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Health For All

Health Coverage and the 12th Five-Year Plan

Punyabrata Gun

[Translated from Bengali by Anirban Biswas]

In the Alma Ata Conference of 1977 on primary healthcare, the World Health Organization (W.H.O) declared the objective of ‘Health for All’ by 2000 AD. The declaration was signed by India also. The target remains, however, elusive as yet. Before the start of the Twelfth Five Year Plan, the Planning Commission of India formed a High Level Expert Group on Universal Health Coverage headed by Dr Shrinath Reddy, chief of the Public Health Foundation of India.

The HLEG defined the notion of Universal Health Coverage in these words:
Ensuring equitable for all Indian citizens resident in any part of the country, regardless income level, social status, gender, caste or religion, to  affordable, appropriate, assured  quality health services (promotive, preventive, curative and rehabilitative) as well  as public health services addressing  wider determinants  of health  delivered to  individuals  and populations, with  the government being the guarantor and enabler, although  not necessarily the only provider of  health and related services.

The picture of the health of the Indian people as presented by the Expert Group may be summarized as follows:

Indicator                                              India       China    Brazil     Sri Lanka   Thailand

Indicator 
 India  Chima Brazil Sri Lanka Thailand
Infant Mortality Rate (per 1000 live births)
50
17
17
13
12
Under 5 Mortality Rate (per 1000 live births)
66
19
21
16
13
Fully immunised (%)   
66
95
99
98
98
Birth by trained attendands 
47
96
98
97
98

The extent of governmental emphasis on health in India  is revealed by the following data:

Country

Total public spending as % GDP (fiscal capacity)

Public spending on health as % of total public spending

Public spending on health as % of GDP

India

33.6

4.1

1.4

Sri Lanka

24.5

7.3

1.8

China

22.3

10.3

2.3

Thailand

23.3

14.0

3.3

Source: WHO database (2009)

HLEG presented a graph of more than 78 millions of people belonging to 11countries, who were pushed below the poverty line for having to spend on medical treatment from their own pockets. In India alone, this fate befell more than 37.3 millions.

India’s Current Health Scenario

  • Largest number of underweight children (46% under 3 yrs);
  • Current infant mortality rate of 50 per 1000 live births;
  • Maternal mortality ratio presently 212 per 100 000 live births;
  • Challenge to meet national goals of 38 per 1000 (IMR) or 100 per 100 000 (MMR) by 2015
  • Rising burden of Non-Communicable Diseases

 

2011
(in Millions)

2030
(in Millions)

Diabetes

61

101

Hypertension

130

240

Tobacco Deaths

1+

2+

PPYLL Due to CVD Deaths  (35-64 Yrs)

9.2

17.9

There is, however, great inter-state disparity in respect of infant mortality rate. It varies from is 72 in Madhya Pradesh, 69 in Uttar Pradesh, 35 in Tamil Nadu, 13 in Kerala. The neo-natal mortality rate varies from 11 in Kerala to 53 in Odissa.

  • 18% of all episodes of illness in rural areas and 10% in urban areas  received  no health care at all
  •  12% of people living in rural areas and 1% in urban areas had no access to a health facility
  •  28% of rural residents and 20% of urban residents had no funds for health care
  •  Over 40% of hospitalised persons have to borrow money of sell assets to pay for their care
  •  Over 35% of hospitalised persons fall below the poverty line because of hospital expenses
  •  Over 2.2% of the population may be impoverished because of hospital expenses
  •  The majority of the citizens who did not access the health system were from the lowest income quintiles

The existing health insurance schemes generally do not provide the expenses of outdoor treatment, cost of medicine and laboratory tests. Yet these are the items, which, taken together, impose the most onerous burdens on the pockets of patients.

It  may be worthwhile to compare India’s position with respect to some other countries regarding the availability of hospital beds. The following table illustrates this position

Country
Beds per thousand persons
Sri Lanka  
3.1
China  
3.0
Thailand   
2.2
Brazil   
2.4
U.S.A     
3.1
U.K
3.9
India    
0.5
Nicaragua 
0.9
Togo     
0.9
Indonesia      
0.6

Source: W.H.O. 2011

The urban-rural disparities about health services are highlighted by the fact that the cities and towns have 80 % of the doctors, 75% of the dispensaries and 60% of the hospitals. The number of degree-holding doctors per ten thousand persons is 11.3 in cities and towns, while in villages, it is only 1.9.  

 Against this background that the HLEG considered the following:

  1. Human Resource Requirements
  2. Access to Health Care Services
  3. Management Reforms
  4. Community Participation
  5. Access to Medicines
  6. Health Care Financing
  7. Social Determinants of Health

Guiding Principles for universal health care framed by the High-Level Expert Group:

    • Universality;
    • Equity;
    • Non-exclusion and non-discrimination;
    • Comprehensive care that is rational & of good quality;
    • Financial protection;
    • Protection of patients’ rights that guarantees appropriateness of care, patient choice, portability & continuity of care;
    • Consolidated & strengthened public health provisioning;
    • Accountability & transparency; and
    • Community participation

 

The vision of the Expert Group was Universal Health Entitlement  for every citizen - to a National Health Package (NHP) of essential primary, secondary & tertiary health care services that will funded by the government. Package to be defined periodically by an Expert Group; can have state specific variations

On Health Financing & Financial Protection:

  • Government (Central government and states combined) should increase public expenditures on health from the current level of 1.4% of GDP to at least 2.5% by the end of the 12th plan, and to at least 3% of GDP by 2022.
  • Ensure availability of free essential medicines by increasing public spending on drug procurement;
  • General taxation as principal source of health care financing – complemented by additional mandatory deductions from salaried individuals & tax payers, either as a proportion of taxable income or as a proportion of salary

HLEG recommended:

  • Do not levy sector-specific taxes for health financing;*
  • Remove user fees for NHP services- this applies even for the ‘non-poor’
  • Introduce specific purpose transfers to equalize levels of per capita public spending on health by different states - to ensure all citizens are entitled to same level of essential healthcare;
  • Accept flexible and differential norms for financing that are proposed by states, recognizing physical and socio-cultural diversities
  • Integrate government insurance schemes into  UHC through India Health Card

If these measures are taken, even on assuming total spending on health remains at the current level of around 4.5% of GDP, there will be a sharp decline in the proportion of private out-of-pocket spending on health - from 67% today to 33% by 2022

The High-Level Expert Group has made two citations while arguing their case against the User Fee in the provision of health facilities.

“User Fees for health care were put forward as a way to recover costs and discourage the excessive use of health services and the over-consumption of care. This did not happen. Instead, user fees punished the poor.”
-Dr. Margaret Chan, Director-General, WHO (2009)

“Among the ‘quick win’ strategies recommended by the Millennium Project was the removal of user fees for primary education and essential healthcare by the end of 2006.
- Dr. Jeffrey Sachs (2005)

Health Financing & Financial Protection: further proposals

  • Primary healthcare including preventive/curative services at primary level along with health promotion targeted towards specific risk factors, should account for 70% of all govt. healthcare expenditures
  • Provide universal financial protection and access to good health care without involving insurance companies or any other independent agents to purchase healthcare services (NHP) on behalf of govt. 

BECAUSE

            Independent agents fragment the nature of care being provided, leading to high health care costs and lower levels of wellness at the population level

  • Central and State governments should purchase services (through agencies linked to Department of Health)
  • Technical and other capacities developed by Ministry of Labour for RSBY should become the core of UHC operations – and transferred to MoHFW.
  • Integrate the services provided under different programs gradually (NRHM and other vertical programs such as, HIV/AIDS);

For provision of health care, HLEG recommended:

  • Strengthen Public Services (Especially: Primary HealthCare- Rural And Urban; District Hospitals)
  •  Contract Private Providers (As Per Need And Availability)– With Defined Deliverables
  •  Integrate 10, 20, 30  Care  Through Networks of Providers (Public; Private; Public-Private
  • Regulate and Monitor health care providers for Quality, Cost And Health Outcomes

Recommendations for Health Care Services:

  • Provide essential & standard health services as part of entitlement for every citizen to NHP at different levels of health care delivery system;
  • Ensure more equitable & improved access to functional beds for guaranteeing secondary & tertiary care;
  • Ensure adherence to & compliance with quality assurance in health care provision at all levels of service delivery;

What should be the key characteristics of reliable and efficient medicine supply systems?

  • At least 15% allocation of public funding for health to drugs;

State must procure all EDL medicines;

  •  Separate AYUSH EDL, with centralized procurement at state level;
  •  Prescription & Dispensing in accordance with Standard Treatment

   Guidelines (STG);

  •  A two-bid open transparent tendering process;
  •  Quality generic drugs ensured;
  •  Warehouses at every district level;
  •  An autonomous procurement agency for drugs, vaccines & 

  diagnostics;

  •  An empanelled laboratory for drug quality testing;
  •  Enactment of Transparency in Tender Act;
  •  Prompt payments

For Access to Medicines,  Vaccines & Technologies

  • Ensure rational use of drugs;
  • Set up national & state drug supply logistics corporations;
  • Empower MoHFW to strengthen drug regulatory system;
  • Transfer Department of Pharmaceuticals to the Ministry of Health.

Recommendations for Human Resources for Health

  • Ensure adequate numbers of trained health care providers and technical health care workers at different levels – giving primacy to the provision of primary health care.
    • Doubling ASHAs from one per 1000 population to two per 1000 population in rural and tribal areas;
    • Introduction of  mid-level health workers such as Bachelor of Rural Health Care (BRHC) Practitioners for recruitment & placement at  rural Sub-Centres and Nurse Practitioners in urban Sub-Centres
  • Improve human resource management and supportive supervision mechanisms at block, district, state & national levels to complement health care service providers;
  • Enhance the quality of HRH education and training by introducing competency-based, health system-connected curricula and continuous education;
  • Invest in additional educational institutions to produce and train the requisite health workforce;
  • Establish a dedicated training system for Community Health Workers;
  • Establish District Health Knowledge Institutes (DHKIs);
  • Establish the National Council for Human Resources in Health (NCHRH).

Recommendations on Management and Institutional Reforms:

  • Develop capacity and cadres for public health and health management
  • Adopt better human resource practices to improve recruitment, retention motivation and performance; rationalize pay and incentives; and assure career tracks for competency-based professional advancement;
  • Develop a national health information technology network based on uniform standards to ensure interoperability between all health care stake holders;
  • Ensure strong linkages and synergies between management and regulatory reforms and ensure accountability to patients and communities;
  • Establish financing and budgeting systems to streamline fund flow.

Recommendations on Community Participation and Citizen Engagement:

  • Transform existing Village Health Committees (or Health and Sanitation Committees) into participatory Health Councils;
  • Organize regular Health Assemblies;
  • Enhance the role of elected representatives as well as Panchayati Raj institutions (in rural areas) and local bodies (in urban areas);
  • Strengthen the role of civil society and non-governmental organizations.
  • Institute a formal grievance redressal mechanism at the block level.

Health beyond Healthcare:
“ Health leaps out of Science and draws nourishment from the Society around it”
- Gunnar Myrdal (Swedish Economist, Nobel Laureate)

Policies and Programmes in  Finance, Water, Sanitation, Agriculture, Food Processing, Education, Rural Development, Urban Design, Transport, Communications, Trade, Environment NEED TO BECOME SENSITIVE AND RESPONSIVE TO PUBLIC HEALTH CONCERNS !

HLEG Recommended…….
Creation of National Health Promotion and Protection Trust to enable :

  • Effective Health Communication, Dissemination and Information Sharing
  • UHC Related Education to People , Patients, Providers
  • Health Impact Assessment of Policies and Programs in Other Sectors (to facilitate convergent action on the Social Determinants of Health)
  • Collaboration with International Partners to draw upon Best Practices, Policies, and Lessons from the Global Context

The High-level Expert Group has concluded its report with a citation:
“If we don’t create the future, the present extends itself”—Toni Morrison( Song of Solomon)

Let us now see what the Planning Commission said in the 12th Plan:

(i)The allocation of public expenditure on health will be raised, not to 2.5% of the G.D.P but to 1.58 %.

(ii) The central allocation will be greater than what the states themselves spend on health. The centre refunds only 15-20% of the money it takes from the states as taxes. Most of the states will not be able to increase their expenditure on health.

(iii) National Rural Health Mission, Janani Suraksha Yojana, Family Planning, Eradication of tuberculosis, malaria, diarrhea—all these are now run with central funds. If the centre gives only one half of the funds allocated in the states , the  allotment will actually go down.

(iii) The government will abandon its pivotal role and act mainly as the manager in the provision of health services.

(iv) Private health services and health insurance will play the main role. In this respect, the Planning Commission has referred to the system of ‘managed health care’ in the U.S.A and Mexico.

(V) Instead of the health package and contractual arrangements, when necessary,  with private institutions as recommended by the Expert Group, t he Commission has recommended improvement of private health services at state expense.

(vi) The profitable third-stage services will be handed over to the corporate hospitals,

(vii) Whatever governmental arrangements are there will be wound up,

(viii) Private health merchants and non-governmental organizations will build up a new infrastructure of treatment by receiving government subsidies.

(ix)  Every family will choose its own private hospital, and the government will meet the cost up to a point,

(x) There is no mention of the national health package,

(xi) In order to build up private hospitals and medical colleges, the government, as incentives, will provide subsidies up to 20% of the total costs.

(xii) Tax concessions will be granted for increasing their incomes,

(xiii) The user fees will all be permissible in hospitals built at state expense.

There is no mention of introduction of drugs under generic names, provision of essential drugs free of cost, control of drug prices.

Hence the question is: Why was the High-level Expert Group formed at all if the Planning Commission refuses to obey its recommendations?
Should we stop at raising the question only, or our task should be to build up public awareness with the demand for universal health care?

Let our slogan be ‘struggle for health’, the slogan of All Bengal Junior Doctors’ Federation movement of 1983.

Just as the report of the Hathi Committee (1975) was our weapon in the struggle for the introduction of pro-people drug policy, the report of the Srinath Reddy Committee should be our weapon in the struggle for universal right to healthcare.  


Dr. Punyabrata Gun may be contacted at shramajibi.swasthya@gmail.com

Frontier
Vol. 46, No. 50, Jun 22 - 28, 2014

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