More Than A Bitter Pill

Universal health coverage (UHC), which aims to ensure that all people receive proper and adequate healthcare without suffering financial hardship, is an integral part of achieving the UN-mandated Sustainable Development Goals (SDG). It enables countries to make the most of their strongest asset: Human capital. Physical and mental well-being is at the core of creating communities that thrive. Health is, therefore, a foundational investment in human capital and in economic growth — without good health, children are unable to go to school and adults are unable to go to work.

India’s economy is soaring and is now the world’s envy but its healthcare system remains an Achilles’ heel. For millions of people, the high costs of treatment continue to undermine economic progress. This is largely on account of the country’s dilapidated healthcare system — a major symptom of the dire lack of funding. India ranks poorly in international rankings on most health indices. According to a recent study published in the British Medical Journal, 54 per cent of health professionals in India, including doctors, nurses, paramedics and midwives, do not have proper qualifications; while 20 per cent of adequately qualified doctors are not part of the current workforce. Despite being the world’s sixth largest economy, India’s public health spending has languished at under 1.5 per cent of the GDP — one of the lowest in the world. In comparison, the UK spent 9.6 per cent of its GDP in 2017 on health and the US spends 18 per cent of the GDP.

Another point to be noted here is that the growth of healthcare facilities has been concentrated in the private sector even as the Governmental hospitals continue to be under-resourced, understaffed and poorly managed, thus delivering poor quality of care. This has led to a rapid mushrooming of unregulated private providers, which today account for 93 per cent of all hospitals — up from eight per cent in 1947. Private facilities also account for 64 per cent of all beds and employ 85 per cent of all doctors in the country. This contributes to the ever-widening gap in access to healthcare between rich and poor communities in India. Out-of-Pocket (OOP) expenditure on healthcare in India — personal spending — contributes to approximately 86 per cent of private expenditure and 60 per cent of overall healthcare expenditure in the country and is much more than the rates in countries like Thailand (25 per cent) and China (44 per cent).

Other indices of healthcare are also alarming — 63 million people are pushed into poverty due to healthcare expenses. Additionally, hospital bed density is merely 0.9 per 1,000 people, while the minimum advocated by the World Health Organisation (WHO) is 3.5 beds per 1,000 people. According to the international consultancy, KPMG, there is one Government doctor for every 10,189 people; one hospital bed for every 2,046 people; and one Government-run hospital for every 90,343 people. These are certainly mind-numbing figures.

Healthcare expenses are a major cause of impoverishment for working families. Private healthcare has catastrophic costs that shave off hard-earned savings of patients and their families, thereby becoming a primary route to bankruptcy. All these have spillover consequences for families, resulting in less money available to households for food, education, housing and long-term plans. A health event is a bigger risk to farmers than an unsuccessful crop. Once they sell their land or livestock, they become indentured labourers and that takes a generation to fix. The effects of poor health on workforce productivity are well documented, too. Indians work for just six-and-a-half years at peak productivity (compared to 20 years in China, 16 in Brazil and 13 in Sri Lanka), ranking 158th out of 195 countries in an International Ranking of Human Capital.

Health insurance is emerging as an important financing tool in meeting the healthcare needs of the poor. Life is a tough ordeal for families hit by “health shocks.” Poor families have long suffered the triple curse of sudden illness — the trauma associated with sickness, financial burden of intensive healthcare and the loss of wages. By managing risks and avoiding debt, those who have micro-insurance policies, are in a position to protect the meagre wealth they accumulate, generate more income and even get a fair chance to rescue themselves and their families out of the mire of poverty.

The poor prefer health insurance to life insurance, as they say, “We die once but go to the doctor many times each year.” By hedging life’s uncertainties, they are in a position to protect the wealth they accumulate, generate more income and can even get a fair chance to rescue themselves and their families out of the mire of poverty.

Community-based health insurance, rather than market-mediated or Government-provided insurance is widely considered an appropriate way of reaching and protecting the poor. The development of private health insurance has potential risks and benefits in terms of healthcare access for the poor. It could result in substantial long-term welfare benefits but it is unaffordable for most low-income families.

One of the flagship programmes of the NDA government, the Ayushman Bharat, a Pradhan Mantri Jan Arogya Yojana (PM-JAY), has committed to achieving UHC for all citizens. The policy is certainly a game changer. With a client base of over 400 lakh, of which 96 per cent are female, the microfinance sector is best placed to offer health insurance. Microfinance already caters to a substantial segment of the target population that desperately requires access to affordable healthcare.

In the last few years, the microfinance industry has been in the forefront of creating innovative insurance products for the underserved, which complemented the Government’s pension platform. The synergy between the sector and Government can help ensure that everyone has the rights and access to improved health outcomes.

India must revitalise its public health system to ensure access, outcome, quality and affordability. Focus must be on finding solutions which are affordable, scalable and yet of a high quality. The Government needs to supplement curative services with preventive measures by strengthening ancillary civic services like insect management, water purification systems, sewage systems and plants for treatment of industrial effluents and waste. Due to poor hygiene and sanitation, people are suffering from pneumonia, malnutrition, malaria and tuberculosis.

The biggest disease burden sits on the bottom pyramid of 500 million people. They don’t have access to reliable diagnosis or proper treatment. If they get diagnosed, they find it hard to get treatment. Government-run hospitals are free for everyone but access is difficult, quality is abysmal and corruption is endemic. Another challenge for the health sector is the lack of provisions to deal with non-communicable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes.

Unlike the short-term effects of communicable diseases, the dual health and economic impacts of non-communicable diseases on individuals, families and households are devastating and long-lasting. It is estimated that India is likely to lose $4.58 trillion before 2030 due to NCDs as a Government-run healthcare system focusses only on maternal and child care, especially at the rural level. This would mean providing a clean environment and potable water so that infectious diseases are contained to the minimum and a stress-free and healthy lifestyle is promoted to ward off the growing threat of non-communicable diseases.

We need a National Medical Service under the National Health Mission that can have a national pool of doctors, who can be distributed across States to correct unevenness of the quality of medical services in different regions. Pooled public procurement and strategic purchasing of equipment and medical supplies will save costs and help attain efficiency, thereby promoting quality controlled health services. Sharing of best practices can help tone up the deficient regions. The flow of talent through this national medical cadre will bring about more balanced development of health services at the national level.

(The writer is Member, NITI Aayog’s National Committee on Financial Literacy and Inclusion for Women) – Daily Pioneer

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