Vol. XLIII No. 25 June 23, 2019
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Turning Health Care into Source of Profit

THE NDA government came to power on a number of promises. Assuring affordable, accessible and effective healthcare was one of them – Swasthya Bharat Samridhha Bharat. But as in other areas, the government has miserably failed in fulfilling any of its assurances in the health sector too. Over its five-year tenure, the NDA government led by Modi has on the one hand, starved the health sector of crucial financial resources, and on the other, it has brazenly given incentives to the private sector, including changes in policy towards increasing commercialisation of health services. This tenure saw the deaths of a number of children in 2017 due to lack of basic facilities at state run hospitals in Gorakhpur, Ranchi and Nasik. These five years also saw the death of 15 women in 2014 due to sterilisation in Chhattisgarh under a BJP led state government. And even after such cases highlighting the dilapidated condition of the health system, the Modi led government has nothing concrete to offer but hyperbole.

The year 2017 saw the drawing and adoption of a new health policy after nearly 15 years – the National Health Policy 2017. It watered down the Draft NHP 2015, developed under the previous regime which had proposed a National Health Rights Act to ensure health as a fundamental right, whose denial will be justiciable. Instead, the NHP 2017 advocated “a progressively incremental assurance based approach, with assured funding to create an enabling environment for realising health care as a right in the future”.

 

INSURANCE-BASED HEALTHCARE vs

PUBLIC PROVISIONING

One can clearly witness the paradigm shift away from building a strong public health system to a privately provided and insurance based healthcare model. Without carefully assessing whether insurance based model of healthcare is suitable for the country, the government is imposing such a model on the people. The NDA government announced the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The PMJAY component would give hospital coverage of up to Rs 5 lakh for about 10 crore families. The costs would be shared by centre and states in a 60:40 ratio.

PMJAY is largely based on the erstwhile Rashtriya Swasthya Bima Yoajana, a model which was fraught with problems and has not led to any decline in the out of pocket (OOP) expenditure for the people. A large chunk of OOP expenditure is on outpatient care which is not covered under the insurance scheme. The poor and the marginalised largely seek outpatient care because they cannot afford to lose their daily earnings.

As of now, five states – Delhi, Chhattisgarh, Odisha, Telangana and West Bengal – have opted out of the AB-PMJAY. For those states which are part of the AB-PMJAY, there are reportedly issues of central funds not being disbursed timely, giving rise to apprehensions regarding last-mile delivery of services to patients which was a major problem in RSBY also.
Even in terms of resources provided for the scheme, the implementation agency of AB-PMJAY, the National Health Agency (NHA), had reportedly demanded Rs 7,400 crore to meet the expenditure for 2019-20 but has been allocated only Rs 6,400 crore. Further, it has been made clear by the government that it would give land and other facilities to incentivise private investment in tier 2 and tier 3 cities – a clear step in favour of private commercial interests. 

 

STARVING OF NHM

This euphoria about an insurance-based healthcare can be juxtaposed with the apathetic treatment meted out to public health schemes/programmes such as the National Health Mission. The share of NHM in the total health budget has consistently declined since 2014-15 from 61 per cent to 49 per cent in 2019-20.

Despite tall claims made by the Modi government, the union government’s budgetary allocation/expenditure for the health sector has remained stagnant at about 0.3 per cent of GDP since 2014-15. To achieve the targeted health expenditure by government (both centre and states) of 2.5 per cent of GDP by 2025, of which 40 per cent should come from the centre, requires one per cent from the union budget, which remains a distant dream.

Thus, what we see over the years is a deliberate weakening of the public health system. If we compare budget allocation for PMJAY with those for National Rural Health Mission (NRHM), this becomes evident. The allocation for PMJAY increased by 167 per cent while for NRHM it increased by a mere 2 per cent, though over 2017-18, the NRHM allocation in fact declined by 1.5 per cent. Further, the allocation for the second component of Ayushman Bharat – the Health and  Wellness Centres – budgetary provisions have been put under the NHM head, which implies that allocation to HWCs would come at the cost of existing interventions under the NHM.

 

INCREASING PRIVATISATION & NO REGULATION 

In addition to the incentives being given under the PMJAY, the private sector has been given an increasing role in managing primary healthcare. In a number of states, the operation of health facilities is being pushed into the public private partnership (PPP) mode which is being opposed by people in Chhattisgarh, Punjab and Rajasthan. To compound the problems further, regulation of private sector is negligible and only a few states have adopted the Clinical Establishment Act. In effect, what these developments indicate is a plot towards undermining public health system and promoting a privatised healthcare model.

 

DILAPIDATED INFRASTRUCTURE;

NEGLECTED HEALTH PERSONNEL

Such stagnation in terms of budgetary resources is being witnessed at a time when overall public health system is in shambles. There is a debilitating shortage of key health personnel – 75 per cent shortfall of obstetricians and gynaecologists, 85 per cent shortfall of surgeons, 86 per cent shortfall of physicians and 83 per cent shortfall of paediatricians at community health centres. Health infrastructure across the country is in poor condition as was highlighted by the CAG report in its audit of NRHM. Nearly 25 per cent of the sub centres are without electric supply, 17 per cent without regular water supply and 10 per cent without all-weather motorable approach road.

Another tall claim made by the NDA in its manifesto was to establish AIIMS-like institutes in every state. Till date over 20 such institutions have been announced in a phased manner, but the projects under Phase I still have huge deficiencies and suffer from inadequate facilities. The performance audit by CAG (2018) reports that besides time overrun of about four to five years in various packages of six new AIIMS, shortage of faculty posts in different AIIMS ranged from 55 per cent to 83 per cent while shortage of non-faculty posts ranged from 77 per cent to  97 per cent; 1,318 pieces of equipment with an estimated cost of Rs 454 crore remained undelivered as on March 31, 2017, for periods up to 25 months from the due date of delivery; out of 42 departments, 6 to 14 speciality, super-speciality and other departments have not become functional; and, out of 7 AIIMS proposed in the fifth phase, only one got approval in July 2016 while no approval has been given in the sixth phase.
In addition, there is increasing contractualisation of health workforce with very less remuneration but enormous work pressure. The backbone of the primary health care – the ASHA and Anganwadi workers have been demanding regularisation and status as a worker but the government has conveniently ignored the demands. 

 

NEGLECT OF MATERNAL AND CHILD HEALTH

Even as the finance minister talked about “women-led development” in his budget speech, the programmes/schemes that are relevant for women’s health have been neglected. Allocations towards reproductive and child health (RCH), which includes schemes like Janani Suraksha Yojana (JSY), immunisation programmes and various key disease control programmes, have experienced a cut of around Rs 4,200 crore compared to the expenditure in 2017–18. Along with this, the allocation for Pradhan Mantri Matru Vandana Yojana (PMMVY), the erstwhile maternity benefit scheme, has largely remained the same as in 2018-19 (BE). It must be noted that PMMVY succeeds the erstwhile Indira Gandhi Matritva Sahyog Yojana (IGMSY). Whereas the incentive provided under IGMSY was for the first two live births, under PMMVY, this has been limited to the first living child.

Further, for ICDS the budgetary allocations by the union government has declined at constant prices since 2014-15, only to recover marginally since 2017-18. Similar to the NHM, the trend in the ICDS budget shows a significant increase in the UPA period (higher during UPA I) but a negative growth rate during the Modi rule, indicating a fall in budgets in real terms during the present government.

 

SPIRALLING PRICES OF MEDICINES

It is estimated that in India nearly 3.68 crore people fall below poverty line because of their expenditure on medicines, which constitutes more than 70 per cent of the total out of pocket expenditure on healthcare. The performance of Modi government in controlling consumer prices of medicines has been quite abysmal. The current Drug Price Control Order (DPCO) is operational since May 2013. Out of 64 months since its implementation, in many months the point to point inflation rate of medicines has been higher than the general inflation. Since November 2016, we have experienced higher inflation in medicine prices compared to general inflation. Also, under the Pradhan Mantri Bharatiya Janaushadhi Pariyojana, a scheme to provide drugs at affordable prices, the allocations have been nearly halved from 2018-19. So much for the commitment to provide affordable medicines!