India's right to health-Nitin Desai
-The Business Standard
This is the season for party manifestos with their vague and quite unexciting promises. But in this sea of platitudes, sometimes something stands out that is worth talking about, because, if implemented, it would be a game-changer. For me this is the reported inclusion of the right to health in the Congress party's manifesto.
It is well known that health status in India is below what can be expected at our level of income. It is a matter of shame that, globally, India accounts for one-third of the deaths of pregnant women and about a quarter of child deaths. Child mortality has declined, but our infant mortality rate, at 56 per 1,000, is significantly higher than that for Bangladesh, a much poorer country.
The government has a plethora of schemes to promote better health. However, the reality is that most health care in India is privately funded. In the aggregate, India spends 4.1 per cent of its gross domestic product (GDP) on health care. But, according to a study by the National Institute of Public Finance and Policy, public expenditure on health care is 1.5 per cent if we include water supply and sanitation, 1.1 per cent if we exclude it, and even less than that if we exclude the health care expenditure of departmental enterprises such as the Indian Railways and defence.
This is what has to change to at least three per cent of GDP so that effective and affordable universal coverage and health insurance can be provided to all Indians.
The impact of such an intervention on poverty levels could be substantial. Catastrophic health expenditures (CHE) that exceed 40 per cent of non-subsistence consumption or 10 per cent of total consumption expenditure are a major - possibly the principal - source of vulnerability for families near or below the poverty line. According to a recent World Health Organisation (WHO) survey, out-of-pocket health expenditures amounted to an average of 10 per cent of total household expenditure and 22 per cent of non-subsistence spending in India. Almost 24 per cent of households spent either equal to or more than their capacity to pay (non-subsistence spending) on health care services; consequently, they had to forego their basic subsistence consumption. This proportion is 35 per cent among poor households. These numbers do not include the cost of travelling to urban areas for health care or the loss of earnings. If one looks at the composition of expenditure, 60 to 70 per cent is spent on medicines and a little over 20 per cent on in-patient or out-patient services.
The stress on a family's standard of living is most acute when a major illness strikes a family member. A survey in Kerala of heart-attack patients showed that 84 per cent faced catastrophic health expenditures. The coping strategies included loans and dipping into savings. But, according to the study, in order to cope, children discontinued their education, got transferred from private schools to free government schools and families moved out of expensive rental accommodation to cheaper ones - or even moved in with willing relatives to cut expenditure.
Clearly, a safety net is required, and the public sector has to step in not just as a payer of costs but also as a provider. But the reason for public intervention as payer or provider must be clearly articulated.
The case for public intervention when there are large externalities, as with water, sanitation, waste management or disease vector control, are obvious and must be supported through the budgets of the local authorities that have primary responsibility for this. A closely related area is the control of communicable diseases such as tuberculosis and HIV/AIDS. The case for pubic intervention here is also the benefit to society at large of a reduction in the pool of infection.
The case for public intervention in mother and child care is that it is a very cost-effective way of reducing future burdens on the health system. One could also argue that a healthy childhood has major benefits in other areas like education. Many of the interventions here, such as immunisation, also have external benefits in the form of reduced pools of infection.
Effective public delivery systems in these three areas will help greatly in reducing the burden of illness in poor families who are more exposed to poor environmental conditions, more vulnerable to infection and are least likely to seek or afford the interventions required during pregnancy and early childhood.
That brings us to the protection required when a family is affected by some non-communicable disease or a severe accident. The answer here lies in a combination of public provision and health insurance to allow people to pay for private health care. Public provision through health centres is required because the private sector will not deliver health services in remote or impoverished areas. However, in many areas, the private sector exists, and access to its services can be improved through a system of universal health insurance. The role of the government here would be to set standards, negotiate fair rates with providers and subsidise the cost of insurance for poor households.
One should proceed carefully with insurance, since the scope for malfeasance is large when such a huge proportion of expenditure is on medicines and out-patient services. Perhaps one can begin with insurance that covers hospitalisation, and also hospital and domiciliary treatment for serious illnesses whose cost of treatment is high enough to threaten living standards of the median household. The system can be gradually extended by folding in existing schemes such as the Central Government Health Scheme and by encouraging other employers to do the same.
Universal and affordable access to quality health care will require many more doctors and nurses and a willingness to serve in remote and impoverished areas. India has around 2.5 million doctors, dentists and nurses - which is below the WHO's critical level of 2.28 per 1,000. Over the past 20 years, most of the expansion in medical education has taken place in the private sector, which accounts for two-thirds of the new medical colleges and almost all dental colleges. They charge high fees and often take substantial capitation fees. Those who pay these fees will not work in public facilities. Perhaps the answer may lie in scholarships tied to a period of service in the public sector.
The right to health is fundamental, since it enables an individual to enjoy all the other rights - for example, education, employment and so on. That is why, if implemented, it can be a game-changer.