The forthcoming election is going to be an inflexion point for India’s health system story — how affordable, how accessible, how equal? Though health is not a political priority as yet, two visions of the future health policy seem to be clearly emerging. One, espoused by the BJP — a centralised hospital insurance-driven health system designed on the Medicare model of the US. The other, of the Congress, calling for guaranteeing every citizen with access to essential health services, resembling the UK and the European model. Both these approaches are widely divergent and will profoundly impact the three pillars of the health system — access, quality and affordability.
Given India’s fragile economic system and multiple demands on it, notwithstanding India being the second-fastest growing economy, sustainability will be a major concern. The two thought streams, propounded by the BJP and the Congress, are embedded in and reflect two social value systems: In the US, it is individual liberty and personal responsibility, while Europe and countries like Japan are driven by ideas of social responsibility and state accountability. The emergence of these two ideological streams had their origins in the rise of Marxism in early 19th century and World War II that devastated UK’s economy, to declare that “Individuals should recognise the duty to be well and restoration of the sick person to health is a duty of the state and the sick person. And so universal coverage as a minimum — a solid and level floor, no interior walls and a roof that need not be level but whose height is determined only by people’s own wishes and means”.
These approaches and ideas manifest themselves in health policy in different ways. With its strong belief in individual liberty, the US confines itself to subsidised care for the poor and elderly, regulates stringently for quality and allows financial incentives like profits to encourage technological innovation. As a consequence, it has over 20 million of its population without access, despite spending 18 per cent of its GDP on health. The UK and Europe, on the other hand, believe in the principle of collective responsibility ensuring every individual’s inherent right to health and wellbeing, thereby making the state develop financial and regulatory systems that guarantee all individuals equal access to healthcare services and products. These countries spend an average of 10 per cent of the GDP on health with far better outcomes than the US.
When India won independence from the British, we were driven by the European values of equality that got imposed onto a highly stratified social system. By providing every citizen the right to vote, we signaled to ourselves that every life matters and has equal value. This was a powerful message in a country faced with huge inequalities. Some successes have been achieved in implementing affirmative action. Over the years, however, the economic and social models trended more along the values of individual liberty rather than social equality. Disparities have widened to such an extent that latest data seems to suggest that 1 per cent of India’s population enjoys 70 per cent of its wealth. While an Indian is among the 10 richest of the world, we also account for the world’s poorest, over 36 per cent of children stunted due to chronic malnutrition, half of the population defecating in the open and nearly three-quarters without access to tap water. The rising burden of disease in India is but a reflection of such deprivation of essential and basic social goods and the wide inequalities cutting across regions, castes, gender and age.
Government, through its various state instrumentalities, and made up of individuals driven by their own ideas of justice and development, becomes the allocator of public budgets and resources. To understand why India is a sick country, why it has such a huge disease burden, such wide inequities in accessing medical treatment, and how it has ended up with a fragmented, broken and dysfunctional system of healthcare, and yet, continues to spend only about 1 per cent of its GDP on health, one needs to understand the values that drive our social, economic and political development.
Notwithstanding the divergent approaches of the BJP and the Congress to health system development, there is room for ensuring that the elected government adopts a balanced approach based on evidence and sets pathways that will help build, in the long term, a sustainable, equitable and affordable health system. But this is not an easy task. Stacked against an incremental and systematic building of the health system blocks, in the manner that Thailand or Turkey did, are powerful lobbies of the health industry that support the narrow agenda of the hospital insurance programme. These lobbies have the support of US-based foundations and donors, World Bank, CII, FICCI, the medical associations and companies related to health insurance, data aggregating IT, medical devices etc. The public health approach that seeks to prioritise comprehensive primary care as an entitlement of every citizen is clearly numbed out and would require peoples’ movements and participation. This is critical as with the meagre resources of 1.1 per cent of GDP, choices are being made. It is easy to say that no trade-off is being made — sadly, the truth is otherwise,
No one would argue that hospital insurance is a wrong policy and that only primary care should be the focus. But a system hanging on hospitals without the foundation of primary care is a sure recipe for disaster as it is clearly unaffordable and unsustainable. Effective primary care not only reduces one-third of hospitalisation but by prioritising well being over sickness, it removes the causal factors to disease and illness. It is important to reiterate the importance of these issues as the last budget showed a 300 per cent increase for health insurance. With the revision of hospital rates, the cost of the health insurance programme will also double and continue to rise.
In the absence of a commensurate increase in health budgets, the price will be paid by the large swathes of the poor and middle classes who desperately need good quality primary healthcare. Its absence is responsible for the proportionately higher number of premature deaths, one quarter of the global TB burden and a million dying just for want of clean air. In the backdrop of such data, does India have a choice?
This article first appeared in the print edition on April 9, 2019 under the title ‘US vs Europe in India’. The writer is former Health Secretary, Government of India
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