By Dr S Saraswathi
(Former Director, ICSSR, New Delhi)
The World Bank and the World Health Organisation have released a joint report “Tracking Universal Health Coverage: 2017 Global Monitoring Report” which exposes the abominable state of healthcare facilities in many countries including India. As health like education is a vital parameter for sustainable development anywhere at any time, the report demands serious consideration and immediate remedial action.
This report is focused on health spending and accessibility of health services — two major problems that drain the resources of the middle and lower income groups. Healthcare is a luxury for common people in India who go to doctors only when they are very sick and incur enormous expenditure and debts. WHO reports have been showing India as the worst performing region in health services after Africa.
Goal No.3 of the Sustainable Development Goals focuses on ensuring healthy lives and promoting well-being for all. Specific targets set in 3.8 are achieving universal health coverage (UHC) including financial risk protection, access to good quality essential health services, and to safe, effective, and affordable essential medicines and vaccines for all.
UHC — recognised by the World Health Assembly as a key imperative for all nations to consolidate public health advances achieved so far — has been accepted by many countries. It means availability of health services including public health services to all people without heavy financial hardships. Indeed, it is an essential investment for economic growth. But, conditions in India are such that an idea as this seems a day dream as healthcare remains a low priority matter in public spending.
Two indicators are set for UHC, namely, coverage of health services, and proportion of health expenditure. This report states that at least half of world’s population cannot obtain essential health services and every year about 100 million people are being pushed into poverty because of heavy expenditure on healthcare described in the report as “catastrophic” spending.
The report reveals that currently 800 million people spend at least 10 per cent of their household budgets on health expenses for themselves and their family. In India, about 17 per cent of households spend more than 10 per cent of household total income, and about nearly one-quarter of the population spend more than one-quarter of household income for health care.
Among BRICS countries, Russia has a predominantly State-funded healthcare system. Expenditure being considered the central point of UHC, the report places Africa and Asia at the lowest level with people impoverished under medical expenses.
Healthcare is a State subject under the Indian Constitution. The expenditure of State governments on the whole is much less than that of the people, but varies substantially between the States. Bihar, Jharkhand, Andhra Pradesh, and Uttar Pradesh governments report lowest health expenditure that is less than Rs.600 per capita per year and at the top is Himachal Pradesh showing over Rs. 2,000. Uttarakhand, Kerala, Jammu & Kashmir, Gujarat, Tamil Nadu, and Telangana governments show an expenditure of over Rs. 1,000 per capita and other States between Rs.500 and Rs.1,000.
However, per capita total expenditure on healthcare has been rising in India, but due more to increase in private expenditure than public. National Health Profile confirms steady rise in private expenditure on health for many years exceeding three to four times the amount of public expenditure.
Noteworthy is the enormous private spending in Kerala and Punjab compared to government health spending. In Andhra Pradesh, private expenditure is very near 80 per cent of total health spending. Health policies of the State governments and availability of professional services vary between States.
The National Health Policy 2017 envisages raising public health expenditure in the country from 1.4 per cent to 2.5 per cent with more than two-thirds of this going to primary healthcare. Diagnostics, drugs, emergency and essential care services in all public hospitals free of cost, and bigger role for PHCs, are envisaged.
A robust health accountancy system will be put into effect to improve public sector efficiency in resource allocation/payments. The principle of equity will inform healthcare by taking into consideration differential financial ability and healthcare needs by districts, and by targeting specific sub-groups and geographical areas to ensure equity.
The Supreme Court, on the basis of international instruments, inferred health as a fundamental right 25 year ago and in 1995 stated that right to health was an “integral fact of a meaningful right to life”. Next year, it declared that it was the primary duty of a welfare State to ensure that medical facilities were adequate and failure to fulfil its obligation would violate fundamental rights. Thus, India had always been in the forefront to acknowledge the importance of healthcare orally and in writing, while remaining in the backyard in taking effective action in the field.
Bulk of public health expenditure goes to wages and salaries and not to medical services. A year back, a study of State health accounts showed that payment to medical personnel in the total public expenditure on health amounted to 86 per cent in Punjab, 72 per cent in Maharashtra, 65 per cent in Kerala, and 52.5 per cent in Madhya Pradesh. Still, there are only grievances leading to strikes over financial aspects of medical professionals.
Healthcare seems to have lost its character as a service and has assumed the role of a business. Result is growing malpractices in the medical profession. A few days back, the Income Tax department uncovered a multi-crore scam involving doctor referral fees in a number of medical establishments in Bangalore. Enormous cash, jewels, and foreign currency accumulated as “referral commission” were recovered in raids by the department. Doctor-laboratories nexus is believed to be flourishing in all States compelling patients to undergo wanted and unwanted tests periodically for diagnosis and treatment, and to find out patient reaction. Poor and illiterate patients cannot even distinguish tests and treatment.
Organ replacement and organ donation has become a big racket ever since organ transplantation has become a medical possibility. Sex determination clinics are started even in remote villages where there is no proper health centre.
Correspondingly medical colleges have become commercial enterprises run on exorbitant capitation fees, erratic selection system, and a practice of extracting enormous donations for admission.
Despite commercialism dominating medical education and hospital management, there is dearth of medical and paramedical professionals in the country. Doctors are overworked and patients are required to share beds in emergencies — a situation far removed from the core principles of UHC.
The National Health Policy 2017 has delineated several key principles of health care like professionalism, integrity, ethics, equity, affordability, universality, accountability, quality care, etc., which are salient features of UHC. The stated objective is also to achieve universal health coverage.
Good professional conduct is a must for doctors and other medical professionals. But, if run on business lines devoid of imparting professional ethics as the first principle, medical education is not likely to infuse humaneness in doctors and managers and administrators of medical institutions.
Indeed, professionalism and professional ethics are required in all fields not just medicine. It means that our entire educational system must be based on certain basic values. — INFA