Renewed Prescription

WHEN NARENDRA MODI, then the chief minister of Gujarat, addressed the eighth Global Healthcare Summit at the Ahmedabad Management Association on 3 January 2014, it was a rare opportunity for the healthcare professionals, policy experts and bureaucrats in the audience to hear directly from him about what a Modi government at the centre might mean for India’s health sector. But when the speech was over 54 minutes later, the audience was none the wiser: the hour had been rife with jargon about “innovation,” “technology,” “better branding” for the health sector, and the need for public–private partnerships in healthcare reforms, but bereft of nuance.

When Modi’s Bharatiya Janata Party finally released its manifesto on the eve of the general elections earlier this year, it was no surprise to see the same rhetoric repeated. The party promised to initiate a new “National Health Assurance Mission,” to expand insurance coverage and bring more people into India’s public health system. As it happens, almost all the major parties set out similar goals on health in their own election manifestos (the Congress, for example, unveiled the idea of a nationwide “right to health” agenda). But for people familiar with India’s complicated, crumbling public health sector, unregulated private sector and highly fragmented state-level insurance schemes, these suggestions seemed equivalent to prescribing a band-aid to cancer patients and wishing them a swift recovery.

India’s ability to move from being a regional power to a global one depends heavily upon how the country performs in sectors such as health, water, sanitation and education. As things currently stand, India accounts for 17 percent of the global population and 21 percent of the global disease burden. The economic progress of the last two decades has led to a significant shift in disease and mortality patterns: the new mass killers are not infectious or parasitic diseases, but degenerative and non-communicable diseases—or NCDs—such as diabetes, cardiovascular ailments and cancers. According to the Global Burden of Disease study from 2010, the country is sitting on an epidemic of NCDs, which account for 53 percent of deaths in India. In 2013, the World Health Organisation found that India has 0.9 beds and 0.6 doctors per 1,000 people. This is considerably low when compared to the global average of 2.9 beds per 1,000 people, and also in comparison to other low- and middle-income countries such as Sri Lanka (3.1 beds), China (3) or Brazil (2.4).

These are the parameters of a large set of problems that the new BJP government, charged with meeting the health needs of 1.2 billion people, has inherited from the previous regime. It faces two big challenges: to contain India’s rising burden of NCDs, and to meet the United Nations’ Millennium Development Goals, whose health-related targets include reducing child mortality, improving maternal health, as well as halting and reversing the spread of communicable diseases—such as HIV/AIDS, malaria and tuberculosis. Current projections show that come 2015, the deadline for fulfilling these goals, India will miss all three of them by significant margins. The new government’s starting point for reform should be two-fold: to increase focus on primary health care, and to improve access to publicly sponsored insurance schemes that protect against catastrophic financial liabilities arising from health crises. (Nearly 40 million people are pushed into poverty annually due to unexpected health expenses.)

As it sets out to achieve these targets, the new government may benefit from one particular trend in India’s healthcare history: health policy has slowly become less centralised. Instead of the centre, the states are now the chief financiers of care, primarily through state-level insurance schemes. True, India’s public health financing system works unevenly across the country’s states and union territories: richer states such as Tamil Nadu and Kerala perform better because they invest in health; poorer ones such as Odisha and Jharkhand get left behind. But as the states make incremental investments in health, the Modi government could work to improve health indicators by taking advantage of the momentum built by the UPA’s flagship health programmes over the last decade.

The UPA government made a concerted effort to promote primary health care, with programmes such as the National Rural Health Mission, or NRHM, and the Rashtriya Swasthya Bima Yojana, or RSBY. The health ministry’s NRHM, launched in 2005, focuses particularly on reducing maternal and child mortality, and increasing access to health-care services in general. The RSBY, an initiative of the labour ministry, was floated in 2008 to insure families living below the poverty line against financial liabilities and “catastrophic health expenses” that involve hospitalisation. It covered 37,191,843 people as of April 2014, and promises to meet Rs 30,000 of hospitalisation costs for every one of up to five members of a family.

The NRHM has single-handedly improved India’s infant and maternal health indicators. Simply providing transport to and from hospitals has significantly increased the number of women opting for institutional delivery across the country. The Janani Suraksha Yojana, under the NRHM, is the world’s largest conditional cash-transfer scheme aimed at increasing institutional deliveries. India saw an unprecedented 65 percent decline in maternal mortality rates from 1990 to 2009—from 560 deaths per 1,00,000 live births to 190. (Even this historic decline, however, is not enough to get us past the Millennium Development Goal targets.)

The launch of the NRHM—funded by transfers from the central government—increased state spending across the board. Bihar and Himachal Pradesh now spend 13 percent more than they did in 2007–2009, and Chhattisgarh and Karnataka spend 36 percent more than they did in that same period. However, this and other programmes did not prevent the public health sector from being severely underfunded, a problem which has skewed the market in favour of private players. Since 2000, the year India signed the Millenium Development Goals agenda, the private healthcare sector—which includes everything from large hospitals and nursing homes to neighbourhood general physicians—has risen from relative obscurity to great prominence. In 2011, the private sector accounted for 93 percent of the country’s hospitals, and 85 percent of its doctors.

With talent, skill and infrastructure largely concentrated in the private sector, the Modi government is likely to turn to public–private partnerships for insurance schemes to meet demand and address health needs in under-served areas. Any serious attempts to fulfil the BJP’s mandate for a “National Health Assurance Mission” are likely to occur along three lines—a massive expansion of RSBY to cover workers in the unorganised sector, an expansion of commercial insurance, and also of state-level insurance schemes. In 2010, 240 million Indians—approximately 19 percent of the population—were covered under various government-sponsored health insurance schemes. After accounting for private insurance, this figure rises to 300 million people, or 25 percent of the population. We are still nowhere close to universal coverage.

Where successful, state-run insurance programmes have paid good political dividends. Over the last decade, the Rajiv Arogyashri in Andhra Pradesh, the Vajpayee Arogyashree in Karnataka, and the Chief Minister’s Comprehensive Health Insurance Scheme in Tamil Nadu, have ensured specialised care coverage to a large number of families below the poverty line. All of these programmes have also helped their respective states avoid the sharp increases in spending that come from relying on private insurance schemes. Andhra Pradesh’s state insurance scheme was a major reason for YSR Reddy’s election to a second term in 2009. Unlike the RSBY, which insures a five-member family for up to Rs 30,000, the Andhra government’ coverage provides Rs 2 lakh to every family below the poverty line, and applies even for serious disorders such as cancer and heart disease.

Many existing public insurance schemes have serious flaws. They are sporadically successful, limited in scope, and most provide financial cover only for hospitalisation while ignoring the costs of primary healthcare, ambulatory services and purchasing medicines. Ideally, the new government would consolidate existing schemes into a pan-Indian programme, which would increase current benefit packages and address other operational constraints by covering both in-patient and out-patient care. More importantly, a pan-Indian health scheme would address the intra-state variations in health indicators, giving poorer states a chance to catch up.

The debate about health reforms in India coincides with a global movement towards the universalisation of health care. In 2012, several leaders of UN-member states and civil society organisations urged the United Nations to include universal health coverage as a target under the Sustainable Development Goals, which will replace the Millenium Development Goals after 2015. The way forward for the new government would be to review all existing programmes of financial protection and the highly fragmented state-level insurance schemes, and attempt to merge them into an overarching framework of universal healthcare. But the government must do more than just expand insurance coverage. It must also assure citizens’ health, as promised in the BJP’s manifesto, by going beyond mere “illness response” to look carefully at early prevention. India needs to reorient its health system towards prevention, screening, early diagnosis and intervention.

So far, the country’s only public health achievement has been the elimination of polio, via a programme that is known to have cannibalised other immunisation programmes such as the measles vaccination scheme. To qualify its success further, the programme succeeded in large part because it was implemented outside the government’s public health system and hospitals; volunteers chased children down at bus stations and conducted door-to-door vaccination campaigns to achieve the polio target. Fortunately, the programme did get the political backing and funding it required.

The NDA has, in some respects, arguably done well to appoint Dr Harsh Vardhan, an ear-nose-and-throat specialist by training, to lead India’s health reforms as the country’s new health minister. In 1993, when he was Delhi’s health minister, Vardhan was the first politician to throw his weight behind the Pulse Polio programme, long before it became a mainstream public health campaign. Within a week of taking charge at the health ministry in May, Vardhan reached out to state health ministers to draw up a 100-day plan for the health sector. Under the overarching goal of achieving universal health coverage, the plan calls for providing free medicine, setting up “AIIMS-like” tertiary care institutions in every state, and focusing on preventive primary care.

The challenges are great, but there is a bright side. Given that leading parties considered healthcare important enough to include in their manifestos in 2014, we can hope that health will increasingly become a significant campaigning issue in the coming decades. Experts have long argued that health would become a mainstream political issue if health data were viewed through an economic lens—that if the impact of disease was articulated in terms of the financial burden of lives lost or affected, the urgency of the matter would become clear. India’s health problems already defy the capacity of a low-income country to deal with in the immediate term. Given the scale of the challenge, even a middle-income country would struggle to cope. If health does not become a national priority now, the rising financial burdens will surpass anything that even the wealthiest countries can manage, and could completely undermine whatever economic growth the Modi government hopes to achieve. If the BJP does build on the work of the previous government, health could slowly become an issue that stands above partisan politics. If not now, then perhaps in the near future, proper healthcare will come to be seen as an investment to fuel the country’s economic engines, on which so many campaign promises depend.