Budget 2013-14: provisioning for universal healthcare or moving away from agenda?

The world trend is to move towards public health systems, but developments in India seem to be in the opposite direction

The government of India is yet to recognise and institutionalise the right to health as a universal right of every citizen. India’s public spending on health, at about one per cent of the country’s GDP, has been among the lowest in the world. On the other hand, with a high burden of out-of-pocket spending on health, millions of people are reportedly being pushed below the poverty line every year. As a result, provisioning for healthcare has emerged as the most critical public policy challenge confronting India at the present juncture.  In this context, the present article focuses on the 12th Five Year Plan’s proposals for the health sector for the next five years, which are expected to influence the allocations for health in the forthcoming Union Budget 2013-14.

The 12th Five Year Plan document promises a lot of deliverables in the health sector over the next five years. It envisages a National Health Mission, moving the National Rural Health Mission (NRHM) into the urban sphere, and launching of an all-inclusive health mission that would work towards achieving universal healthcare in the country. In a welcome initiative, the plan document proposes to increase India’s overall public spending on health (combined spending on health by the Centre and all states) to 2.5 per cent of GDP (including budgetary allocations made towards Water and Sanitation, Integrated Child Development Services and Mid-Day Meal scheme) by the end of the 12th Plan period. The 12th Plan proposes an allocation of Rs 2,68,551 crore for the next five years, which is a significant increase from the total Plan expenditure on health over the 11th Plan period. It rightly recognises the need to reduce out-of-pocket expenditure of households on health and step up the share of public spending on health to almost 70 per cent of total health spending (government spending and out-of-pocket spending) from a current share of roughly 30 per cent.

The Plan document also highlights the importance of enhancing availability of drugs within the public healthcare sector, for which the Plan proposes to set up 3,000 more Jan Aushadhi Stores  in rural areas across the country, during the five-year period, where medicines would be provided free of cost. With regard to this specific proposal, there exists a growing expectation from the Union Budget 2013-14 that it would make a separate allocation of up to Rs 30,000 crore for financing the provisioning of 348 major generic drugs free of cost within the country as a step towards universalising access to medicines in rural areas.

Enter PPP

However, the roadmap for financing of the proposed allocations for health over the next five years is where the dichotomy of the Plan surfaces. While suggesting certain initiatives like introducing “sin tax” on harmful items like alcohol and tobacco for financing the health sector, the Plan proposes general tax revenues as the principal source of finance for public health, to be supplemented by partnerships with the private sector and contribution of corporate sector as part of corporate social responsibility. The Plan proposes to increase public expenditure on health by 34 per cent annually for the next five years and also proposes to keep the share of Centre-state expenditure at the existing 30:70 ratio.

We may note here that in 2004-05, the United Progressive Alliance government at the Centre had acknowledged in its charter of governance, the National Common Minimum Programme (NCMP), that it needed to increase the country’s total public spending on health to the level of 2-3 per cent of GDP by the end of its tenure—financial  year 2008-09. Now, a similar target (or rather, a more diluted version) has been set for stepping up the country’s public spending on health for financial year 2016-17. This only implies that the government is not very keen to acknowledge the implications of the acute shortage of financial resources for health sector, which have persisted over the last decade.

As regards the proposed division of financing responsibility between the Centre and the states, given the growing dominance of the Centre in the domain of public resource mobilisation in the country (in collection of tax revenue), the inability of several backward states to step up their own mobilisation of revenue, and the shrinking share of untied transfers to states within the total transfers from the Centre, it was necessary for the Planning Commission to ask the Centre to shoulder a bigger share of the financing responsibility in the next Plan period instead of continuing with the same 30  per cent share in overall public spending on health. In fact, unless the 14th Finance Commission suggests some radical changes in the domain of Centre-state sharing of resources (which seem unlikely from the terms of reference given to this Finance Commission), the 12th Plan period might not witness significant increase in states’ spending on health, which in turn would imply that the country’s overall public spending on health would continue to be much lower than the required levels.

Instead of ensuring adequacy of financial resources for provisioning essential health care to all, there seems to be a wishful thinking on part of the Planning Commission to expect large contribution from the private sector for creating universal access to health care. This, in fact, comes across as the growing unwillingness of the government to provide for a healthy existence for the poor and vulnerable sections of the population. It also reflects the willingness of the Planning Commission to usher in private operators as partners within the public sector health care system.

No roadmap for achieving development goals 

This is where the dichotomy of the Plan document gets reflected. While the Planning Commission on the one hand recognises the increased burden on the households due to an increase in the share of private service providers within the health sector and highlights the demerits of such services, it moves ahead with a roadmap of providing the private operators with a public infrastructure without any robust system of regulations and monitoring mechanisms. Experts have correctly pointed out that with such an approach the government ends up subsidising the private sector instead of the people.

Taking into account the international experience, in countries with universal access to health care like those in Europe or Latin America, the systems have been achieved through government. In Asia, universal healthcare in Sri Lanka and Thailand has also been achieved by active participation of the government.  While the world trend is to move towards public health systems, the developments in India seem to be in the opposite direction.

Despite accepting or acknowledging that the country faces an acute shortage of skilled human resources (to the extent of at least 6.4 million skilled people), the country is still far from fulfilling the Millennium Development Goals (MDGs) in health (in terms of reducing infant and maternal mortality rates and improving child sex ratio, TFR and malnutrition among children). Studies have shown increased poverty levels among rural population due to high expenditure on health, and an acute need to increase per capita public spending on health. But the Plan document fails to provide a solid roadmap for generating adequate financial resources and depends on the private sector for additional resources. The approach of the plan document, if analysed closely, therefore, raises doubts on whether we are moving towards universalisation of healthcare or moving away from it.

The author works with Centre for Budget and Governance Accountability (CBGA) and can be reached at sona@cbgaindia.org


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  • Health sector reforms which

    Health sector reforms which India needs - hopes of a Public health professional from budget As now are the budgetary days in India, lots of talks are there on the issues of strengthening public health and education system. Some media reports are there about the possible Health System Reforms and Universal heath cover in India but we will only know how our worthy planners and ministers have planned to take care of our health in the next year on the Budget day, I am writing with a perspective to review the direction of government in health sector in recent past, to bring in notice some recent developments in the world in terms of economical public health delivery system, recent trends in development of policies in health sector, priority problems and some possible suggestions for practical implementation of those up to grass root level of healthcare provision in India. Multiple issues and aspects have been touched in the article fulfilling the need of the subject, however, each aspect requires further detailed elaboration. There is urgent need to address following lacking areas in health care provision and improvement in general health of Indians - 1) Because of global economic slowdown it will be difficult for India to continuously raise the health budget to meet the growing demands of Health care provision for chronic illnesses. Even country like U.S. is thinking of strategies and methods to provide best possible Health services at minimum possible resources. On 28th June 2012, the U.S. Supreme Court uphold the Affordable Care Act, which is the most important legislation since the Civil Rights Act. Under this health care law, many insurers are required to cover certain preventive services at no cost to public1. Today, human suffering and the cost to U.S. society is measured by national trends in population health. The U.S. expends over 17% of the gross domestic product on health services; yet, ranks approximately 30th in health outcomes compared to other countries. This 17 % of U.S. GDP will amount to 30 times the Indias Health budget. But still they are looking for innovations to improve health and health care at reduced cost. They are studying what is driving the rise in costs, what is waste, and how billions of dollars can be saved. The most exciting opportunity provided is for every public health professional to participate in positive change. India however, still struggling to provide universal basic healthcare has its own problems of wasteful expenditure e.g. wilful postings of doctors at lucrative sites on long deputations, non availability of simple and easily available instruments halting work all due to lack of accountability, mismatched staff there are cases where surgeons are working as program officers at District level while hospitals lack surgeons. Is it not more important to curb wasteful expenditure for us when we are not able to provide basic health care? Possible solution will be target based focused attention on different levels of health care provision in every state in collaboration with a central advisory committee using NRHM funds. Better will be going higher to lower levels, first strengthening of tertiary level hospitals for country like India. 2) The second major problem in health care provision as per Govt. is lack of health care providers, out of which serious concern is shortage of doctors in public health system in rural areas and has been a major concern for the last two Union Health ministers which has led them to create a brand new medical study course for rural medical science B.Sc.(community health), the final shape of which we are unaware of till now. But here rises a big question, that do we really so badly require thousands of new health care providers when we are not using the existing manpower to its full potential? This should be our first priority. As a part of the health care delivery system we have observed that although we talk about overburden on Govt. hospitals but it is only at the level of large tertiary care hospitals and few District level hospitals while majority of the block level community health centres (CHC) and primary health centres (PHC) where doctors are available remain non functional due to lack of interest of doctor itself, lack of monitoring/ false reporting and if doctor is willing to do justice to his work gets limited by lack of supporting staff, laboratory facilities, medicines or pathetic atmosphere of workplace thanks to ego clashes among doctors. The Patient which can be easily managed at these centres now move to higher centre leading on to overburden there and again limiting the quality of health care. Is it not more important to first focus on these issues and making these units functional up to their maximum potential? Possible solution which can be applied is to identify the manpower lying vacant or underutilised and utilising them in more productive way. In management terms it is called Resource levelling, but it requires management and planning with authorative powers at district levels and even lower. It is worth to mention that in India , civil surgeons/ CMOs who are responsible for such work are not able to perform as par with the other district authorities e.g. IAS . Reasons might be various, but worth mentioning is that lack of support from ministers and beurocrats if someone tries to do so. Country has infrastructure and capacity in approximately 335 medical colleges (about half are government medical colleges and rest are private), which produce around 40,000 medical graduates annually. After getting education, very few of them join health services due to uncertain career prospects and lack of proper facilities and emoluments. It is a matter of great concern that young doctors are reluctant to join government job and prefer to work in urban settings that too in private setup. It is difficult to say whether our teaching standards are successfully addressing societal needs and expectations by preparing students with knowledge and skills in disease prevention and health promotion.3 The problem which is more severe is lack of specialists, but still there are various places where specialists are serving as District program officers rather than providing treatment care of the concerned speciality, is it not mismanagement of human resource? 3) No system exists for purposeful community focused public information or seasonal alerts or advisories or community health information to be circulated among doctors in both private practice and in public sector. PHCs were meant to be local epidemiological information centers which could develop simple community. Civil Surgeons and panels have no active role in pre planning and preventive advisory until the epidemic has already occurred. Majority of Medical Officers cant even count the various national health programs running in their own districts. No estimates are being provided to them regarding disease burden in their area of PHC. To tackle this issue the Indian Public Health Standards(IPHS) report suggest recruitment of Public Health Program Manager at every CHC level2 which has not been implemented. It carries a lot of advantage of carrying planning activities from district level to block level.? How can a newly recruited Medical officer will perform until he be made aware of local situations and modalities of work in his area ? but who will do so is unclear because District Program officers are given charge of some specific programs and no one is there to provide holistic situation. Induction training at many states is being provided after 6 months !! The need is to enhance micro planning, setting responsibilities and liabilities, proper monitoring , sorting out local issues, charting realistic targets, empowering district administrators for manpower management. 4) The separation of public health, research and education, and medical health services when done was basically intended to spur advancement in health science and practice; but it has cause stagnation of information due to lack of inter-linkage between state health departments and medical colleges. The challenges we face today in the 21st century are to strengthen the interconnection, not the separation, of our institutions that link evidence with practice, practice with public health, and the training of health scientists with health professionals. It is duty of health scientists and professionals to bring better health and better health care to society. But all these measures need continuous support by policy makers. There is a need to communicate more among persons in a health related leadership role, whether a scientist, practitioner, legislator, academic, or health industry businessman. All have a responsibility to seek accurate information about why we need health care reforms. If we are in a health related profession, then we are responsible for the health of our children and adults. There are many fields in medical profession: as mentioned, researchers, public health physicians, general physicians, surgeons, medical practitioners, geneticist, pathologist, teacher for basic medical sciences. However who are confronted with patients directly need to be addressed properly by formulating laws. Possible solution which can be suggested for this problem is to regenerate a link between medical colleges and research centres and state health services via Department of community medicine, it will also solve the problem of students lacking in hand on experience of health services jobs. Presently it is limited to some of the programs which varies state to state. 6) Defunct Public health care delivery system - as every body knows the enjoyment of highest standard of health is a fundamental right of every human being. The Indian healthcare industry is witnessing growth at a rapid pace and it is expected that the sector will touch US$238.76 billion by 2020 with annual growth of 14% 4. But this growth basically represents growth in private healthcare sector and Pharma industry. All of 80 per cent of healthcare is now privatised and caters to a minuscule, privileged section. The metros are better off: they have at least a few excellent public health facilities, crowded though they might be. Tier II and III towns mostly have no public healthcare to speak of. Millions of Indians living in small towns go through the same agony--not knowing where to turn to in the absence of a good health system. Because of that, thousands travel to Delhis overburdened AIIMS and Safdarjung Hospital, which are staffed with excellent doctors. The rest just pay for a private system designed to extract the maximum from each patient. Public health is a big question in small cities. They have government hospitals, which are not well-equippedin terms of infrastructure or adequate numbers of doctors and other staff. Why cant Public Health care provision sector can not join and grow along with this growing sector? A healthy nation needs healthy people. We all agree that our citizens must be literate. Perhaps it's time to ensure that all of those literate remain healthy and functional as well. We can do better. The possible reason easy to understand which is of utmost importance is that it is not possible to accomplish the motive of health for all by funding Healthcare as subsidy. How long the health care delivery system will run as a subsidy? Indian economy will not be able to bear expenses of quality healthcare to all citizens. Should we not make the larger public sector hospitals self reliant by allowing their management to run parallel health facilities comparable to private sector ones at some decent charges along with the already existing hospitals ? When people are able to pay and have belief in larger institutes like AIIMS but only go to private sector because of difficulties due to overload and rush. Provision of such a system will create a situation of competition which will check the highly exaggerated cost in corporate hospitals. In the health sector, the buzz these days is all about Universal Health Care (UHC). While health activists see in it potential to ensure access to quality health care for common citizens, commercial bodies seem to be eyeing the huge scope for profit from sickness, in a field already characterised by large scale commercialisation and imbalance of information between providers and users.5 Indian Govt. is planning for the Universal Health Coverage with a central and state expenditure of 85:15 respectively, but it will be hurried step to jump into this before judging the benefits of similar schemes like RSBY(Rashtriya Suraksha Bima Yojna). There will be much bigger problem of money leak and corruption without hawk eye supervision mechanism for public private partnership. We should learn from countries like USA where this system is well developed, but they still believe that it cannot be made possible until you have a well developed mechanism of preventive health care services, disease surveillance system and health promotive programs. Otherwise it might be a disaster for a nations economy. Lets think carefully about what we actually do as physicians, and as we do this consider the words we are using. Most health care providers are not dealing in health they are in the business of rescue and repairmedicine. On the whole, results are good (sometimes spectacular)  but the benefits are not available fairly across society. We should take first step in the process of organizing a true system with equitable access to quality, affordable rescue and repair services( insurance cover).The end of the beginning, not (even) the beginning of the end  But even then the deeper problems will remain. The development of new and better treatments and medical technologies is never-ending  and of course this should be encouraged and welcomed  but rescue and repair services will always struggle to keep up and costs will continue to climb. We will never get ahead of this curve unless we start to reduce the incidence of the major chronic diseases and conditions, by embracing health promotion and disease prevention. We havent even scratched the surface yet  but if we dont start doing so soon, the country is going to be bankrupted by health care costs. The cost of prevention per person is far less than the cost of the variety of cures, from surgical to pharmacological. The health of the population has gone beyond the health sector and involves the development sector in the recent past, reiterating the principle of multisectoral approach in PHC. The physiological risk factors can be delayed if the behavioural risk factors are given due emphasis at an early stage.6 Should we not encourage involvement of Health professionals and management people in policy making rather only depending upon Administrative people learning from our failures in various programs? Although these issues require more debate and separate discussion. Some of the solutions emerging are as follows: 1. The States must appoint Public Health Manager at CHC level as per IPHS 2007 preferably MD community medicine/ Social and Preventive Medicine decreasing the workload on the part of civil surgeons/CMOs. 2. State Health Departments should collaborate and involve Medical colleges in development of local strategies and concerned speciality of medical college should be associated in local action plan of any national program, rather than both planning separately. This plan should be then further be micro-planned by Public health managers at block level along with District Program Officers. Should be monitored with appropriate tools like realistic target achievements, setting up liabilities. 3. These Public Health Program Managers should provide purposeful community focused public information / seasonal alerts/ advisories/ community health information which should be circulated among doctors in both private practice and in public sector. Importance should be understood as now we are facing Swine flu. 4. Necessary focus on adding practical education to medical students on prevention of non communicable diseases. Initiation of Preventive Medicine clinics at medical colleges by Dept. of Social and Preventive Medicine to identify and timely manage chronic diseases in families of diagnosed patients, providing Primary, secondary and tertiary level of Preventive care and various other roles without much new investment. 5. There is a need for flexibility in fixing compensation for health personnel in order to make the government services more attractive. Further promotions should be linked to training and attainment of higher knowledge and skills relevant to service delivery. Why only a single rank of MO for around 16-20 years before promotion to SMO? 6. The state health directorate should have a full fledged HR department with specialized staff and dedicated budget. The states should develop short and long term human resource strategies and plan by adopting the standard process of manpower planning. 7. The existing recruitment rules should be reviewed and modified in the light of changing job requirements and improvement in overall education level. Recruitment of programme staff should be undertaken with a view at long term utilization. District level recruitment in NRHM is presently having a lacuna to retain trained staff. 8. The state governments should devise policy for providing better housing and education facility for children of Doctors to make rural posting more attractive. Financial incentives only will not work. Why not their children can be provided education in Army schools? Terms and Conditions like non allotment of home district should be waved off. 9. The state government should consider time bound promotion and transfer and deputation policy for all categories of staff. Why not make it more transparent by setting detailed guidelines rather than lending decisions in hands of few officials? Better working environment will attract honest and hard working doctors. 10. The state should undertake proper training of supervisory staff and effective monitoring of supervisory activities in order to strengthen supervision. 11. The states need to adopt a comprehensive training policy based on the actual needs as per the job requirement. 12. Make the larger public sector hospitals self reliant by allowing their management to run parallel health facilities comparable to private sector ones at some decent charges along with the already existing hospitals. Large Public sector hospitals should be allowed to initiate separate hospitals for Health tourism, NRIs and Upper middle class nationals , funds generated from these will help research activities at those centres and can also make some hospitals self reliant. 13. These hospitals will be a tough competitor for corporate hospitals and will bring down the highly exaggerated cost. 14. District Hospitals and tertiary hospitals need more of the managerial posts , having fresh minds and newer ideas under the supervision of Senior doctors/ SMO. If we truly wish to avoid bankrupting the country with healthcare costs we must emphasize prevention, specifically teaching prevention. It requires a major shift in the way healthcare practitioners and other providers approach the need to better educate our population about maintaining individual health. Over the past century the disease model has become predominant and the wellness model has come to be perceived as a fringe approach, poorly understood and suspect. There are many reasons why the current model emerged and holds such a strong position. It has been easy to comment on the difficulties in educating the population but we have the methodology, educational and psychological research, teaching resources, and technology needed to do the job if we would "wake up and smell the coffee". It will require healthcare providers to assess the knowledge and comprehension of each client. The topic areas will need to be prioritized to ensure that the greatest threats to each individual's ability to remain well are addressed. Initially it may seem as if the cost of an office visit would increase. The long term result would be savings for the individual who would spend less as chronic illnesses were avoided or significantly reduced in severity. A gradual but significant improvement in the quality of life is the expected as an outcome if chronic illnesses can be reduced and limited in severity.

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  • Dr Singh's comment is

    Dr Singh's comment is extremely important , enlightened and deserves consideration.

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