March 18, 2014
Development Strategy|Social Justice
The Right to Health
By Nitin Desai
This is the season for party manifestos with their vague and quite unexciting promises. But in this sea of platitudes sometimes something stands out that is worth talking about, because, if implemented it would be a game changer. For me this is the reported inclusion of the right to health in the Congress Party’s manifesto.
It is well known that health status in India is below what can be expected at our level of income. It is a matter of shame that, globally, India accounts for one-third of deaths of pregnant women and about a quarter of child deaths. Child mortality has declined but our infant mortality rate at 56 per 1000 is significantly higher than in Bangladesh, a much poorer country.
The Government has a plethora of schemes to promote better health. But the reality is that most healthcare in India is privately funded. In the aggregate India spends 4.1% of GDP on health care. But according to a NIPFP study, public expenditure on health care is 1.5% if we include water supply and sanitation, 1.1% if we exclude it and even less than that if we exclude the health care expenditure of departmental enterprises like Defence and Railways.
This is what has to change to at least 3% of GDP so that effective and affordable universal coverage and health insurance can be provided to all Indians.
The impact of such an intervention on poverty levels could be substantial. Catastrophic health expenditures (CHE) that exceed 40% of non-subsistence consumption or 10 % of total consumption expenditure are a major, possibly the principal source of vulnerability for families near or below the poverty line. According to a recent WHO survey in India, out of pocket health expenditures amounted to an average of 10% of the total household expenditure and 22% of the non-subsistence spending. Almost 24% of the households spent either equal to or more than their capacity to pay (non-subsistence spending) on health care services, consequently they had to forego their basic subsistence consumption. This proportion is 35% among the poor households. These numbers do not include the cost of travelling to urban areas for health care or the loss of earnings. If one looks at the composition of expenditure 60-70% is for medicines and a little over 20% for in-patient or out-patient services.
The stress on a family’s standard of living is most acute when a major illness strikes a family member. A survey in Kerala of heart attack affected patients showed that 84% of the patients faced catastrophic health expenditures. The coping strategies included loans and dipping into savings. But, according to the study, in order to cope, children discontinued their education, got transferred from private schools to free government schools and families moved out of expensive rental accommodation to cheaper ones or even moved in with willing relatives to cut expenditure.
Clearly a safety net is required and the public sector has to step in not just as a payer of costs but also as a provider. But the reason for public intervention as payer or provider must be clearly articulated.
The case for public intervention when there are large externalities as with water and sanitation, waste management or disease vector control are obvious and must be supported through the budgets of the local authorities who have primary responsibility for this. A closely related area is the control of communicable diseases like TB and HIV/AIDS. The case for pubic intervention here is also the benefit to society at large of a reduction in the pool of infection.
The case for public intervention in mother and child care is that it is a very cost effective way of reducing future burdens on the health system. One could also argue that a healthy childhood has major benefits in other areas like education. Many of the interventions here, like immunization also have external benefits in the form of reduced pools of infection.
Effective public delivery systems in these three areas will help greatly in reducing the burden of illness in poor families who are more exposed to poor environmental conditions and more vulnerable to infection and least likely to seek or afford the interventions required during pregnancy and early childhood
That brings us to the protection required when a family is affected by some non-communicable disease or a severe accident. The answer here lies in a combination of public provision and health insurance to allow people to pay for private health care. Public provision through health centres is required because the private sector will not deliver health services in remote or impoverished areas. But in many areas the private sector exists and access to its services can be improved through a system of universal health insurance. The role of the government here would be to set standards, negotiate fair rates with providers and subsidise the cost of insurance for poor households.
One may proceed carefully with insurance as the scope for malfeasance is large when so large a proportion of expenditure is on medicines and out-patient services. Perhaps one can begin with insurance that covers hospitalization and also hospital and domiciliary treatment for serious illnesses whose cost of treatment is high enough to threaten living standards of the median household. The system can be gradually extended by folding in existing schemes like the CGHS and encouraging other employers to do the same.
Universal and affordable access to quality health care will require many more doctors and nurses and a willingness to serve in remote and impoverished areas. India has around 2.5 million doctors, dentists and nurses which is below the WHO critical level of 2.28 per 1000. Over the past 20 years most of the expansion in medical education has taken place in the private sector, which accounts for two/thirds of the new medical colleges and almost all dental colleges. They charge high fees and often take substantial capitation fees. Those who pay these fees will not work in public facilities. Perhaps the answer may lie in scholarships tied to a period of service in the public sector.
The right to health is fundamental as it enables an individual to enjoy all the other rights to education, employment and so on. That is why, if implemented, it can be a game changer.