PUBLIC GOOD: Healthcare reforms being delayed

K Yatish Rajawat

healthThe most important piece of reform that is being delayed is healthcare. The cost and quality of healthcare just does not attract media as isolated incidents of violence do. While violence leads to loss of life, poor healthcare has much higher human cost. Not only does poor healthcare leads to loss of life, it also destroys families of the patients.

Government data claims that more than 63 million people have been driven into poverty due to the high cost of healthcare. This happens because there are no controls over costs in healthcare. Somehow, the Ministry of Health and Family Welfare also seems to be totally unconcerned about the problem.

Health Minister Jagat Prakash Nadda seems to be ignoring the elephant in the room in the form of high costs. It is unfortunate but the health ministry has never got an attention by successive governments as it has been typically a low priority ministry. Health is not equated to home, finance or even Railways, though it has a much higher impact than any of these.

Since healthcare is a state subject it is not taken seriously at the central level. The administrative structure for implementation of policies is also very warped up. As a result the government cannot really regulate the sector properly. World over the federal or central government regulates healthcare and it is considered the most important area for reforms.

Take the moribund and shrouded in corruption body Medical Council India, not very different from Board of Cricket Control of India. Senior officials, including chairman MCI have been accused of corruption in giving clearance for medical colleges. Nothing much has come out of these charges and the toothless but important regulatory body stumbles along. Medical negligence by doctors is one of the areas, presumably under the Medical Council of India, but over the years it has never exercised this power.

The lack of government initiative in this area is strange more so because an omnibus policy has been developed by the MoHW. The draft National Healthcare Policy (NHP) 2015 is been doing the rounds for some time now. Though, the policy has very wide ramifications, it has not yet caught the eyes of politicians busy with Bihar elections and sniping at each other on the lynching crisis.
NHP 2015 breaks down the divide between the urban and rural healthcare services. These are two different buckets and most of the government expenditure has gone into building a network for the rural areas. UPA-2 announced a National Urban Health Mission in 2013 but did not allocate funds for it.

Broadly, NHP covers the following areas:

1. NHP 2015 focuses on the cost of care and financial protection makes it one of the core pillars. It effectively shifts the issue from just availability to what is the cost of it and affordability. Eighty per cent of the healthcare services are in private hands. And there has been no control over pricing or quality. NHP 2015 addresses the issue of quality directly and tries to deal with pricing.

2. NHP2015 sets an ambitious target of healthcare expenditure at 2.5 per cent of the GDP. Thus it is trying to balance the control of the private sector. Currently the healthcare expenditure is just 1.04 per cent of GDP. This is still lower than several developing countries including Thailand and Brazil but it is still important that the target is double of the current expenditure

3. Cost of care or affordable healthcare: It envisages using both private and public healthcare service provider to give this. A healthcare card for every family, without any discrimination based on income. This is an interesting shift as it is not only the poor who will get the healthcare card but every Indian citizen. The card is almost like a right to access affordable healthcare.

4. A network of healthcare service provider is to be established. The lowest rung made up of healthcare and wellness centers. The current Asha network is expected to be supported, replicated in urban areas with preventive healthcare centers.

5. NHP 2015 plans a shift from free healthcare to prepaid care. The concept being that the population will pay for this healthcare in the form of healthcare cess that will be levied like the education cess. A portion of the excise on cigarettes and liquor will also be converted to healthcare cess. This shift means that the citizens are already paying for the availability of healthcare. Therefore they should be provided universal access to free drugs and diagnostics.

6. NHP 2015 acknowledges that it is not possible to provide healthcare services through the public hospital facilities. Therefore, purchasing healthcare services from the private sector will be a crucial component of the universal access. This already exists in different form under ECHS and other services for government officials both retired and serving. NHP 2015 is extending this model for all citizens and this is the most ambitious part of the policy. As the policy framework does not lay down any budgetary estimates specifically for such a wide ranging option.

7. Quality of healthcare services varies widely as there is no regulatory control over them. All standards especially quality standards are voluntary in nature. NHP 2015 does not address this issue fully. It says that the standards set by NABH and NABL, both industry owned bodies, will be made mandatory and leaves it at that. It talks about incentives for following standards but does not put down a regulatory structure to manage, control and ensure a consistency of quality across healthcare service providers.

8. NHP 2015 acknowledges the corporatization of healthcare in India and sees the trend growing much faster in coming times. It sees the private healthcare sector growing seven times from $40 billion to $ 280 billion over the next five years. A lot of venture capital and private equity fund is moving into healthcare opportunity in India. The growth is expected to go from 14% to 21% over the next decade NHP wants to leverage the for-profit model of healthcare service providers as part of the universal healthcare access. With such a large growth expected in healthcare services both quality, cost and availability has to be regulated. This is the area that NHP 2015 fails to adequately address.

9. NHP draft talks about the nexus of insurance companies and hospitals that have been milking government healthcare schemes. But it does not suggest solutions to prevent it fully especially with universal healthcare being another massive insurance scheme buying services from private healthcare.

While the draft policy is ambitious and grand in its vision, it has been gathering dust for the last nine months. The reason it may be gathering dust is that the powerful corporate healthcare lobby is not interested in bringing such drastic and dramatic changes.

K Yatish Rajawat is a columnist and policy commentator based in New Delhi, he tweets @yatishrajawat