Tuesday, August 25, 2009

National Health Bill and Right to Healthcare

Dear Friends of mfc and phm
I have been closely reading the debate and find that we are all saying the same thing but in different ways. Colin is using the legal lens, Abhay the universal access lens etc..
I find the Health Bill very complex and complicated and full of legalities. I would prefer a health rights bill which is simple like the Health Canada Act which spells out the basic principles and mandates the rights. The details are taken care of separately through various other mechanisms.
The public sector-private sector dichotomy is the key issue to sort out when we univresalise healthcare access. Thailand is the most recent example having done this successfully. Pooled public financing is the key tool to control the health sector. Three-fourths of the population will have to be completely supported directly by state agencies without any expectation of contributions. The rest will contribute through their employment or business and over time the proportion of contributors would increase with economic development. The national government needs to create a public agency by law which will have the authority to pool all resources for the health sector from government, employers, individuals in the contributory group, social insurance funds etc.. and then this agency will have to purchase health care from all providers whether public or private within the framework of rules and regulations governing the nature, character, quality and quantity of services to be provided. This is the only way in which any universal access healthcare suystem operates in the world. The only exceptions are countries where healthcare is a near state monopoly like Cuba, Sweden, etc.. Given the largest private health sector that India has the Cuban or Swedish models are not feasible for India. The Thai and Brazil models which are more recent and emerge from a political economy closer to India's are more realistic options for India to emulate. Structurally Brazil being a federation may have more learnings for India but Thailand has managed the private sector better. The private sector in India is much larger than any country in the world, unregulated, unethical and unwilling to be part of public domain and joins PPPs only when they can milk the state - that is the unfortunate character of the Indian bourgeosie whether a small time bania, a doctor or an Ambani.
Thus the task in India for universal access to healthcare is not going to be as simple or easy. The other problem is the middle class. The moment we have some money we debunk the public sector and shift to the private sector. Mumbai city is a classical example. Until mid eighties the public health facilities run by BMC and govt in Mumbai were very robust and many of us used them. As late as 1989 my daughter was born in a public hospital. The middle classes were the voice and the poor benefited from that voice. The schools of BMC met the same fate. In the eighties with grant-in-aid institutions being set up, the middle classes migrated to the private schools and the BMC schools lost their voice. Fortunately the public transport system has survived because all classes use them - this is thanks to there being not enough roads to accomodate private vehicles - the many flyovers being constructed are taking us into that direction! Let us look within and ask how many of us use the public health system when we fall ill or send our children to government schools?
This brings me to the point of existence of dual systems, one for the poor (read public) and one for the rich (read private). This way we will never get to universal access. Universal access means the existence of a single system that is managed and control by a multistakeholder public agency who conrols it through their power of being a single-payer of services. Provision of services can be by a public or private provider as may be organised under that system. All people whether rich or poor or any other vulnerable category have the right to access any facility mandated under the organised and regulated system, whether public or private and access services without making any direct payment. There are generally two types of organised mandates, one like the UK NHS where families are assigned to local GPs paid using capitation who provide primary care and are gatekeepers for referral and higher levels of care or the portable Canadian system which allows open access to ay provider who are paid on fee-for-services basis.
We already have a public network of primary care, secondary care and tertiuary care facilities and we need to build around them by infusing human resources from the private sector by using one of the above systems of payment through an organised mechanism. Getting doctors and nurses is a genuine problem for the public health facilities and therefore we need to think out of the box and find ways of getting providers to work with the public health system.
We need to intensify this debate and get govt also to respond to this. I recently wrote a critique of the NRHM budget in the EPW of August 15 2009 and it was called Sinking Flagships and Health Budget. Our friend in the ministry Amarjeet Sinha promptly responded saying that he was going to respond to my provocative article. Thats good news and we must thus take the present debate also to them.

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