Half –hearted at half-way: Missing political will for walking the talk in health care

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Midway through the tenure of the present union government, its commitment to the basic health care of common citizens, is grossly marked by its failure to walk the talk. Despite its ostensible policy measures such as adopting National Health Policy 2017 and enacting health rights related legislations, one cannot but miss the imprint of its overarching slogans – ‘ease of making business’ and ‘minimum government’ – in its faint political will to strengthen the health care system that is absolutely required to convert these policy talks into systemic mechanisms.

Policy Measures: The data of the fourth round of National Health and Family Survey – 4 (2015-16) released on March 1, 2017 points to improvements in some of the key and critical areas of population health outcomes. As a positive measure, during 2016=17, government initiated several policy measures of considerable significance to the health rights of citizens.

  • The National Health Policy 2017: The policy strikes a right chord with the aspirations of citizens with the goal of ‘attainment of the highest possible level of health and well-being for all’ and ‘universal access to good quality health care services without anyone having to face financial hardship as a consequence’. The pathway suggested for such an achievement is proposed to be by increasing access, improving quality and lowering the cost of healthcare delivery. Though the policy falls short of recognising right to health care as a fundamental human right, the components of universality is set as the goal of the policy.
  • Key Legislations: The Parliament passed four key health and marginalization related legislations during this year. These include Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) (Prevention and Control) Bill, 2017 which was passed on April 11, 2017, Mental Health Care Act 2017 and the Maternity Benefit (Amendment) Act 2017 which makes provision for commissioning mother (in surrogacy) and a mother adopting a baby below the age of three months to be eligible for maternity benefits Act 1961, and the Rights of Persons with Disabilities Act 2016. These are purported to address the issues concerning discrimination and access to care of the persons living with HIV/AIDS, persons with disabilities and persons with psychosocial disabilities. They fulfill the demands of key sections of the marginalized communities needing health care with dignity. Other policy initiatives include introduction of the Surrogacy (Regulation) Bill, 2016, and amendment made to the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 stipulating prescription of drugs in generic names.

A Failing System – The Unchanged Trajectory: NHFS – 4 was reluctantly commissioned by this government and with an undue delay. The improvements can be safely attributed to the overall efforts done in the last one decade to improve the public health system and includes primarily the National Rural Health Mission. For example, compared to NFHS 3 (2005-06), women receiving least four ante-natal care visits by health care professionals (51.2 percent) increased by 14 percent, institutional births (78.9 percent) increased by 40 percent. However, these national average figures vary substantially for the disaggregated categories of income, educational qualification and for rural-urban populations. In addition, they do not indicate any significant improvements for the poor and marginalized, who solely depend on the public health system for their health care needs.

The NITI Ayog which completely replaced the Planning Commission at the initiative of the current government has neither a priority nor any road map for health care of the citizens. Meanwhile, keeping in line with its philosophy, it has unceremoniously shelved the whole proposal for Universal Access to Health Care as a policy discourse in the country. Quite in contrast to its policy talk, the government on the other hand, is increasingly promoting privatization in health care, as a pill to the ills of health care as is evident from its reluctance to increase budgetary allocations, reluctance to enact regulatory provisions, to initiate systemic measures to protect patients’ rightsa, and notify under-the-carpet policies to disentitle the poor.

Low budgetary allocations: As pointed out by the National Health Accounts Estimates (2013-14), and as accepted by in the Situational Analysis for the NHP 2017, government spends merely 1.15% of GDP on health care which equates to 3.8% of general government expenditure and 8.6% of the total health expenditure. i.e. a paltry sum of Rs.1, 042 per capita expenditure on health care. The per capita government expenditure on health care, i.e. Rs.1042, is one of the lowest in the world. 2017-18 budget allocations also do not spell any ray of hope for all the policy measures as it remains abysmally low at 1.2% of GDP.

Enhanced emphasis on privatization: The continued emphasis on insurance, private sector engagement and a policy eco-system encouraging business in health – has been readily accepted in a document of the Government of India, which forms the background for NHP 2017. System strengthening has taken a back seat, and the drying coffers as well initiatives-to enhance the business of private health care industry are a major worry for the citizens. The National Health Accounts Estimates (2013-14) suggest that the out of pocket expenditure amounts to 72.9% At the same time, the government continues to rely on ‘insurance’ as the primary means of ‘assuring health’, which in turn indicates siphoning off government reserves to private business, instead of strengthening the health care system

Relegation of regulation of private health care establishments to the backburner: As the private health care provision has seen a gigantic expansion in the recent years, citizens have been demanding regulation of private health care industry. The Clinical Establishment Act 2010 (CEA) was one such intended measure by the earlier government which has remained a toothless tiger without notification of required rules. It requires notifying rules on standard treatment protocols and regulation of medical profession. In addition, other policy measures such as regulation of medical education, capping on drug pricing and bringing all essential life-saving medicines under Drug Price Control Order 1978 towards making drugs available and affordable to all citizens. However, no steps are being taken towards this.  Contrary to the sloganeering by the government, the ground reality seems to be ‘minimum governance and zero government’ in health, thus giving a free hand to the private-corporate health care sector

Disentitling conditionalities: During this year different conditionalities were levied on the poor, which disentitle them even of the existing health care provisions such as maternity benefits. Many states continued to bring in legislations making two child norm, adhaar card and bank accounts mandatory in addition to the existing documentary requirements of BPL card. The new labour Code on Social Security and Welfare disentitles all women with more than two children to the maternity benefits which were hitherto universal under the Maternity Benefits Act 1961. As a gift to the women at the completion of three years, the government has restricted this eligibility only to the first child, as per the notification by the ministry of women and child development.

Citizens Demand Universal Access to Health Care: Increased unemployment, agricultural distress, drought and migration, decreasing food sovereignty and access to food and nutrition have added to the woes of the rural and under-resourced communities, increasingly pushing them into the trap of diseases – health expenditure and debt. A disaggregated view of data in terms of state, region, urban/rural location and vulnerable community show enormous inequity in health outcomes and access to health care. Among other things, citizens aspire for a free and affordable access to health care of quality and treatment with dignity.

Even by conservative estimates, government should spend 3.5% of GDP in health care, with immediately increasing the health budget to 2.5% in the coming two years, with a plan to spend at least 65 percent of such budget on comprehensive primary health care. Immediate notification of rules of the CEA on Standard Treatment Protocols, standardisation of pricing of health care services, capping prices on medicines, bringing all essential and life-saving medicines under DPCO 1978 and complete free treatment to all citizens as an entitlement are the need of the hour. All conditionalities that disentitle citizens to any health care provisions such as two child norm, adhaar card, Below Poverty Line (BPL) documents and the like should be done away with making health care universally accessible to all. Contrary to its resounding slogans of minimum government, the test of government’s sincerity to citizens’ health and wellbeing, will be seen in its commitment to transform policy pronouncements into a robust health governance and a strengthened health system to deliver at least a universal primary health care to all citizens and protect patient rights by regulating private health care.