As Indians of all political persuasions brace themselves for a year of high drama where a fractious national campaign could end in an uncertain verdict and unforeseen coalitions, what will the future content and course of our health policy be? Will 2014 emerge as a year when health finally gets prioritized on the national development agenda, or will it get sidelined in the dust and din of politics as usual?
As is widely discussed in public health forums, but seldom acknowledged in political debate, India’s major health indicators fare poorly in comparison with our neighbours and economic peers. Our infant and maternal mortality rates are far higher than Sri Lanka’s and we are worse off than Bangladesh and Nepal in current rates and the recent speed of decline. Our child malnutrition and immunization rates are worse than those of many countries in sub-Saharan Africa. Even as we worry about our diminishing demographic dividend because of child mortality and malnutrition, we lose more potentially productive years of life due to mid-life cardiovascular deaths in the age group of 35-64 years than China, the US and Russia combined.
Health has floundered both because of poor public financing and a weak health system, which adversely impact each other. At just over 1% of gross domestic product (GDP), India’s government spending on health is in the bottom 10 of all countries, while our out-of-pocket expenditure (70%) gives us the dubious distinction of contributing the largest number of persons impoverished by personal expenditure on healthcare. The under-resourced health system predictably underperforms and is unable to spend even its limited funding. Instead of priming the health system to function better by financing the scale-up of infrastructure, expansion of the health workforce, and infusion of public health and managerial expertise, policy makers use the “poor absorptive capacity” of the public health system as an alibi for curtailing the much needed funds. Akin to starving a sick child.
The National Rural Health Mission (NRHM) and the Rashtriya Swasthya Bima Yojana are major initiatives that have attempted to provide a partial response to these challenges in recent years. While conferring some benefits, they have not comprehensively addressed health needs and have been unable to integrate primary, secondary and tertiary services into a seamless continuum of easily accessible, appropriate and affordable care. At the same time, policies and programmes in other sectors have not been adequately aligned to promote and protect health—whether in water, sanitation, nutrition, environment or urban development.
The 12th Plan (2012-17) has committed itself to the goal of Universal Health Coverage (UHC) and records it as the prime guiding principle of the National Health Mission, which emerged in late 2013 through the merger of the nascent National Urban Health Mission with the NRHM. However, the moves towards UHC have been tentative at best, with no clear operational framework from the centre or an engaged embrace by the states. The slowdown in economic growth has also dampened the enthusiasm of policymakers for ushering in programmes to implement UHC with the required scope and scale.
It is high time for political leaders across the spectrum to recognize that continued neglect of health, through under-investment and poor management, will impose a huge cost on our development and impede economic growth. It is also a basic right that cannot be denied to the citizens of any civilized society.
There is need for a national consensus, involving all parties and all governments in our federal polity that health must be prioritized in the development agenda and must not fall prey to political discord or administrative ennui. The recent announcement by the Rajasthan chief minister that she will continue the previous government’s policy on free provision of essential drugs and diagnostics brings hope that such a consensus is possible.
If such a high-minded concord is indeed achieved, the road map for action is clear: (1) initiate UHC by strengthening rural and primary healthcare; (2) invest in a multi-layered health workforce, recognizing that technology enabled frontline health workers and allied health professionals can not only enhance the outreach and effectiveness of health services, but also offer millions of jobs for youth, especially women; (3) provide quality assured generic drugs free of cost at public healthcare facilities to increase access to essential medicines and substantially reduce out-of-pocket expenditure; (4) merge all existing financial protection schemes into a single-payer health financing system that is predominantly tax-funded and employer-financed; and (5) establish credible and effective regulatory systems to mandate standards and monitor accountability within the different components of the health system.
Will this happen in 2014? The answer may be more than a “may”, if May 2014 opens the road to enlightened politics and enables agreement on a non-partisan agenda for national development.
K. Srinath Reddy is president of the Public Health Foundation of India (PHFI).