The right priorities for healthcare spending
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What do patients actually want? Will they settle for compromised, sub-standard healthcare as long as prices are affordable? Or does the vast majority prefer the best quality possible at rational cost? This question needs to be pondered upon and answered correctly before priorities are decided, strategies fixed and actions taken by policymakers and service providers.
Today, India is experiencing a dramatic transition in disease burden, with non-communicable diseases taking centre stage. With this transition, we need to recognize the threat posed to the social and economic well-being of the country and find sustainable solutions to address it. The only sustainable solution lies in robust infrastructure, effective resource mobilization and capacity-building within our states. We must improve the quality of doctors and nurses, healthcare delivery systems, better hygiene and sanitation levels, and not just focus on controlling the prices of drugs.
Simply fixing the prices of medicines will not help anyone, least of all the patient. Patented medicines are a small percentage of medicines used in India. Off-patent medicines represent over 90% of the medicines on the World Health Organization’s (WHO’s) list of essential drugs, yet millions lack access to quality medicines in India. Solutions need to be holistic, far-reaching and inclusive, and must be decided after discussion with all stakeholders, including patients and patients’ organizations.
The fact is that access to healthcare for India’s vast population remains an enormous challenge. The real barriers to access are deficient infrastructure and manpower constraints that need to be tackled first.
As a study by IMS Health found, while a majority of our population resides in rural and tier-II/III/IV towns, healthcare infrastructure, including hospitals, hospital beds per patient, path labs, diagnostic centres and trained doctors, is severely limited. This needs to be addressed on an urgent basis.
The biggest issue is our low spending on healthcare. India stands right at the bottom of the list when it comes to budget allocation for healthcare. In the World Health Statistics 2015, WHO ranked India 187th among 194 countries. This is a sad commentary on a nation with high aspirations. We are a country of over 1.25 billion people and Indians represent almost one-fifth of the world’s population. Despite being a proud democracy with a fast-growing economy, we have always had a disproportionately small health budget. From being a meagre 0.9% of GDP (gross domestic product) in 2005, (according to the Economic Survey 2015-16), government expenditure (Central and state governments combined) on health as a percentage of GDP has gone up by a whisker to about 1.3%. These figures seem even more dismal when we compare them with other developing nations, such as Thailand and some African countries, which spend over 5% of their GDP on health. India comes across as tight-fisted and short-sighted. Our neighbour China places a far greater premium on health as compared to us.
Not all is lost, though. Some promising steps have been taken recently. Under the National Health Mission, support is being provided to states and union territories to strengthen their healthcare systems and provide accessible, affordable and quality healthcare to all citizens. Moving closer to universal health coverage wherein people will be able to access the quality health services that they need without suffering financial hardship, is a key goal of the 12th Plan.
The government of India has been implementing the Rashtriya Swasthya Bima Yojana (RSBY) since 2008. This is a centrally sponsored health insurance scheme which covers our below poverty line population and 11 other defined categories (Mahatma Gandhi National Rural Employment Guarantee Scheme workers, construction workers, domestic workers, sanitation workers, mine workers, licensed railway porters, street vendors, beedi workers, rickshaw pullers, ragpickers and auto/taxi drivers) that are enrolled under the RSBY. This population is entitled to cashless health insurance coverage of up to Rs30,000 per annum per family. Out-of-pocket expenditure, up to Rs30,000 per family each year, is provided under the RSBY.
Unfortunately, the prevalence of health insurance coverage is very low in the country. The number covered under health insurance policies during the financial year 2015-16 was 358.9 million, which is approximately 30% of India’s population. The Insurance Regulatory and Development Authority of India (Irda) has notified Irda (Rural and Social Sector) Obligations, 2015 that mandates for every insurance company to offer insurance coverage to the rural and defined social sector population. This is a step in the right direction.
India needs an all-encompassing healthcare model that is truly able to achieve the objective of improving access to quality healthcare,with the government in a lead role and all stakeholders playing a part. It is extremely important to include patients and their viewpoints in all discussions, so that the solutions genuinely favour them. Such consultations, with patients and patient groups, are not a practice in India while developing policies and programmes under the universal health coverage initiative. Finally, the healthcare delivery system must be patient-centric rather than price-controlled, unsafe and sub-standard.
Bejon Mishra is founder, Partnership for Safe Medicines, India.