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The health agenda
Political parties must do more than just pay lip service to universal healthcare in their election manifestos.
V R Murlidharan
The governance of the public health sector has become more complex than we imagine. To improve overall health, the sector will have to coordinate and collaborate with other sectors, nationally and regionally, and with several stakeholders. There is no sector that does not have an impact (positive or negative) on public health.
What is to be done? Traditionally, policymakers assumed that the achievements of the public health sector should be measured in terms of increase in life expectancy. But the sector per se can, at best, contribute only to a limited extent in improving life expectancy. Much depends on policies and programmatic interventions in other sectors of the economy, including nutrition, water, housing, transportation, energy, employment, pollution (in both industry and agriculture), transportation, etc. We have made considerable progress towards health-related Millennium Development Goals over the past decade, but are woefully behind (in terms of health indicators and public spending on healthcare) compared to some neighbouring countries and those at a similar stage of economic development.
Such a perspective is important while designing effective policies and programmatic interventions in public health. Election manifestos mean nothing unless there is an underlying perspective of health. “What must governments do?” in programmatic terms should (and will) flow only from such broad underlying perspectives. So, what must political parties commit themselves to?
One, they must address sub-regional inequity in health status and access to healthcare. Irrespective of the state from where an MP is elected, she must dedicate limited resources to reduce intra-state and -district inequities in access to public healthcare facilities. There is evidence to show that inequity exerts perhaps the most detrimental influence on the overall health of a population. Even economically advanced states and districts exhibit an unacceptable level of variation in health and the presence of public healthcare facilities.
Two, they must spend scarce resources more “effectively”. This means, as in many countries, substantial resources (at least 35 per cent of the state budget for health and family welfare) should be allocated for primary healthcare services, beefing up primary health centres (PHCs) and health sub-centres (HSCs) and taluk-level facilities. While there is a definite case to double or triple budget allocations, we need to begin with only a modest increase. The government must ensure this is done. Politically, every government says so, but it must be shown in practice. A cursory glance at the budgets of various states and the Centre will show how slow their response has been in the past.
Three, double the presence of field functionaries at sub-centres at the earliest. No state is yet to fulfil the norm of having two multipurpose workers for every sub-centre, as conceived in the early 1980s. A large portion of HSCs are in a condemnable state and need immediate attention. This alone will enhance the credibility of the public health system.
Four, MPs must provide free-for-all “essential” drugs in government facilities. It is a pity that most states are still struggling to effectively address this issue, while we already have a highly replicable drug distribution system in place in some states, as in Tamil Nadu. The government should establish “pharmaceutical outlets” (as part of cooperative societies).
Five, devise “comprehensive” tertiary healthcare insurance schemes and make them accessible to both BPL and APL populations. It is no use addressing only BPL populations, particularly for higher secondary and tertiary care services, as they financially affect most sections of society. It is not impossible to attract the so-called better-off populations to government facilities. The recently established NICUs (newborn intensive care units under NRHM) and ward-500 units established in Tamil Nadu are proving to be competitors to private facilities offering these services.
Six, establish a PPP policy unit, blessed by a legislative body. There has been lip service across states (except for a few programmatic efforts) in building partnerships with private providers. This requires a comprehensive approach and commitment to “enhancing access to essential care”. The recent rhetoric of universal health coverage will remain a pipe dream until we mobilise all resources on a war footing to strengthen the public healthcare system, which is often misunderstood to mean only “beefing up public facilities”. Strengthening the public health system also means designing policies to let it function optimally.
We need two declarations from all political parties aspiring to be at the helm of affairs: an essential package of services that will be made free to every citizen of India; and that access to essential healthcare is a basic human right and that creating conditions to guarantee the highest attainable health status is the constitutional mandate of every government, be it at the state or Centre.
The writer, professor of economics at IIT Madras, served as member, mission steering group, National Rural Health Mission.