February 22, 2020
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In Sickness And In Wealth

A likely switchover to a 'pay-and-be-treated' regime can only compound the misery of the poor

In Sickness And In Wealth
Abhijit Bhatlekar
In Sickness And In Wealth
It's a 'revamp' of the healthcare system one should well be wary of. Free or subsidised medicare at public hospitals and medical centres could well become a thing of the past as the government puts the final touches to its National Health Policy (NHP), 2001. Similar to the strategy adopted by the food ministry for the Public Distribution System (PDS), those above the poverty line may now find themselves bracketed as "those who can afford to pay" and be asked "reasonable user charges" to avail secondary and tertiary healthcare facilities.

The switchover to the 'pay and be treated' mode in a country which has a sizeable population living below the poverty line has understandably caused concern to those monitoring public health. Says Robert J. Kim-Farley, the World Health Organisation (WHO) representative in India: "It must be ensured that there is total access to healthcare and that such services are affordable. Sometimes the costs of hospitalisation are so high that it alone can push one below the poverty line. These points need to be considered while finalising the policy."

This is just one of the contentious issues in the draft NHP due to be finalised in a fortnight. Coming as it does after a gap of nearly two decades, it has angered several organisations working in the health sector who have alleged that it is anti-people, lacking in vision and a total 'sell-out' to transnational forces eying the huge health market.

Over 1,000 countrywide organisations associated with healthcare and health policy have come together under the banner of the Jan Swasthya Abhiyan (JSA) and are contesting several points in the policy. In its critique, the JSA says: "The draft introduces the concept of user fees, albeit couched in the usual sugar-coating of 'those who can pay'. Global experience of user fees at any level shows that they serve only one purpose—to drive out the poor. While the targeting of primary healthcare is to be welcomed, this should not constitute an argument for legitimisation of the government's retreat from providing comprehensive and quality secondary and tertiary care. The draft hints at this possibility in different sections and at encouraging the private sector to occupy the space that would be left vacant."

The policy draft does admit grave deficiencies in the health sector and notes how only 20 per cent of the population seeks OPD services and is forced to turn to private clinics. It also admits the collapse of the primary healthcare system and acknowledges the poor coverage of women's health and prevention of infant mortality. Ironically, its prescriptions fail to address the problems or offer solutions.

The draft policy, for instance, admits that public health investment has been 'comparatively low' and plans to raise it from 0.9 per cent to 2 per cent of the GDP by 2010. But experts say it's still well below the WHO-recommended share of 5 per cent. "The policy does not admit that public health investment in India has been abysmally low. In fact, considered as a percentage of total health expenditure, it is perhaps the lowest in the world, making it the most privatised health system in the world," says B. Ekbal, vice-chancellor of Kerala University and chairman of the health subcommittee of the Kerala Sastra Sahithya Parishad.

What makes this pill even more bitter is the strong influence of MNC forces in drafting the health policy. "Nearly 80 per cent of the health services in India is already controlled by the private sector.The policy provides further space for it without putting any defined mechanisms of keeping a check," says Pune-based community health expert Anant Phadke, associated with the Medico Friend Circle.

Phadke has a point. The policy calls for providing incentives to the private sector to move to the primary healthcare system. However, the experience in urban centres has been discouraging. The incentives in terms of subsidised land, water, electricity and duty-free import facility doled out to high-profile private medical centres and hospitals in the urban areas has seen little benefit for the poor. Very few of these hospitals conform to the mandatory provision of free medical care to the population below the poverty line or the reservation of a certain percentage of their beds for the poor.

The government is being accused of shirking its responsibility of improving public health services. The policy has dropped the earlier much-publicised goal of universal healthcare. Says Mira Shiva of the Delhi-based Voluntary Health Association of India (VHAI): "After wrapping up the PDS, the government is trying to wash its hands of the healthcare services. How can the healthcare services be left to the private sector when there is absolutely no regulatory or social control over it? At this rate, profit maximisation, irrational healthcare, irrational use of medical technology will proliferate. Entry of large corporations into basic needs with the backing of the international trade regime will become a very dangerous situation for India."

The health ministry counters this by saying that the new policy proposes to regulate the private sector with the enactment of suitable legislations by 2003 and also evolving guidelines for the conduct of clinical practice and delivery of medical services. Experts take this with a pinch of salt. Observes Shiva: "Despite all the rules in place, sex-determination is still so rampant."

The policy is also being criticised for a diffused focus. It is being said that the issue of health has been discussed in isolation without even considering the associated and vital areas of nutrition, food security, water, sanitation and even population control.

In fact, the advisory note by the WHO country team has suggested that "the vision for health needs to be strengthened". It has also touched upon women's health which, as also pointed out by several NGOS, has been dismissed with a vague mention in the policy. According to the WHO suggestion, "the final NHP may more clearly spell out strategies, interventions and targets for improving maternal health". It has also pointed out the need to focus on food safety, lack of which results in starvation deaths.

Ravi Duggal, director of Cehat, a prominent Mumbai-based healthcare NGO, points to the absence of a focused drug policy in the NHP. "This a serious anomaly and the health department must exert its right to determine the drug policy, especially with regard to price control over the WHO list of 300 essential drugs. This is extremely critical in the context of India switching over to the product patent regime under the new WTO/TRIPS arrangement from 2005. The advantage India has of lowest prices of drugs in the world will be lost if a drug policy favouring public health concerns is not put in place before the 2005 deadline."

Interestingly, the policy also has plans to attract overseas patients for comparatively low-cost treatment as a means of generating foreign exchange.To which S. Srinivasan of Low Cost, an NGO that manufactures low-priced drugs for the poor, says: "First, let us manage our staggering health system rather than look for foreign currency."

Undeterred, the officials at the health and family welfare ministry are busy finalising the policy. One thing they say with certainty is that the PDS formula will definitely make its way to the health sector.
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