By Shivaji Sarkar
Health has remained an issue for decades. Out-of-pocket expenses, the euphemism for increasing individual spending on seeking health assistance is eroding incomes. Public health care unfortunately has remained in unenviable state.
Amidst this the NITI Ayog (NY) has pitched for public private partnership (PPP) model to improve health services in the country against the back drop of dismal performance of public hospitals at district level. In other words, it suggests virtual handing over the district hospitals built by State governments to private sector for 30 years, two generations!
District hospitals just after primary health centres are health spots. Despite the State governments spending, hospital services have not improved the way these should. The high population, despite its dividend in some areas, is a deficit in health. Infrastructure is over-burdened and India faces the twin epidemic of continuing and emerging infectious diseases as well as chronic degenerative diseases.
Economic deprivation in a large segment of population results in poor access to health care. Unwary of facilities there is high non-utilisation of scanty health services and increase in avoidable risk factors. India faces high burden of disease because of lack of environmental sanitation and safe drinking water, under-nutrition, poor living conditions, and limited access to preventive and curative health services.
Expenditure on health by the Government continues to be low. It is not viewed as an investment but rather as a dead loss. States under financial constraints cut health budgets. Growth in national income by itself is not enough, if the benefits do not manifest themselves in the form of more food, better access to health and education.
The NY’s prescription for handing over even the rudimentary public services to the private sector is apparently a desperate move. It is based on the premise that the State is unable to invest and there has to be a system even at public cost. The NY possibly has not taken into account that private sector involvement adds to the cost of delivery and further burdens the people with additional expenses draining their resources.
In the mid-1990s, the Planning Commission came out with a view that any services being availed by an individual from government departments was to be considered an income. This was a move to bring down the number of people below poverty line. It might have improved the statistics or not but it certainly did not help conceal the reality.
The nation thus has been reinventing the wheel for a long time. In between the rise of the insurance industry has led to another situation. Those having medi-claims are billed too high against the normal costs. The Rashtriya Swasthya Bima Yojana (RSBM) has helped the poor to an extent but it has not been able to make the health care universal.
The malaise of the sector is deep and complex. The pharmaceutical industry, it has become obvious, has been fleecing the people. The way public and NDA government’s moves brought down the prices of several drugs and equipment, including heart stents and other overpriced medical aid, is a testimony that the industry is more interested in its profits than the welfare of the people. This is a global trend. In the US, the industry is acting against the Obamacare.
Thus opening up public district hospitals to the private industry would change the shape of health care is a bit over-expectation. In many cases, where such liaison was tried to be established, it was found not only in India but elsewhere that it ended up in benefitting the private sector and the costs to the care-seekers increased manifold.
Thus despite possible good intention, the NY apparently has given a quick draft to solve the deep-rooted problem, which is how to raise the finances for this critically important sector. Any ailment leads to losses to the suffering people — the high costs of treatment and wage loss.
The sector needs large funding. According to the Union Budget 2017, the allocation for Health Ministry for 2017-18 is Rs 47,352.51 crore in comparison to allocation in 2016-17 of Rs 37,061.55 crore, an increase of 27.76 per cent from previous year. The revised allocation for 2016-17 was Rs 38,343.33 crore. But this was above the 20 per cent cut in budgetary allocation in 2014-15 due to fiscal strains.
States also add to this. But it is too inadequate for the 125 crore people. Compared to even the road sector the allocations are too little. In 2015-16, expenses for the road sector were from Central Road Fund (CRF) collections of Rs 69,809 crore in 2015-16 and Rs 54787.21 crore from 2012 to 2015. The CAG noted burdening users of Rs 28361 crore while providing benefits to private parties by fixing a longer concession period.
The CAG said the NHAI failed to fulfill the role assigned to it by the government and provided undue benefits to three large corporate. That is the crux. The benefits in a PPP model go to the so-called service providers. Health is too delicate a sector. The NY’s proposal to link it to PPP is fraught with danger. The leakages are likely to be large and benefits negligible.
India has an abysmal doctor-patient ratio. Regulation of medical colleges emphasises more on curbs in supply than on ensuring that doctors with a licence to practice are of a minimum quality. Such irrational restrictions need to go. Unless India produces more doctors, whether for the public or private sector, healthcare delivery will not improve.
The NY draft is faulted for another reason. It has not done the study at the ground level. Before coming out with the draft, it should have studied the conditions and done surveys in 100 districts having hospitals and primary health centres (PHC). The people should have been asked about their needs, problems and expectations. The number of users at any government hospital is high and so is the workload on the skeletal medical staff, even at medical colleges set up in remote districts of UP, including the VIP district of Kannauj.
The NY should not suggest simplistic solutions. It needs to redo a holistic study on the health system all over the country. Different States have different experiences and needs. The model has to be State specific and not omnibus. No way can it be a PPP model to burden the users. —INFA