A draft National Health Bill, put forth by the United Progressive Alliance (UPA) government, has helped kick-start the first serious discourse in India on the way forward in providing universal health care. India is the only country where three-fourths of health expenditure is out-of-pocket and health care is a major cause of indebtedness.
The draft health Bill, in its present form, may be an ambitious and voluminous document, but it provides a broader vision to health and emphasis on good quality health as a legal right. It also brings in determinants to good health, such as clean drinking water and an emphasis on setting down quality norms and standards for both public and private hospitals.
Head of the Public Health Foundation of India, K Srinath Reddy, said: “The legislation has looked at health beyond health care.” He called for shaping the Bill so it could move towards a national health service, which could provide health care to all and stop out-of-pocket payments completely. Just targeting vulnerable groups does not help. “Position the state as key Central figure in providing health care while paying attention to vulnerable groups,” Reddy said.
Since the setting up of the Bhore committee, which envisaged and set up a three-tier health care system for the country, soon after Independence, this is the first time an active consultation process has been started with various stakeholders. Public health activists, academicians, bureaucrats and economists were among those present at the first such consultation in Delhi.
The process of consultation is only a start to a long process of setting India on the path of its health sector reforms. The Bill itself will need several drafts before it can be accepted by stakeholders. Moreover, as health is a state subject, the law, would subsequently need to be adopted by states, before it can become nationally applicable. Over the years, lack of political will and apathy has destroyed public health systems, concurred the experts.
India has amongst the poorest record globally on its health indices. “The government spends only 1 per cent of its gross domestic product (GDP) on health despite promises by the UPA government before the 2004 elections that it would be increased to 2 per cent,” said former advisor to Planning Commission, N J Kurian, adding that the increase had been only about 0.2 per cent.
Not that there isn’t more spending. India spends a total of 5 per cent of its GDP on health care. But much of it comes through the private sector. “The health system, which has become highly privatised is in need of a major revamp,” said Amar Jesani, who works on medical ethics. The public-private partnerships, a way of outsourcing health care to private players, should be stopped while increasing public health expenditure, he said.
Heavy reliance on the private sector has not improved health systems. In fact, they have deteriorated, with affordability becoming a big hindrance to access. User fees are imposed by public hospitals, denying access to a large number of poor. “Those who do not have their below poverty line cards cannot access the services,” said Renu Khanna, from Sahaj, a non-government organisation based in Vadodara.
A single-payer system, as pointed out during the discussion, would address the needs of Indian society. Currently, the Indian health care system is heading the way of the extremely problematic and highly privatised American health care system, with a high dependence on private insurers.
Three-fourths of the out-of-pocket medical expenditure in India, 70 per cent is on out-patient care, which is not provided by private insurance companies. “In some rural areas, there are no hospitals within 50 to 100 kms,” said Kurian, questioning the role of private health insurers, who could provide relief, at best, to a few.
Abhay Shukla, joint convenor of Jan Swasthya Abhiyaan, the Indian circle of the People’s Health Movement, a worldwide network of people’s organisations, said: “Huge hospitals being run for medical tourism where most people do not have access. The state should guarantee services from primary to tertiary care.”
These stakeholders hope to generate a progressive movement on the issue in the country. “At the end of the day, health is of everyone’s concern. The poor may worry about just a place for having a delivery, while the rich may worry whether what they get at hospitals is good health care at all? ” said Khanna.
