universal health coverage.
That India is far from attaining the Millennium Development Goals (MDG) relating to health is well-known. We were assured (or asked to believe) that, over the 11th Plan period, seven health goals relating to infant mortality, maternal mortality, fertility, under-nutrition among children 0–3 years, anaemia among women and girls, clean drinking water, and the sex ratio among children 0-6 years would be realized. We have failed to achieve all seven. In fact, the child sex-ratio which was to increase to 935 by 2011–12 sadly fell to 914 by 2011. Public expenditures on health was to be stepped up from around one to at least 2% to 3% of the gross domestic product (GDP). Even here, despite economic growth and the potential it generates for additional resource mobilization, we have been let down. Public expenditure on health hovers around 1.2% -- still among the lowest in

the world. This has led to an extremely high burden of private out-of-pocket health expenditures, which a huge part of the population cannot afford.
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The diagnosis in the Approach Paper is stale, but still relevant. The analysis admits that preventive healthcare has so far not received the attention it deserves. The state should play a lead role in building a ‘culture of familiarity and knowledge around public health’ by involving multiple stakeholders; and families and communities must be ‘empowered to create an environment for healthy living’.
The Approach Paper is well-meaning and makes all the right exhortations. It wants health policy to make children an urgent priority and ensure convergence of health and child care services. Special requirements of different groups, e.g., integrated geriatric health care and other needs specific to the elderly, ‘adolescent friendly’ health support services (and counselling) for victims of sexual or substance abuse, those infected with HIV/AIDS, those who are differently–abled, and those who belong to the lesbian, gay, bisexual and transgendered (LGBT) community should be met. It “hopes” to address the urgent issue of population stabilization by providing dedicated funding for family planning services in high fertility states, bundled with reproductive and child health services. It calls for prioritising convergence among all the existing national health
programmes, giving physical fitness due importance, encouraging innovative management reforms within health delivery systems, and devising an accountability matrix to track performance and progress.
How do we achieve what has not been possible in 60 years over the next five years? Missing completely from the Approach Paper is a vision and a strategy to achieve universal health coverage.
India should boldly embrace the idea of universal health coverage (UHC). Health and rising health costs affect all Indians, not just the poor. Piecemeal approaches that seek to assure health care only to certain segments of society (the poor and privileged government servants) will not work. Everyone must be assured equitable access to affordable and appropriate health and public health services of assured quality. The high-level expert group on UHC has articulated a vision under which every citizen will be entitled (as a right) to essential primary, secondary and tertiary health care services. A national health package should offer both in-patient and out-patient cashless care - with people free to choose between public sector facilities and contracted-in private providers who function under a well-regulated and monitored system.
The question of health financing needs to be addressed upfront – in addition, of course, to the many other shortcomings of health systems relating to human resources, health infrastructure, and so on. As envisaged, public spending on health should be increased from the current level of 1.2% to at least 2.5% by the end of the 12th Plan. Priority should be given to primary health care by earmarking at at least 70% of all healthcare expenditures to primary care services so as to establish a primary healthcare system that offers effective and affordable protection to all against common illnesses. The government should stop levying user fees of any kind given the growing evidence of its adverse consequences. General taxation should be the principal source of health care financing – complemented, if necessary, by additional mandatory deductions for health care from salaried individuals and tax payers. The central government should introduce specific purpose transfers as well as flexible and differential norms to equalize the levels of per capita public spending on health across different states. Finally, all government funded insurance schemes should, over time, be merged and integrated with the UHC system.
Clearly, the state has a critical role to play in ensuring UHC. Private markets cannot guarantee reliable healthcare because of inevitable failures (information asymmetry and the public goods character of healthcare) inherent in the market for medical attention and care. Despite this, many influential policymakers seem to be attracted by the idea that private healthcare, properly subsidized, or private health insurance, subsidized by the state, can meet the challenge.
Can India afford to invest in ensuring universal rights to health, or for that matter in basic education, food security or employment guarantee? This is the wrong question to ask. Derek Bok, lawyer, educator and former president of Harvard University would say: “If you think education is expensive, try ignorance.” This is exactly the situation in India today. We are paying a heavy price for not enhancing people’s capabilities by ensuring health and nutritional security, providing decent education and ensuring a decent quality of life for large segments of our population. The right question to ask is whether India can afford not to invest in ensuring these basic constituents of decent living. And the obvious answer is no – if we care for political and economic stability, peace and prosperity.