Primary Mistake


Jan Egeland

Until about four decades ago, specialist healthcare (secondary and tertiary care) was largely a province of public hospitals, and the private sector largely kept itself to the provision of generalist healthcare. This underwent a transformation with the rise of the advanced medical interventions comprising tertiary-care medicine like organ transplantation and open heart surgery. Given these highly-profitable medical advances, the private sector quickly turned its attention to tertiary care. With little being done to erect a robust public health infrastructure that could make healthcare available regardless of one’s ability to pay, highly-priced sophisticated medical interventions kept pushing into the Indian healthcare scenario. This has evolved into an entrenched characteristic of modern Indian healthcare.
A glimmer of hope was kindled by the Union Budget 2018-19 hailing the concept of health protection, only to be met with a set of dismaying figures. With the National Health Policy (NHP) 2017 seeking to double government spending on healthcare from 1.15 per cent to 2.5 per cent of GDP by 2025, a 20 per cent increase in allocation year-on-year is necessitated for 7-8 years to attain the objective. The budget, however, has kept this to a meagre 5 per cent increase over the revised estimate of 2017-18.
How, then, does it plan to achieve extensive health protection? It does so by banking on a publicly-funded insurance scheme to cater to the secondary and tertiary care needs of about 40 per cent of the population delivered largely through private hospitals, thus confirming the bias towards privately delivered specialist healthcare.
The insurance sum of Rs 5 lakh per family per year under the National Health Protection Scheme (NHPS) appears to be unrealistically aspirational considering its 2016 iteration, which allocated Rs 1 lakh per family per year, is yet to take off. Publicly-funded health insurance through private hospitals is by itself no bad move, since it can significantly increase access to quality secondary and tertiary care and reduce the burden of hospital expenses. However, as a means of achieving universal health protection, it is likely to be highly inept and saddled with compromises. If the lack of sufficient practical precedent isn’t enough, the idea appears to be untenable even in theory. A strong primary care system is vital to achieving universal health coverage.
It is futile to expect private entities to be interested in assuming a prominent role in primary-care provision, which is a much less rewarding enterprise than tertiary care. This certainly cannot go unappreciated by the finance minister, who therefore slides in “secondary and tertiary care hospitalisation” along with health protection under the NHPS. Even the biggest incentives are unlikely to succeed in persuading private entities to venture into rural areas, which would still prefer to concentrate on urban pockets. Experience from Chhattisgarh, which has the Chief Minister’s Health Insurance Scheme in addition to the NHPS, attests to this. With such a colossal publicly-funded insurance scheme in place, one could expect the practice of over- and unnecessary prescription and treatment to receive a major boost, unless adequate mechanisms to check the same exist.
There are evaluations that establish how the Rashtriya Swasthya Bima Yojana (RSBY) has largely failed not only in substantially improving access to health services for the poor but also in reducing out-of-pocket expenditure, which stands at around 69 per cent today (nearly 71 per cent of which is on medicine). This is because such schemes are directed to address in-patient care needs, leaving out-patient needs unattended. To be able to attach some meaning to the concept of health protection, a focus on primary care is imperative. All the current budget has to offer to primary care is a sum of Rs 1,500 crore for transforming 1.5 lakh sub-centres. Since the adequacy of this sum is anybody’s guess, the FM invited private and philanthropic entities to adopt these sub-centres. On the one hand, the budget proposes a colossal health insurance scheme to cover specialist care expenses delivered largely through, over generalist care and private over public healthcare, has to go for universal health care to become a reality.