Friday, April 2, 2010

Is India Getting Serious about Universal Access to Healthcare? by Ravi Duggal


The Assam Government is riding high on its Public Health Act which seeks to provide some guarantees to access healthcare as a right to its citizens. We have seen newspaper reports and press releases but where is the Bill or now Act. It does not seem to be there in public domain so we don’t know the details. What we know that there is a guarantee to access health care in public and private hospitals in an emergency for 24 hours. What does this guarantee mean and how will it be supported financially? Further, is this really new? Not at all. The Supreme Court provided this guarantee  many years back in its judgment which was categorical that on the basis of right to life no one can be denied healthcare in a public or private hospital which caters to emergency services wherein it was the responsibility for the receiving hospital to provide first aid and stabilize the patient and then refer them to an appropriate institution where they could afford healthcare.


Apart from this there are other announcements about daily payments to patients if the hospital does not provide drugs etc.. Well all this sounds nice and definitely steps forward but we don’t hear anything about its sustainability, financing, budgets, organizational structures to manage it, regulatory norms, legal accountability. A newspaper report says that the health department will be empowered to fix responsibility and accountability. Is this some sort of a cruel joke? How can the health department which will be responsible for this implementation or service provision be the body to assure accountability? Accountability bodies are independent of the implementation like IRDA and SEBI – neither IRDA provides insurance nor SEBI does trading.


While one acknowledges and welcomes the creation of this law, whatever its details, as a good first step, the critical question that is unanswered is what is the infrastructure in Assam to deal with a right to health guarantee? What are its finances and budgets to make this happen? Has a costing been done? No where in the world has universal access to reasonable healthcare been provided with less than 3% of GDP – most often it is closer to 5% of GDP as a requirement. So how is Assam placed on this front? These are the hard questions to answer. And haven’t we learned from the past fiasco of Assam afew years back when they paid a hefty premium of over Rs. 25 crores to ICICI to insure all its citizens and not more than 10% of this amount returned as benefits and definitely not to the “aam aadmi”. Only ICICI and probably some politicians and bureaucrats made gains from that!


Not to be left behind on All Fools Day Maharashtra announces health insurance for all in two years – cashless access to life saving procedures including cardiac, kidney, neuro surgeries in all state and private hospitals above 100 beds strength under the scheme to be called Rajiv Gandhi Jeevaandayi Yojana. Again good intentions and a step forward but no information on the organizational structure, financing strategy, budget allocations and costing etc. I am very skeptical about schemes or yojanas because that’s what they precisely are, some form of scheming to milk state resources or merely a plan without any direction or strategy. The question worrying me here is that this insurance is limited to hitech surgeries and procedures/interventions. Whos is behind this – definitely a corporate giant. Haven’t we learned already from the Apollo Hospital experiences taking state governments for a ride in Delhi and Chattisgarh as well as elsewhere. Is Maharashtra the next target. Give us the details to clear our doubts.


What we don’t look at is good practice within government. There is already a good example in Mizoram of a vibrant public health system which is providing universal access to primary and first level referral care to its citizens now for many years. Why don’t we learn from that experience and see how they have done this?


Then there is the much debated National Health Bill. We debated it nationally for over a year and now it seems to have been sent to the freezer. No actions seem to be happening. Our close neighbour Thailand has achieved universal access recently and that is a good developing country success to learn from. There are many other similar stories happening worldwide – Brazil, Mexico, Venezuela, Ghana, Costa Rica.. If Thailand and these other countries can do it then why cant India. The problem is our bureaucracy and the political class. They only believe in patronage politics and that is why keep announcing schemes, especially close to elections. For India resources is not a constraint. Raising an additional 2% of GDP for healthcare is no big deal. A simple 1% turnover tax on stock and commodity market exchanges transactions can rake in over 8% of GDP annually, enough to assure right to healthcare and education for all.


The question lies in the political will from our political class and the mindset and thinking of the bureaucratic class. One does not see that changing easily and that’s why I express skepticism. But yet I continue to have hope in civil society continuing to push for right to healthcare through the Jan Swasthya Abhiyan and similar other movements across the country. If Obama can dent to some extent the US Health policy and move closer towards universal access, then what is keeping Manmohan Singh and his state counterparts from taking the health sector head on to change the way it functions.

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