Early last year, Prime Minister Manmohan Singh announced the government would work towards providing Universal Health Coverage (UHC) for all. As intents go, it is as noble as it gets. This, because the operative word here is ‘universal’. Much like the Indian Constitution promises every citizen justice, liberty, equality and fraternity, the PM proposed health care be added, as a “fundamental right”, whether you’re above the poverty line or below it.
Soon after the announcement, at a high level ministerial meeting in Delhi almost every minister pledged to work together. In the months that followed, two ambitious programmes were announced: National Urban Health Mission (NUHM) and Free Essential Medicines. When implemented, it would cost the country Rs 22,000 crore and Rs 28,560 crore, respectively. But the agreement had irony written all over it.
On December 27 last year, representatives of various states fought fiercely over how the proposed food security bill ought to be financed. But when it came to the UHC, there seemed near consensus. For various reasons though, the idea didn’t take off.
As things stand now, funding for the National Urban Health Mission and Free Essential Medicines have been deferred. Finance Minister P Chidambaram’s latest proposals mention one of them in passing. “It’s a bit of a disaster… with two years of the Plan over, there’s not much one can do towards the UHC in the remaining three years,” says AK Shiva Kumar, a welfare economist from Harvard and convener of Kolkata Group, and advisor to the Sonia Gandhi-led National Advisory Council (NAC) on universal health financing. Bureaucrats in Delhi are ambivalent too. While slow economic growth may come across as a plausible reason, truth is, nobody seems to be in charge.
As for the states, while providing health care is their responsibility, by all indications, they aren’t prepared. “Which state has projected its requirements for the medium term or has prepared any plan? There may be many states that don’t even know about the UHC,” says M Govind Rao, director of the National Institute of Public Finance and Policy and a member of the 13th Finance Commission. Instead, he discovered, states are using money from the Centre to cut spending on health care, instead of using these funds to augment it.
On its part, the Central government has always acted unilaterally and rarely consulted states on national health schemes, points out Priya Balasubramaniam, study director of the UHC. The Rural Health Mission, for instance, was delivered in a top-down manner.
Caught in this crossfire are initiatives that could drift so far apart that pulling all of them back into a single framework—the UHC—will be a challenge. Making matters worse is that there is little evidence to indicate that political or administrative will exists to integrate essential (primary), general (secondary) and specialised (tertiary) health care services under one umbrella.
Who bells the cat?
Prathap Reddy, chairman, Apollo Group of Hospitals, has a question. “To what extent can the government absorb health care costs?” The answer, he says, lies in first addressing the basics, or primary health care (PHC). “Clean drinking water alone can help eliminate gastric ailments that afflict 200 million people.” (See package ‘Why We Need to Challenge Old Thinking…’ on page 78.)
The problem here isn’t a lack of funds. In fact, nearly three-fourths of the country’s health budget goes into addressing PHC through the National Rural Health Mission (NRHM). The country spent close to Rs 21,000 crore in 2012-13 alone.
Where it has been used wisely, things have worked. Take Bihar. Infant mortality rates there used to be among the highest in the country. Today, it is on par with the national average. “This mission has shown what a little boost to public health spending can do,” says Amarjeet Sinha, former health secretary, Bihar. But if you leave out states like Bihar, Assam and Rajasthan, most of the others are a black hole.
In a first ever estimate on the quality of primary care in the country, World Bank economist Jishnu Das and his colleagues studied rural Madhya Pradesh and urban Delhi. In 63 percent of the cases they looked at, treatment provided in public clinics was provided by insufficiently trained personnel. To drive the point home, Dr Naresh Trehan, chairman and managing director of Medanta, points to the Accredited Social Health Activists (ASHA), or community health workers in the country. “There are 800,000 of them at the village level. But they’re trained badly. We need to ask how can we upskill them? How can we make them our frontline workers who identify early signs of a disease?”
To achieve that, PHC delivery needs to reinvent itself. There are creative solutions on offer. Gautam Sen, chairman of Healthspring, a general practice (GP) chain in Mumbai, has proven that in Radhanagari, Maharashtra. With financial assistance from Hindalco, Dr Sen runs a primary care centre that caters to 150,000 people and costs the company just Rs 12 lakh each year. He trains his own staff.
R Poornalingam, former managing director of Tamil Nadu Medical Services Corporation (TNMSC), set up the country’s first technology-driven drug procurement and distribution system for the state. An advisor at the World Bank now, he noticed something rather ridiculous on a recent visit to Jharkhand. “Rs 100 crore worth of drugs were procured. But the health secretary did not know what to do with drugs worth Rs 35 crore. There was no demand.” When he was in Chhattisgarh, he found suction equipment worth Rs 150 crore being dumped in toilets.
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(This story appears in the 22 March, 2013 issue of Forbes India. To visit our Archives, click here.)
Thank you Seema and Nilofer for a well written piece. A lot of the national debate on UHC in my view has focussed only on the two dimensions of \"insurance\" and \"private sector\" and not enough attention has been paid to design isssues. Many countries have successfully implemented UHC using insurance companies and private sector service providers but none have done so without careful attention to design issues such as those mentioned by Dr.Srinath Reddy in the article. To my mind there are several that would need to be addressed carefully: a. Mandatory Gatekeeping at the sub-centre / panchyat level health facilities (well below the so called Primary Health Centre in the Government). b. Use of Electronic Health Records and enrollment of the entire population at the sub-centre level that goes hand-in-hand with the Gatekeeping function. c. Implementation of a Certificate of Need (CON) process for the licensing of hospitals to avoid over-supply and \"excessive\" competition. d. Development of creative HR strategies to bring trained manpower closer to the household -- including the use of Nurse Practioners, formally qualified Ayurvedic Physicians formally retrained as primary allopathic medicne providers, use of the Pharmacy and Dentistry graduates in primary care. e. Requesting IRDA to allow Managed Care models to emerge in which the insurance function is permitted to be combined with the healthcare function so that private sector solutions can start to emerge. A lot of this does not require money immediately but just careful thought towards putting in place a design that, in the long run, will coverge towards UHC as the political will to allocate the necessry resources builds.on Mar 31, 2013
Every year 70,000 students pass out with a B.Pharma from India\'s 1100 pharmacy colleges - most of them are sub optimally employed. 3 years of clinical experience should make them a good bridge between ASHA workers and Doctors.on Mar 19, 2013