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Planning Healthcare for All?

The Planning Commission's High Level Expert Group has given its provisional progress report on developing a framework for universal health coverage. Its mandate is to suggest a strategy for universal health coverage rather than a universal healthcare system. The latter would be geared to a progressive socialisation of healthcare based on human rights. Universal coverage, on the other hand, would mean a system that will continue to be dominated by the logic of the market. But all said and done, the Planning Commission's group has done a good job and has tried to keep its focus on socialisation of healthcare.

COMMENTARY

Planning Healthcare for All?

Anant Phadke

This progress report contains many farreaching and progressive provisional recommendations based on many inputs from various civil society experts, some of whom are members of the HLEG. However,

The Planning Commission’s High Level Expert Group has given its provisional progress report on developing a framework for universal health coverage. Its mandate is to suggest a strategy for universal health coverage rather than a universal healthcare system. The latter would be geared to a progressive socialisation of healthcare based on human rights. Universal coverage, on the other hand, would mean a system that will continue to be dominated by the logic of the market. But all said and done, the Planning Commission’s group has done a good job and has tried to keep its focus on socialisation of healthcare.

I
n October 2010, the Planning Commission of India with the approval of the prime minister, appointed a High Level Expert Group (HLEG) to develop a framework for universal health coverage (UHC) to be implemented over 2010-20. Given the abysmal health and healthcare scenario this move by the United Progressive Alliance government seems to be among the more enlightened ones aimed at facing the next parliamentary elections. Elections cannot be won by mere deceit, money and muscle power as people have begun voting for improved services and concessions. (Unfortunately, it is also true that elections can be won by populist measures like the Aarogyasri health scheme as seen from the Andhra Pradesh experience.) Indian employers and the government are increasingly realising that official expenditure on healthcare is handled wastefully and that there is almost explosive dissatisfaction amongst people about the healthcare situation.

The HLEG’s terms of reference (TORs) includ e preparing an investment plan for human resource requirements, physical and financial norms to ensure quality UHC, critical management reforms to improve effi ciency, effectiveness and accountability, guidelines for the constructive participation of communities, and preparing policies regarding the production, import, pricing, distribution and regulation of essential medicines, etc. A subgroup has been formed for each of these TORs and the groups have given their analysis, and provisional recommendations. The HLEG’s first (February) “progress report” is a consolidation of these subgroup reports.

The progress report gives the impression that within four months, a lot of wide-ranging expertise has been harnessed to formulate fairly broad-based analysis and recommendations, though the detailed, in-depth rationale and finalisation is awaited. Since it is clear that this report is only a provisional one, it is questionable whether any public good is achieved by keeping it confidential.

it is beset with potentially inconsistent if not contradictory positions.

The final report is due in June and it is imperative that concerns about the UHC are discussed in wider circles and that the HLEG comes up with consistent, and finalised recommendations in all aspects. I will touch upon only some of the key recommendations of the progress report and point out some of the problem areas.

The potential problems with the HLEG’s recommendations partly arise from the formulation of its mandate. The HLEG has to suggest a strategy for universal health coverage, and not a universal healthcare system. The latter would be an organic whole, a system geared to a progressive socialisation of healthcare based on the logic of human rights, and overcoming the commodification of healthcare. Universal coverage may mean merely covering the entire population through a system which will continue to be dominated by the logic of the market in healthcare. Further, there is a perception that the UHC’s main objective is “preventing catastrophic health expenditure” and not progressive realisation of the right to healthcare. It remains to be seen whether the final recommendations are influenced by this limited interpretation of UHC or otherwise.

The HLEG has outlined the “core principles” (actually core elements) of UHC which have also been formulated in the concept note1 of the Medico Friend Circle’s (mfc) national meet in January 2011 on universa l healthcare. (The MFC is a 38-year old natio nwide platform of pro-people health workers and experts which has been deliberating since 2009 on a universal healthcare system. Many HLEG members participated in the MFC’s January meet and have used some of the inputs gathered there.) Even mere enumeration of the core elements of UHC gives an idea about the broader scope of its concept – universality and comprehensiveness of care; equity; non-exclusion and non-discrimination; financial protection from illness expenses; quality and rationality of care; protection of patients’ rights; portability

Anant Phadke (anant.phadke@gmail.com) works with Sathi-Cehat and Shramik Mukti Dal.

Economic & Political Weekly

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May 21, 2011 vol xlvi no 21

COMMENTARY

and conti nuity of care; core role of public financing; substantial contribution of taxbased funds; consolidated and strengthened public health provisioning; accountability, transparency and participation.

The progress report then undertakes the demanding task of recommending measures on the basis of these core elements, to achieve UHC in today’s complex situation. The official policies and practices followed so far have led to people having to bear the double burden of both the “older” diseases of malnutrition and infections and the “newer” diseases of pathogenic development (the so-called “lifestyle diseases”). Moreover both the public and private healthcare systems are beset with serious problems. In this context, provisioning, financing, and governance – all the three aspects of healthcare – need an overhaul to achieve UHC. I will refer to only three major elements, though the progress report also deals with changes needed in healthcare management and human power planning to achieve UHC.

Healthcare Financing

The progress report has argued for universal financial protection that covers both inpatient and outpatient care under the “evidence based belief”. It holds that it should be possible to provide a clearly defined set of healthcare entitlements including preventive, primary, secondary and tertiary health services that will address the essential healthcare needs of every citizen. It further argues that the best way to offer this protection is to ensure that all aspects are fully financed through pre-payment and provided free of cost at the point of service, with the public and the private sector collaborating to do this within a well-defined regulatory and contracting framework. To implement this in a situation wherein the majority of the people cannot access even primary healthcare implies mobilising an unprecedented amount of public funds. The HLEG recommends stepping up the level of public spending on health to a minimum of 3% to 4% of GDP by 2017 from the current abysmally low 1%.

This estimation by the HLEG needs to be revisited as it is based on a rather dated estimate by the National Commission on Macroeconomics and Health at the 2004-05 prices of Rs 1,160 per capita needed to provide healthcare to all. A recent estimate in Ravi Duggal’s paper for the mfc is Rs 3,000 per capita, i e, 4.88% of GDP amounting to Rs 3,200 billion.2 A detailed examination of these estimates is needed since the implications for any such quantum jump are stupendous. Out of this estimate of Rs 3,200 billion for UHC, if 20% comes from private sources, the public fund requirement would be Rs 2,560 billion – more than three times the current public health spending of Rs 792 billion! It is a moot question whether state and local governments and public sector companies can triple their health budgets. The central government will have to contribute considerably more.

Secondly, in many states a substantial part of the enhanced central grants remains unutilised. This problem has to be solved by implementing major reforms. Will this happen? Will the government have the political will to mobilise this amount of funds for healthcare? Evidence indicates that if there is a political will, the government can make a substantial increase in the healthcare budget. The union health budget increased from Rs 81 billion in 2004-05 to Rs 217 billion in 2009-10 at current prices; mainly for the National Rural Health Mission. Again, the central government’s tax revenue has been increasing phenomenally from Rs 2,703 billion in 2005-06 to Rs 6,341 billion in 2010-11. This is despite the huge tax concession given every year by the government to the rich and the corporates. (Tax forgone due to income tax exemptions to corporates alone has increased from Rs 346 billion to Rs 883 billion during the same period.) India’s tax-GDP ratio is just 13% compared to a minimum 25% in the advanced countries which have achieved universal or near-universal healthcare. The HLEG talks about increasing it. But it is not clear how the specific suggestions made by it would achieve the target. Besides, there is no discussion about the far-reaching political implications of a significant increase in the taxation on the “haves”.

The progress report recommends that the bulk of the required funds for UHC have to come from taxation and the

May 21, 2011

Consolidated Fund of India. To supplement the pool available for UHC, the report recommends that funds in the Employees’ State Insurance Scheme, the railways, defence, the Central Government Health Scheme and the fund for the Rashtriya Swasthya Bima Yojana (RSBY), Kalaignar and Aarogyasri schemes should be pooled with other UHC resources and that contributory health insurance be made mandatory for the entire organised sector. It argues that evidence indicates that use of conventional insurance models to purchase healthcare with pooled public resources may not be an appro priate choice for a variety of reasons. Further, it recommends that direct provision with contracting-in of the private sector where necessary and not the purchaser-provider split may be the best purchasing option.

Healthcare Provisioning

The progress report recommends a mix of public health services with regulated, “contracted in” services of those private providers who accept certain conditions. In the perception of the report, a strengthened public sector would effectively fulfil the multiple roles of promoter, provider, contractor, regulator and steward. It states that while the private sector will be required to play a role, “the bulk of the healthcare provision at all levels would need to be provided by the public sector”. It may be pointed out that out of the 1.5 million registered medical graduates, less than 10% and a much smaller proportion of postgraduate doctors are in the public sector. Considering this how do we expect that by 2020, the public sector would provide the “bulk of the healthcare provision at all levels” unless by the “bulk of the healthcare provision” is meant only a substantial and critical portion of healthcare provision? Incidentally, compared to the WHO recommendation of a doctor per 1,500 population, the progress report recommends an MBBS doctor per 5,000 population. The current norm is of two MBBS doctors per primary health centre (PHC) catering to 30,000 people. But the scientific basis for this ratio or that of the other human resource recommendations is not mentioned. There are no recommendations for human-power norms in urban areas.

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The progress report argues that it is possible to offer reasonable choice of providers to citizens between multiple public and private providers through the means of a nationally portable Health Entitlement (Smart) Card which can be used across public and contracted-in private providers without the need for using insurance-led purchasing models or purchaser-provider splits. It admits that there is a serious concern about how the Direct Provision System will “perform”. But it maintains that various steps proposed in this report to improve the performance of the public health system, combined with the competitive pressure exerted on it by the contracted-in private sector, would take care of this problem.

Minimum Health Cover

The recommendation that every citizen be guaranteed a minimal healthcare cove r package biased towards preventive and primary care to decrease the societal disease burden, which will in turn decrease the need to utilise expensive tertiary care for preventable sickness is welcome. Further, the report clarifies that public and contracted-in private facilities should offer only UHC benefits to the population and would be entirely cashless for all users to take away all incentives on their part for “induced” demand. They (and the healthcare personnel serving within them) will not be permitted to offer any additional care using out-of-pocket expenditure or honour any private voluntary or community-based insurance plans for providing supplementary healthcare either in the facility or after-hours in a “private practice”.

The report suggests that “private providers should be ‘contracted-in’ on the basis of standardised rates and norms for service delivery and functioning rather than ad hoc Public Private Partnerships (PPPs)”. It maintains that such “contracting in” of the private sector through systematic and transparent processes would strengthen socialisation of healthcare, expand pro-poor investment, and expand services in the health sector. The Insurance Regulatory and Development Authority’s (IRDA) regulated private voluntary/comunity-based health insurance will continue to be available, but only at facilities that are not contracted-in to serve NHEC cardholders.

Access to Medicines

As regards access to essential medicines by the needy, the progress report estimates (without giving any rationale or other details) that around Rs 30,000 crore annually (close to about 0.5% of GDP) would be needed to supply quality generic drugs. This is on the condition that their rational use is enforced through a pooled public procurement for supply through public health system as well as through private chemists contracted-in into the UH System. Currently Rs 50,000 crore worth of medicines are sold through the private chemists/ sector, while an additional Rs 5,000 crore is procured at the government level and yet majority of the people do not get the essential medicines they need. Along with widespread poverty, and a grossly inadequate public health service, the other important reason for this deprivation is a very low value placed on the money spent by patients on medicines. This is due to the production of irrational medicines, irrational combinations of medicines, their irrational use and exorbitant pricing by the pharma industry (since most of the medicines are out of the purview of the price control).

The HLEG has pointed out that part of the solution lies in centralised procurement mechanism through the transparent tendering system (as in Tamil Nadu) in each state and one at the central government level for the public sector. It has also recommended weeding out hazardous, non-essential and irrational medicines and irrational fixed dose combinations from the market and price control of essential medicines. This is to be supplemented with various measures to protect self-reliance including full use of the flexibilities in the Trade-Related Aspects of Intellectual Property Rights (TRIPS) regime as clarified in the Doha Declaration and refusal to include data exclusivity provisions in the pharma-related legislation. All these measures have been demanded for a long time by the All India Drug Action Network. Their implementation would require a different kind of political will than the one seen in the prevalent politics of shielding the rapacious pharma industry. The HLEG has also rightly recommended the formation of an essential medicines list for ayurvedic, unani, siddhi and homeopathic (AYUSH) medicines. It has also asked for measures to ensure universal availability of quality AYUSH medicines in adequate quantities. However, in the absence of a clear emphasis that AYUSH medicines would form part of the people’s choice in all health facilities, mere availability will have little value.

Planning and Governance

The progress report does start with the accredited social health activists (ASHAs), and other community health workers (CHW) rather than with hospitals. It also sees the participation of communities, local elected bodies and non-governmental organisations (NGOs) as a prerequisite for successful implementation of UHC. Its specific recommendations include:

  • Teams of two to four community workers rather than a single ASHA (each with training in specialised areas) to facilitate lateral support, with similar deployment in urban areas. Creation of empowered and transparent entities at block/ taluka, district, state and national levels for health promotion, deliberation on health priorities.
  • Citizens’ health assemblies to be organised at each level at regular interval s.
  • Provision of risk-free grievance redress and information services through the Jan Sahayata Kendra or ombuds person.
  • Procedure for free and fair adjudi cation of grievances and corrective measures.
  • At panchayat and municipality level, a committee including at least one elected representative (swasthya panch) to conduct periodic social audits or hearings on health issues.
  • Preparation of national bills that sanction and outline the powers of the above empowered entities.
  • Greater involvement of NGOs in oversight and capacity-building for community participation in health.
  • The report suggests a series of both systemic and institutional management reforms to rationalise the management of the public health system. One would add that this has to be accompanied by interna l democratisation because the hierarchical structure and functioning of the healthcare system is demotivating. The sickening,

    Economic & Political Weekly

    EPW
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    COMMENTARY

    arbitrary, and corrupt rule of the babu s is the cause of many maladies. Transparency and accountability should not stop at the district level or at the directorate level but must be applicable to the secretariat level and above.

    The progress report has clarified that the regulatory framework as proposed under the systemic management reforms would be applicable to the entire private sector, to ensure quality of care, rational interventions and medication, as well as safeguarding of patients’ rights and ethical practices. Here one would add that the regulation should not be thrust from above by bureaucratic means but it has to be participatory, multistakeholder. Even then given the socio-political culture in healthcare, such regulation is going to be a Herculean task.

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    Overall, given the various constraints, the HLEG has done a good job. India has one of the most heavily privatised and skewed healthcare systems in the world. Yet some people conceive UHC within the framework of such a system in which the government is primarily a purchaser of private healthcare providing a huge market for the corporate healthcare players. At the other extreme are people who wish away the fact that a majority of the qualified doctors are practising privately and the public sector does not have even onefourth of the doctors needed for UHC. It is heartening that the progress report steers clear of both these positions while keeping the focus on socialisation of healthcare. A more radical set of recommendations not backed by a commensurate churning in

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    -society at large would merely convert it into a yet another radical report gathering dust. Various inconsistencies and weak points in this report need to be corrected but it is equally important to build a stronger opinion in favour of UHC broadly on the lines formulated by the HLEG and in the background papers3 of the mfc’s national meet on UHC.

    Notes

    1 “Towards Universal Access to Health Care in India”, Concept Note for Medico Friend Circle, Annual Meet 2011, Abhay Shukla, Anant Phadke, Rakhal Gaitonde, Medico Friend Circle Bulletin, 342 to 344, August 2010-January 2011, pp 1-13, http://www.mfcindia.org/curissue.pdf

    2 “Financing the Universal Access Health Care System”, Ravi Duggal, MFC Bulletin, op cit, pp 19-23.

    3 http://www.mfcindia.org/main/bgpapers/bgpapers2011/am/bgpapers2011am.html.

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    May 21, 2011 vol xlvi no 21

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