No debate on healthcare in India
My former domestic help came to work one day in the early weeks of demonetisation, looking dreadfully ill. She had fever and the local pharmacies were refusing to sell her drugs for old money, which is the only thing she was left with after the government banned the use of Rs500 and Rs1,000 denomination notes.
Although she has a bank account, she has no credit card and doesn’t use her debit card (either she is suspicious of it or lacks the confidence).
I rummaged through ancient wooden drawers and was able to find some lower denomination notes, so that we were able to put together enough legal tender for her to buy the drugs she needed. She was better in two days.
This week’s column is not about demonetisation. It is about healthcare, the burning issue that no one—no political party, no fire-breathing politician—wants to talk about.
The Indian newspapers were full of reports of Obamacare—the US healthcare initiative of outgoing President Barack Obama—and will no doubt carry further reports when the new President does with it what he will do. Yet for the most part, there is only silence on healthcare in the world’s largest democracy.
The National Democratic Alliance (NDA) government has advanced the date for presenting the annual budget to 1 February, so that its proposals are passed by Parliament by 31 March, in time for the new financial year, which, in turn, will improve the efficiency with which projects are implemented, giving government departments enough time to plan and spend the money allocated them.
Yet, with only around a fortnight to go, it is astounding that a nation of 1.3 billion, with up to 90% working in the unregulated informal sector of the economy, has not immersed itself in debating how much the government plans to spend on what, and how it plans to find the money to execute precisely those projects that it wants implemented with greater efficiency.
This is not the failure of a particular government; it is the failure of the Indian state.
The biggest challenge for any country—developing, developed, least developed, emerging—is to ensure a population that is educated and healthy (conjoined areas), and that lives long and productive lives.
For a variety of reasons, the most successful nations in the matter of delivering healthcare are those that have in place programmes and services that have struck a balance between state responsibility and private sector involvement, usually tilting toward the former.
The fundamental view is that a healthy and educated workforce is the primary responsibility of the state, and that the private sector can help in achieving that goal by encouraging efficiency in delivery.
The best known commonly acknowledged healthcare systems are those of the UK, the Scandinavian countries and Canada, and all have varying degrees of robust state-led healthcare systems.
In the latest Commonwealth Fund ranking, an annual exercise, the UK tops a list of 11 developed countries, followed by Switzerland, Sweden, Australia, Germany, the Netherlands, New Zealand, Norway, France and Canada, with the US coming in last, as it does every year.
They were ranked for quality, access, equity, efficiency and healthy lives.
Ironically, the US, which prides itself on its market-based healthcare system, turned out to be the most expensive.
The report says, “People in the US go without needed healthcare because of cost; more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost.”
By contrast, the Netherlands, the UK and Germany provide universal coverage with low out-of-pocket costs, while maintaining quick access to specialty services.
Another frequently cited ranking is one by the World Health Organization (WHO) from 2000, which places India at 112 in a list of 191 countries.
As expected, such rankings are fiercely controversial on many counts, including the methodology used to compile them.
But there’s a common strand.
Countries that are best at delivering good-quality healthcare at low cost to their populations are signed up to the idea of universal health coverage.
It is not that India is not signed up to the idea—it’s just that it appears to be doing nothing much about it.
If it had done so, my domestic help—even in the exceptional circumstances of demonetisation—would have been able to access the drugs she needed.
In the absence of a health insurance scheme guaranteed by the state and vigorously enforced—and perhaps because she is a woman and a poor woman at that—she was turned away by the high street chemists who are answerable to no one.
It was an unconscionable act.
The WHO ranking attempts to measure the “expectations” of populations about the healthcare system. It is safe to assume that my former domestic help had no expectations of the system.
Yet—and she will be unaware of this fact because there is no debate on it—India does have a universal health plan in place. In 2012, the previous United Progressive Alliance (UPA) government declared grandly: “India is embarking on an ambitious target of achieving universal health coverage for all during 12th Plan period. Everybody will be entitled to comprehensive health security in the country. It will be obligatory on the part of the State to provide adequate food, appropriate medical care, safe drinking water, proper sanitation, education and health-related information for good health.”
The 12th Five-Year Plan ends in March and those grand pronouncements are set to remain on paper.
The current National Democratic Alliance (NDA) government’s push to universalize a state insurance scheme, along a welfare state model, is also praise-worthy.
In the meantime, far too many Indians will die before their time in 2017, too many in their infancy, too many women in pregnancy.
Even as India makes a tortuous climb up the rankings for ease of doing business, the nation accords scant regard to healthcare, encouraging rampant self-medication and turning a blind eye to escalating out-of-pocket expenses.
Dipankar’s Twitter handle is @Ddesarkar1