TWO years have passed since the installation of the BJP led government at the centre and there is growing frustration at the inability or unwillingness of the present government to provide leadership in key areas of public policy. The health sector typifies the hands-off policy of the present government towards important areas that impact on welfare and livelihoods. There has been a singular lack of purpose in policy making and implementation in the health sector. Till date there has been no movement forward in unpacking of the vision around ‘health assurance’ – a phrase coined by the BJP to exhibit its commitment to healthcare. BJP’s ‘health assurance’ has remained an empty slogan, devoid of content or vision. This has been so in spite of at least one high level committee having been constituted in the early days of the present government to spell out the government’s concrete vision. The committee’s report, submitted more than a year ago, has since gathered dust and appears to have been silently buried. The draft of a new National Health Policy was unveiled over a year and half back and public comments were invited. Reportedly the comments were compiled and the revised draft has been lying with the ministry for the last six months. Indications of the government’s unhappiness with the health policy draft come from reports in sections of the press of a sharp rap on the knuckle from the Niti Ayog for suggesting a key role for public services. A letter from the Niti Ayog to the ministry, leaked to the press said: “Even though one might find it morally and ethically reprehensible – this system of two-tier care – one for those with means and a voice and the other for the voiceless and indigent will continue to exist in the short or even medium term as it would be logistically impossible to shift the majority of patient load from the private to the public sector”. The Ayog further castigated the policy for recommending increase in public investment, arguing: “We need to assess whether drastically increasing investments will run in to the law of diminishing marginal returns, besides posing a challenge to the absorptive capacities of the state health systems.” The mantra of needing to contain the fiscal deficit was invoked to slash by 20 percent committed funds to the health sector towards the end of 2014. The union budget of 2015-16 was equally harsh, and effected a 5.7 percent cut in total allocation to the health sector – down from Rs 35,163 crores in 2014-15 to Rs 33,152 crores. Simultaneously, allocation for the flagship Integrated Child Development Scheme (ICDS) to the ministry of women and child development was halved, from around Rs 16,000 crores to a meager Rs 8,000 crores. Also slashed was the budget for HIV/AIDS with the National Aids Control Organisation’s (NACO) budget plummeting from Rs 1785 crores to Rs 1395 crores. The 2016-17 budget is a continuation of previous trends. The government’s flagship programme, the National Health Mission (NHM), has seen a insignificant rise in allocation – from Rs 19,135.37 crore in 2015-16 year to Rs 19,437 for 2016-17. Given the impact of inflation and population increase this actually represents a 6-7 percent decrease, per capita, in allocation for the National Health Mission. The impact of these cuts on expenditure is starting to be felt on the ground. The National Rural Health Mission’s activities have stuttered to a standstill in many states. Within six months of the new government’s installation, absorption of funds had started stalling – just 42 percent of allocated funds were spent in the first six months of the 2014-15 fiscal year. The government’s own data (in the yearly Rural Health Statistics) points to extremely disturbing trends. The number of Auxiliary Nurse Midwives (ANMs) serving in the public system actually saw a reduction between 2014 and 2015, as did the number of specialists working in public facilities. In March 2015 only 18.8 percent of sanctioned posts for specialists in rural public facilities had been filled. Infrastructure creation through the NHRM is also slowing down and only 288 new Primary Health Centres (PHCs) and 33 new Community Health Centres (CHCs) were set up in 2014-15 as against 572 and 176 respectively in the corresponding period in 2013-14. Serious shortages of consumables and human resources have surfaced, with widely reported periodic stock-outs of medicines for the HIV and TB programmes. A METHOD IN THIS MADNESS Clearly, there is a method in this madness. India’s health system is one of the most privatised in the world and public expenditure is one of the lowest. Of the total expenditure on health care in India only 32 percent is public expenditure – the 16th lowest (among 190 countries in the World Bank database) in the august company of countries such as Sierra Leone, Afghanistan, Haiti and Guinea. India performs even worse for public spending on health care as percent of GDP. At 1.3 percent of GDP spent on health care India stands 12th from the bottom in the company of Myanmar, Haiti, South Sudan, Timor-Leste and Pakistan. Innumerable public documents have hammered home the need to increase public investment in health by an order of magnitude, including successive Planning Commission documents. The ten year tenure of the UPA government saw only a marginal rise in investment in percentage of GDP terms. The NDA government, defying all logic appears committed to reverse even this marginal commitment to increase public investment. The BJP government would like to cap public expenditure at a minimum level and at the same time, through public policy measures, encourage the growth of private providers. In spite of the earlier Planning Commission’s High Level Expert Group’s (HLEG) clear recommendation to wind up the government’s health insurance scheme (the Rashtriya SwasthyaBimaYojana), the present government is aggressively pushing forward the insurance scheme because the main service providers attached to the scheme are private. Numerous reports and studies have shown that the existing national and state health insurance schemes have failed to rein in catastrophic health expenditure incurred by the poor. These schemes, largely implemented through partnerships with private providers, have been indicted in several states for defrauding the system of hundreds of crores by performing unnecessary surgeries (for example a huge rise in unnecessary uterus removal operations) and for not contributing to better health outcomes. The government is also aggressively pushing for private health insurance and the 2015-16 budget explicitly encourages this by announcing tax relief to those who purchase private health insurance. At the same time states such as Rajasthan and Madhya Pradesh are leasing out existing rural public facilities to the private sector. The ideologues of the BJP do not hide their fondness for the private sector. They would benefit if they were to rationally peruse the record of the private medical sector, both in India and globally. Instances abound of fleecing, callous neglect, and serious professional misconduct within major sections of the private medical sector. The private sector in India is also fast transforming into a corporate sector, thus gobbling up small and medium practitioners, many of whom are being forced to become franchisees of large corporate hospital chains. At the same time the government has exhibited a singular reluctance to operationalise the Clinical Establishments Act, supposedly designed to regulate the private sector. The masterly inactivity of the government in promoting public services and public oversight and its progressive withdrawal of support to public services is part of a particular vision of health care provision. In this vision, the role of publicly provided health services is replaced by outsourced services to the private sector. Insurance mechanisms and not public provisioning is the hallmark of this approach. Concurrently, given that public financing is being reduced, what is promised are basic and not comprehensive services. Even these basic services are largely reserved for primary levels of care, thus paving the way for an ever larger penetration of private facilities, especially in the hospital sector. Finally, as we saw in the 2015 budget, private health insurance is incentivised for the rich and a section of the middle class. While not made explicit, this is the vision of the present government towards health care.