Universal health scare

The country’s planners are debating how to provide healthcare to all. In a drastic shift from the 65-year-old public health system, the Planning Commission in the 12th Five Year Plan considers introducing an insurance scheme, which will allow a major role to private players. Will it work?

Vibha Varshney in Delhi, Alok Gupta in Bihar and Aparna Pallavi in Andhra Pradesh examine how the existing health insurance schemes are faring. They find there is a lot to learn from their shortcomings and successes before a new model of healthcare delivery is prescribed

By Aparna Pallavi, Alok Gupta, Vibha Varshney
Last Updated: Sunday 07 June 2015

Universal health scare


Free and easy access to healthcare for all. India has been striving to achieve this since Independence. But the country’s poor health indices remain a cause for concern. This is the reason expectations soared when the Planning Commission dubbed the 12th Five Year Plan the Health Plan. When the draft of the chapter on health was leaked recently, it raised alarm—the Commission had taken radical decisions to turn around the country’s public healthcare delivery system by giving a greater role to private players.

Crumbling health sector
  • In 1986-87, 31.2 per cent of the drugs prescribed in public hospitals for in-patient treatment were free. According to Planning Commission’s high level expert group (HLEG), the percentage reduced to 8.99 in 2004
  • People spent as much as 67 per cent of the treatment cost out of their pocket in 2011. Around 74 per cent of this was on medicines, HLEG says
  • Planning Commission’s July draft shows the country’s total expenditure on healthcare is about 3.3 per cent of GDP. About 32 per cent of this is public funded
  • Public health sector faces a shortage of human resources. Almost 88 per cent of posts of specialist doctors, 76 per cent of doctors, 80 per cent of lab technicians, 53 per cent of nurses and 52 per cent posts of ANMs (who offer maternal and child healthcare) lie vacant, the draft notes

The July draft, as it is called, suggested that India should embrace insurance to achieve universal health coverage. As of now general tax is used to meet the essential health requirements of all people. The Commission also pegged the government spending on health over five years at 1.58 per cent of GDP, ignoring the key recommendation of its own High Level Expert Group (HLEG) to increase public spending to 2.5 per cent during the Plan period. No one but the Planning Commission was happy with the draft.

The Ministry of Health and Family Welfare made its discontent clear by sending a critique of the draft to the Commission. The letter criticises the proposal to restrict the ministry’s role, saying it nullifies the success of the National Rural Health Mission. It also notes that the budget is too little.

Members of HLEG are not happy either. When the group was established in October 2010, it was assigned the responsibility of preparing a health delivery model unique to India that could help achieve the much desired universal health coverage. The group had suggested strengthening the public health system. Since India has a presence of a strong private healthcare sector, HLEG suggested that the government could contract private players to fill the gap in public healthcare delivery. Despite ambitious insurance schemes being piloted in several states as well as by the Ministry of Labour and Employment, HLEG had steered clear of insurance, saying it fragments healthcare and cannot cover all the citizens. HLEG has sent its critique of the draft to the Planning Commission.

Members of the Jan Swasthya Abhiyan, the Indian arm of People’s Health Movement, an international network of public health experts, are also against the draft. They say it is an abdication of the government’s duty and an effort to fill the coffers of the corporates.

Samrat Mukharjee

The Planning Commission is now rewriting the health chapter. A two-member committee has been set up under the National Advisory Council of the ruling UPA government to ensure that the objections raised are addressed in the final document. The Plan document is expected to be finalised by the National Development Council in October. This makes the next few weeks crucial for negotiations.

The changes being made are still under wraps. But sources say that the Commission is merely changing the language of the draft and not revising its content substantially. The latest information suggests that funds for healthcare delivery in the 12th Plan Period are likely to remain at 1.58 per cent of GDP. Insurance is likely to be the mechanism for providing universal health coverage.

The promise of free healthcare through insurance is seen as a populist move before the elections. It is said in 2007, when the ruling Congress Party launched the Rajiv Aarogyasri scheme in Andhra Pradesh, its popularity soared and the party returned to power.

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  • Very nice. Well-presented

    Very nice. Well-presented article. But a key point is (in my opinion) being missed by most stories covering Universal health care - the fact that health is a state subject, and in the end, the "shape" of UHC will depend on state-level advocacy. Too much is being made of the HLEG document - a great work and an important contribution to policy, but in the end, state-level policies (and politics) will determine the shape of UHC locally.

    Posted by: Anonymous | 8 years ago | Reply
  • Universal Health Care will

    Universal Health Care will become another big headache of India if it goes by the planning commission way. The already flourishing Private sector is destined to benefit and poor people further robbed.

    Posted by: Anonymous | 8 years ago | Reply
  • This is another fraudulent US

    This is another fraudulent US scheme that is coming India's way and have clearly greased enough palms at the center. After sucking the patients dry here, the insurance companies and their bedfellows- FDI investors/ consulting groups, have reached Indian shores. The plan is simple- get GOI to "subsidize" insurance premiums and provide next to no healthcare. Simple.

    Every registered Doctor in India needs to be encouraged to honor some time in the rural areas- say, 2-4 weeks per year, make it a rotational system of sorts. That way the urban/ rural divide can be reduced and more health care can be offered to the rural areas. The government can work out special schemes to give decent incentives to these doctors and work with them directly rather than through insurance companies.

    Posted by: Anonymous | 8 years ago | Reply
  • It is indeed an important

    It is indeed an important point. But, with centre's pushing the model, the states might find it difficult not to implement it. The Planning Commission suggests that the model should be piloted in one district in each state. Pilots are usually carried out in areas with best capacity to implement - it is then easy to claim success. The "success" would ensure that each state has to implement. Public health experts suggest that instead of implementing in one district in each state, the model could be tested in a few states. Simultaneously, in some states, steps should be taken to strengthen the public health system. This would provide a way to find out which model is more suited to the country.

    Posted by: Vibha Varshney | 4 years ago | Reply
  • It is not a very cost

    It is not a very cost effective method. Instead, a system that would provides better primary health care would help the poor more. Also, there is no focus on prevention of diseases which would escalate the price of health care even more.

    Posted by: Vibha Varshney | 4 years ago | Reply
  • The US healthcare system is

    The US healthcare system is in shambles. The country spends the most on healthcare and yet people are not benefited. The industry there is opposing health reforms that might make it easier for the poor to access health. Obviously, we should not follow them. Short term rural postings would strengthen the primary health care - this would be better than depending on  private industry and telemedicine.

    Posted by: Vibha Varshney | 4 years ago | Reply
  • Certainly it is the happy

    Certainly it is the happy news to all. Based on the status (SWOT) of the existing schemes, several doubts raises which include:

    £ Who is going to get the BENEFIT?

    £ Is it the need of the people? How many are going to get
    the Benefit? At what Rate?

    £ Why the implementation should be handed over to the
    Private Hospitals?

    £ Why not the existing Government Hospitals with added

    £ What is the position of existing Health Care Schemes?

    $ Are the existing one are effective in terms of cost and

    $ The whole process is gong to be a BUSINESS Model or
    SERVICE Model?

    $ Are the designated hospitals are accessible?

    £ Are we learn from the past experiences and ratify in
    future one?

    ..... the list will continue. It is the public money and should be spent to the public with effective measures both in terms of cost and targeted group.

    Let us hope that the planners and policy makers will understand the real health needs of the people, make the SWOT of the existing schemes and make need based strategies for the health and wealth of the PEOPLE and NATION.

    Posted by: Anonymous | 8 years ago | Reply
  • With the entry of big

    With the entry of big Corporates in the arena of health care the focus has shifted from Compassion and Competence to Commercialization and competition. Its a well known fact that Corporate house give targets to different departments which they are expected to achieve; no matter if they convert a simple case of pain abdomen into an appendicitis. Revenue generation is the prime target. Unfortunately these corporate houses have been getting support from respective governments which come out with newer legislations every now and then to corner the low cost medical practices of individual doctors. Indirectly the corporates are getting encouraged and they keep on increasing the costs of every procedure in the name of quality and comfort. Hospitals have been made to look like 5 star hotels to attract people.

    No discussion about innovation in health care in India would be complete without examining its impact on millions of Indians who have little or no access to adequate medical services. In global comparisons of health care spending, India is among the lowest ranked, with government health-related spending less than 5% of GDP. Rural Indians spend nearly 27% of their income on health care, and 35% of hospitalized Indians fall below the poverty line.

    A big problem is that public health services in India are overcrowded and groaning under the strain of crumbling infrastructure. The system is also dogged by corruption, with providers levying informal fees for services that should be provided free of charge. Meanwhile, private health care in corporate hospitals is prohibitively expensive and often unregulated. The only ray of hope can be promotion of individually owned small set ups which are finding it difficult to survive these days due to policies of governments that are often dictated by corporate houses. At this crucial juncture, we should concentrate more on the promotion of the health of the people and try to achieve the prestigious MDGs (Millennium Development Goals). If India fails, the whole world fails as we are the major contributors of Infant Mortality, Maternal Mortality and Childhood Malnutrition in the world.

    Posted by: Anonymous | 8 years ago | Reply
  • Hi Vibha, This is a

    Hi Vibha,

    This is a well-researched article touching upon a crucial issue of public health. Hope you will follow-up the story when the plan document is finalised.

    Posted by: Anonymous | 8 years ago | Reply
  • The are mainly two causes for

    The are mainly two causes for the poor health in India, one is malnutrition due to poverty and the second is due to bad quality of food in well to do families & even middle class.
    Next cause of diseases are degradation of environment, polluted water, air and earth.
    Hence the necessity is for the primary health centers with Health assistants / general nurses to work with families to guide & educate them. It is cheapest of all because 90 % of diseases can be treated at this centers.

    Posted by: Anonymous | 8 years ago | Reply
  • Very enlightening article,

    Very enlightening article, well written. I do not think we lack any evidence or we need to produce any more evidence to understand what is wrong and how to right the wrong in a country like India which is ruled by two economists who do not want to see any reason.
    Two world bank oriented economists are running our country. One plans and the other one executes and their mindsets are clear: destroy the public, hand it over to the private. Their decisions get made elsewhere other than the parliament. It is evident from the fact that they not accept any public health evidence unless it suits their decisions. It is a commonsense to understand that unless the public health system is strong, people are not going to get any healthcare as 68- 70 percent of health expenditure is out of pocket and much of it is spent on OPD care. This is a sheer commonsense knowledge and do we think the Dy Chair person of Planning commission and PM are such idiots that they do not understand this much of common sensical public health? It is a tragedy that we are ruled by people who do not have respect for democratic functioning and for whom the poor do not matter.

    Posted by: Anonymous | 8 years ago | Reply
  • Universal health is the only

    Universal health is the only alternative for the health of a common man.quality health can be provided to everyone from the villager to the first citizen of the country, by adopting universal health system.
    The cost can be borne by the whole nation according to their income capacity.
    Money should not play any role between the Doctor and the Patient.
    Dr Rajamohan

    Posted by: Anonymous | 8 years ago | Reply
  • I fully agree with the

    I fully agree with the remarks: ÔÇ£This is another fraudulent US scheme that is coming India's way and have clearly greased enough palms at the center. After sucking the patients dry here, the insurance companies and their bedfellows- FDI investors/ consulting groups, have reached Indian shoresÔÇØ, and that the healthcare scheme being pushed in India, and may find its way in Pakistan, is the American version.

    The US healthcare system has to protect its multibillion pharmaceutical industry and promote their system of medication which does more harm than good and fails to provide the sustainable healthcare that is needed in cases of ill-health and disease.
    The following is a case that needs to be examined with open mind and that is to go for a sustainable healthcare system that is provided by the OD-S-RR approach. This approach seeks to reverse the wrongs done by the ÔÇ£oxidantsÔÇØ using reductants or antioxidants, which is provided by the much safer alternative systems that include the Unani and Ayurvedic systems.

    The Book: Life Processes Health Aging & Disease, an Ecosystem Approach to Life Processes, Mirza Arshad Ali Beg, 2012, Research & Development Publications, Karachi, deals with sustainable healthcare system as follows:

    Contemporary healthcare all over the world is presently dominated by use of chemicals and pharmaceuticals that have had very limited value in dealing with some of the greatest scourges facing human health, including chronic diseases, psychiatric diseases and even certain infectious diseases. These are, according to the Oxidative Dehydration Theory on Life Processes, Health, Aging and Disease, oxidants that remove free energy or driving force from the cellular environment and therefore do not provide remediation in the real sense. The remedy lies in restoration of the free energy status by reversal of oxidative dehydration. This may be done by acts of reductive rehydration or by antioxidants.

    The allopathic or western system of medication has vigorously attacked and keeps attacking the scientific basis, efficacy and safety of the diverse range of modalities befitting approaches that are commonly placed among complementary and alternative system of medicine (CASM). Simultaneously, the CASM community, the natural products industry, health freedom organisations and large numbers of consumers and protagonists of the alternative systems including ESM, have argued that these attacks are unjustified and have reciprocated by exposing the apparent lack of efficacy and poor safety record of allopathic system.

    These differences of opinion are so deep-seated that the polarity between the two contrasting approaches has become increasingly reinforced. The relative lack of resources within the CASM community, the natural products industry and the health freedom movement, by comparison with the pharmaceutical industry and orthodox medical system which it supports, means that it is by and large proving very difficult to improve the acceptability of modalities of the CASM in mainstream healthcare.

    All the available indicators suggest that orthodox healthcare, which is dominated by interventions with new-to-nature pharmaceutical drugs, is not sustainable. ÔÇÿEvidence-based medicineÔÇÖ (EBM) is increasingly being used both as a means of justifying pharmaceutical intervention as the worldÔÇÖs dominant approach to healthcare and its ever-wider application to discredit or even outlaw some CASM approaches.

    The Oxidative Dehydration theory on Life Processes, Health, Aging and Disease is seen here to provide the much needed scientific evidences that the CASM requires. The ecosystem approach applies the principles of sustainability to healthcare and may be among the effective ways of altering the perception of established and emerging CASM modalities from the vantage point of government authorities and the current medical establishment. Additionally, such an approach provides significant assistance to transition in mainstream healthcare that is characterised by improved take up of biologically compatible modalities, as found within CASM. With the identification of scientifically established criteria for sustainability in healthcare, only those approaches meeting the criteria stipulated would be accepted. Sustainability principles have been applied in a range of industries where social or environmental degradation has been implicated, and it is unfortunate that the same have yet to be applied to healthcare.

    The OD-S-RR approach is presented in the Book to provide a base to trigger the transition towards sustainable healthcare. The OD-S-RR approach would help to reduce, if not eliminate, the existing polarity between orthodox healthcare and CASM approaches and would encourage such approaches that function harmoniously with biological systems and human metabolism.

    From the perspective of cost/benefit ratio also the pharmaceutical chemical and biopharmaceutical therapy do not offer much advantage and concerted efforts are required if mainstream attitude on life processes, health, aging and disease has to change over from the in-vogue oxidant/oxidative dehydration therapy to reductant/antioxidant/reductive-rehydration therapy. Moreover the former system has been a burden on the healthcare system because of the costs involved. It may be noted that the economy of scale, the increasing cost of R&D involved and the sales promotion to remain in business all add to the cost of drug. The cost has been set to increase ever since the biopharmaceuticals have been introduced.

    The alternative system of medicine (ASM) including the Tibbe Unani suffers from the drawback that it has low budget for sales promotion while the allopathic system is in the hands of multinationals which have separate allocation for sales promotion and also the long handle that they can use to get their products introduced and to continue to remain in business.

    It may be true that scientific methods of evaluation are lacking in the case of ASM and also that there was something lacking in the approach that did not lend support to the Unani or Ayurvedic systems of medication. However it was unfair to take advantage of the deficiencies to marginalise the sustainable approaches. This has occurred while the healthcare hierarchy provides only too insignificant improvement in its offer to the majority of the population that is either forced to accept or choose to accept pharmaceuticals and biopharmaceuticals as the most effective and scientifically-validated form of medicine.

    Encouraging a paradigm shift that requires all forms of healthcare to be bound by principles of sustainability is one of the credible measures to provide a level playing field for all healthcare modalities which encourage those approaches that are compatible with the complex biological and energetic systems. The OD-S-RR theory being based on the principles of sustainability does just what has been stated.

    Dr. Mirza Arshad Ali Beg
    Former Director General PCSIR Karachi

    Posted by: Anonymous | 8 years ago | Reply
  • The situation can be

    The situation can be rectified by investing more in strengthening the public health system. Unfortunately, while this would help the poor, nobody would make money. The solution the planning commission has come up with will help the corporates more than the poor. If we take RSBY as an example, it provides 30,000/- for a family of five for hospitalisation. Anyone who has been ever hospitalised would know that this will just sufficient for one day! This cannot be the answer to India's health needs.

    Posted by: Vibha Varshney | 4 years ago | Reply
  • True. In the draft plan

    True. In the draft plan document, the public machinary has been given the responsibility of taking care of preventive care. But the problem is if enough money is not invested in this sector (this could happen if major chunk of the money is diverted to private sector for curative care), the public sector might not be in a state to take care of prevention.

    Posted by: Vibha Varshney | 4 years ago | Reply