Opinion Insurance isn’t enough: Universal Health Coverage must guarantee care

In other words, strengthening the health system’s foundations is not only about building health centres. It is about establishing systems that guarantee care as per need and an actively interventionist state with the capacity to enforce laws, rules and regulations to protect patients from the imperfect market that characterises the health sector.

Given the paucity of budgetary resources, India has done relatively well. Several communicable diseases have been either eradicated or controlled. Maternal mortality and infant mortality have also shown impressive reduction. The reduction in communicable diseases (which continue to disproportionately rage in the northern states) means that 60 per cent of mortality now is due to non-communicable diseases — the four leading causes being cardiac ailments, cancers, COPD and diabetes. These diseases are expensive to treat and require longitudinal attention. They are the results of sedentary lifestyles, rapid urbanisation, shifts in dietary habits — increased intake of junk foods, alcohol, tobacco and other addictive substances — and the ageing of the population.

The implication for the health system is substantive: Revamp itself to shift from episodic to long-term care. Such revamping would require resilience, different skill sets and functioning within an accountability framework to ensure the continuum of care. Since the causal factors are modifiable, appropriate laws, regulations, public health policies and a community-based primary healthcare system, run by family doctors and public health specialists, would be required. Countries have shown that such investment in primary healthcare has helped avert hospitalisations by one-third. As hospitals are expensive, this is savings in real terms.

India’s Ayushman Bharat programme consists of two components — one, the strengthening of primary care facilities by better availability of drugs and human resources for providing 12 services free of cost; and two, insuring 50 crore poor persons for Rs 5 lakhs sum assured. This is indeed a welcome initiative. Yet, the general perception is that the health system is too costly, too privatised and lacks a strong foundation. Considering our achievements have been impressive, why this perception? I offer some reasons.

One, India’s public spending has, for the last seven decades, been an average of about 1 to 1.2 per cent of GDP, going up to 1.3 per cent at best — the WHO norm is 3 per cent. Such low public funding means that the functioning of public facilities is suboptimal and despite the impressive government social health insurance programs for hospitalisation, out-of-pocket expenditures continue to range between 45-54 per cent of the total health spending, against the SDG goal of 20 per cent. Two, a messed up human resource planning with lopsided incentive structures and the non-availability of appropriately trained and skilled personnel. Vacancies at all levels continue to plague the system. For example, in the Community Health Centers with 30 beds located to serve 1 lakh population, the vacancy level of specialists is 80 per cent, forcing people to seek private care, incurring huge expenditures, or going to district hospitals, overcrowding them in the process. Why does the decades-old norm of posting specialists at CHCs not get reviewed since the model does not seem workable?

Three, India’s health delivery system comprises both the public and private sectors. The private sector per se is not the problem. Of concern is the emerging trend towards corporatisation, commercialisation and profiteering, resulting in excessive diagnostics and unnecessary surgeries. The huge capital investment required to establish tertiary hospitals is increasingly being mobilised from equity and venture capital that demand a minimum 25 per cent return on investment. Many corporate hospitals, that provide nearly half of tertiary care in India, are being steadily bought up by foreign investment companies — Black Rock, for example, has majority control in the Manipal group. As a result, the cost of care is getting steep.

The government is further narrowing space for middle-class people to avail free or highly subsidised care by leasing/selling off district hospitals (about 30 currently) to investors or corporates on conditions such as free treatment to the poor — something that the government does not have the capacity to enforce.

The situation is indicative of a state abdicating its responsibility to govern and reflects an ideological vacuum. Understanding UHC as merely provisioning of health insurance is flawed: What use are the vouchers if there is inadequate supply or poor quality provisioning of services? What is needed is for the state to do the hard stuff — invest in health, provide good governance and build the capacity to enforce laws, regulations, rules and contracts. UHC is a goal that today’s India can aspire for only if the state can govern and align its politics for power with people’s welfare. The question and challenge for democratic societies are how to bring change in an environment where people’s aspirations are low and the political system is able to get away with doles and not be held accountable. That is the key and the concern.

The writer is a former health secretary, the Government of India