What ails health-for-all scheme?

Bharat Dogra

Freelance journalist

IF government claims are to be believed, then India is on the verge of big achievements in the areas of health and nutrition. Unfortunately, these claims are unlikely to be realised because of two reasons. Firstly the claims are not backed by the necessary commitments of public investment which remain at low levels in health and nutrition. Secondly, this pushes towards over-dependence on the private sector. But the high-profit orientation of the private sector and its tendency to use even limited public investments to fill its coffers makes it even less likely that the objective of health for all will be realised under the policy regime.  

According to the National Health Policy 2017, the public health expenditure should be around 2.5 per cent of the GDP, with the Union Government contributing about 40 per cent of this. This should be taken as a minimum as the actual need is significantly higher. By this norm, the government should be spending at least 1 per cent of the GDP on health. However, the reality is that this has been stagnating at around just 0.3 per cent in recent years. Without making the overall threefold increase that is needed as a minimum, the government goes on making more and more ambitious announcements.

The union budget this year has made more grand announcements than ever before but the resource position remains extremely weak. And, incredibly, compared to the revised estimate of the previous year, the National Health Mission has declined by about 2 per cent.

 The decline in the critical reproductive and child health component of the mission has been to the extent of 33 per cent. The scheme for helping mothers and newborn children, called the Pradhan Mantri Matra Vandana Yojana, has also seen a cut compared to the revised estimate for the previous year. Also, its coverage as well as benefits have been reduced, compared to the original plan.

The establishment of 24 new medical colleges by upgrading district hospitals has been announced, but the allocation for this sub-head has been reduced to Rs 2,888 crore compared to the previous year's revised estimate of Rs 3,300 crore.

The Pradhan Mantri Jan Aushadhi Scheme for improving the availability of low-priced generic medicines had targeted opening 3,000 centres. But only 850 could be opened. And this year, an additional target of 1000 centres was made, but the budget increased by only Rs 9 crore compared to the previous year.

In the case of nutrition, with a revision of the cost norms of the Supplementary Nutrition Programme, a big increase in the budget for this needed but this has not been provided in the Union Budget. The time-bound targets of the National Nutrition Mission are laudable but these are not backed by the necessary resources. 

The absence of a specific allocation for the National Health Protection Scheme of providing health insurance benefits to 50 crore people announced in the Budget has been widely commented upon. The scheme that comes closest to it is the Rashtriya Swasthya Bima Scheme, which has had a curious trajectory of appearing under different names in different ministries. While the government has been working overtime to work out its details and finances, the Health Ministry was caught unprepared by the ambitious announcement. This shows that only a hurriedly cobbled framework can emerge at this late stage, not a well-planned scheme before such a huge commitment is made.

Besides, the very desirability of devoting a large share of very limited public resources to an insurance based health model is questionable. Especially at a time when the rural health infrastructure remains highly understaffed and deprived of several essential facilities. In Community Health Centres, there is shortage of specialists to the extent of 82 per cent.

Will such critical shortages and challenges be ignored in the push towards the insurance-led model, even though it has been experienced that in this model sector, the private sector extracts excessive profits while patients do not get expected benefits? 

The high-profit orientation of the private sector has been worsening, with shocking cases reported almost daily. The medicine sector remains dominated by similar trends.

 This combination of low public investment and high-profit orientation of the  private sector (starting from medical education) is a huge obstacle in the path of realising the objective of health for all.