Saturday, September 12, 2009

UPA's Public Health Performance

UPA’s all flagship programs are under stress. During their previous tenure the UPA formulated their strategy and had 3 to 4 years for the various flagships to build their foundation. But we see that success has eluded them, especially in the social sector arena of health, education and welfare. The National Rural Health Mission attempted to do what the Minimum Needs Program did way back in the eighties. The MNP succeeded in creating the rural health infrastructure – the PHCs and subcentres - as per the 1981 National Health Policy to support the goal of Health For All by 2000 AD. This even pushed the public health spending upto 1.6% of GDP, the highest ever for the country. While the physical infrastructure was in place, the human resources, medicines, equipment etc were far from adequate and failed the strategy. And then we were subjected to SAP and the macroeconomics that followed spelled disaster for the social sectors, halving the public health spending from the MNP peak to a mere 0.8% of GDP. To stem this collapse of the public health system the NRHM was launched with a target of pushing public health spending to 2 to 3 percent of the GDP by making architectural corrections.

At the end of their first tenure the UPA managed to take public health spending barely to 1 percent of GDP, no where close to their target. The rural public health system continued to suffer from the same malaise as earlier – not enough doctors and nurses, inadequate medicine supplies, poor maintenance etc. What was worse is that the reasonably robust urban public health system also began to collapse with rapid private sector growth and expansion, including the support of private health insurance. Thus the inadequate public investment in health during the previous UPA regime actually led to the boom of private healthcare which had now jumped to 5.5% of GDP. Since private insurance covers barely 2% of the population, most of this expenditure is out-of-pocket indicating a huge burden on households who often had to sell assets or take loans for their hospitalization needs. Thus the UPA government failed to make any significant impact in the public health domain.

The failure is both political and bureaucratic because there is a complete lack of political will to push radical reforms or the architectural changes the NRHM strategy document talked about as well as the inadequate capacity of the bureaucracy to facilitate the structural changes. During the period of the UPA regime we saw in Thailand a major transformation where social insurance and increased public financing catapulted Thailand to the status of a universal access country assuring equitable access to basic healthcare for all. If Thailand could do it given a very similar historical trajectory to that of India then why can’t UPA facilitate the same for India? The answer lies in viewing the entire health system, both public and private, as a single system and creating a regulatory mechanism and a financing strategy of a single-payer instrument and to accommodate that under a single umbrella. Well the first 100 days of the second UPA regime does not show any inclination towards that end. Hence civil society has a long struggle to get the UPA on track to achieve the goals of universal access to basic healthcare.