‘We are still not serious about health care’

INDIA’S new health policy proposed nearly 15 years after the last one is too little too late, suggests a lack of political will to declare essential care as a public good, and further incentivises the private sector in service delivery, according to former Union Health Secretary Sujatha Rao. Considered one of India’s most competent bureaucrats, Sujatha Rao, with over two decades of experience in the health care sector, is the author of Do We Care? India’s Health System , published recently by Oxford University Press. The book is a scathing indictment of the political executive’s abdication of its responsibility to provide basic health services to citizens, which is their right. She calls for a fivefold increase in public spending on primary health care, taking into account the unique requirements of the different regions and developing a participatory and stakeholder-interest model rather than a top-down, prescriptive and hospital infrastructure-dependent approach. She says that involving private insurance companies in the sector increases costs nearly fivefold for both the state and the consumer, apart from failing to address the catastrophic impact illness has on the finances of households, pushing millions of Indians deeper into debt and poverty.

Excerpts from an interview she gave Frontline in Hyderabad:

Before we get into the new health policy, how healthy do you think India is? And how much is this a reflection of the country’s health policy?

Globally, we contribute a fifth to a quarter of the burden of disease, though we account for only 17 per cent of the population. We have neglected health in our development dialogue and never looked at promoting the well-being of our citizens as an investment for the future. In other words, if India wants to take advantage of the population dividend, then we have to ensure that our youth are strong and healthy. Sick people do not produce wealth.

Too many young, productive lives are being lost owing to road accidents, non-communicable diseases, particularly vascular diseases—where a 30-year-old Indian has a 25 per cent chance of dying because of these diseases compared with a 70-year-old is a serious statistic—and highly preventable and low-cost diseases like malaria and TB.

This situation can be redressed only by having a health care system based on the foundation of strong primary health care that consists of prevention and early diagnosis and treatment. The current trend of focusing on hospital treatment is flawed. I am happy that the National Health Policy (NHP) 2017 is seeking to shift focus to primary care. This is a good development.

TOO LITTLE, TOO LATE

The main thrust of the new health policy seems to suggest an admission of chronic under-funding of the health sector over the years, and an increase in tax-based funding up to 2.5 per cent of the GDP( gross domestic product) by 2025. Is this too little too late?

Yes, it is absolutely too little, too late. Over these 70 years, India has never spent more than 0.9 to 1.2 per cent of the GDP on health. With this little money, which is about 20 per cent of total health spending in India, we are able to provide only about 15 per cent of primary care and about 20 per cent of secondary and tertiary care and half of medical education, and so on.

So, if we are envisioning a universal-access-to-all care in a single-payer mode, then public spending will have to be fivefold more as a minimum. In fact, international experts have estimated that $85 (about Rs.5,500) per capita public spending is required for providing comprehensive primary care alone. Against that we are barely spending $17 (about Rs.1,100). Even after discounting purchasing power parity, a 2.5 per cent of GDP in public spending is inadequate.

Let me give you just one more figure to put it in the right perspective. The NHP talks about ensuring what are called Indian public health standards in all government facilities in high-priority districts, that is, personnel, drugs, equipment, and so on. There is no definition of what is meant by high priority though, but I figure them to mean the 270 districts that account for three-quarters of maternal, infant and child mortality and communicable diseases and a correspondingly poor public health service delivery infrastructure and low per capita income. Achieving these standards alone, according to the Ministry’s estimates, will require about Rs.1.4 lakh crore, of which about Rs.1 lakh crore is only for capital expenditure. More than three quarters of this amount would be required in the high-priority districts. Against that, in the last 10 years we have barely spent about Rs.10,000 crore as a whole, and half of that in the high-priority districts.

I know there is a perception that we have spent a lot on building useless infrastructure. That is totally untrue as the DLHS [District Level Household Survey, conducted by the Indian Institute of Population Sciences, Mumbai] data will show you. Leave alone rural areas, look at our public hospitals in Delhi, with two patients sharing a bed. Before Thailand announced universal health care [UHC], it not only had a history of reforms but also, since 1995 for five years, spent its entire budget on building up the rural health infrastructure. Can we do that? Could this policy have committed itself to that? What secondary care can we provide in decrepit, worn-down hospitals? And in the underserved poor areas the private sector is so weak as to be nonexistent, except the quacks.

The private sector is not a charity house. It has to earn and earnings can only come when there is the capacity to pay. So if we want the private sector to serve in these remote areas, then we have to have a clear policy and a set of fiscal incentives. I don’t see any of that in the policy. So yes, I think the figure of 2.5 per cent of GDP as spending [for health care] has no basis.

Frankly, I believe that in India the health discourse spends too much time discussing how much the public spending, as a percentage of GDP, should be. I argue that instead of that why don’t we say what the government ought to provide to all its citizens as its obligatory duty? And for that, spend whatever it takes. But the minimum has to be provided to all citizens—tap water, nutrition, environmental sanitation and basic health care. The concept of public goods and the multidimensional nature of poverty needs to enter our dialogue because health and well-being go beyond doctors, hospitals and drugs. For example, just enforcing the mandatory use of helmets and incentivising the use of the bicycle may have huge health dividends that we don’t normally factor in.

INCENTIVISING PRIVATE SECTOR

How different is this NHP from the last one in 2002?

Well, NHP 2017 is very similar to NHP 2002 and does appear to be a revved-up version of it. Even to the extent of specifying time-bound targets that are impossible to achieve by merely reiterating the “more of the same” approach. If there is a shift in strategy to achieve these targets within the time frame indicated, the policy does not spell it out. So I don’t know how they will eliminate diseases like kala-azar in the next few months.

Having said that, NHP 2017 makes a much more elaborate exposition of how the private sector will be incentivised and collaborated with. That is fine with me, but I must say upfront that I don’t at all agree with profiteering in health. What bothers me is the weak exposition of the regulatory framework that ought to be put in place. For example, despite a nationwide outcry for reforming the Medical Council of India, and despite the scathing report of the Standing Committee of Parliament and the Supreme Court taking a stern view on its functioning, the NHP simply glosses over it. Likewise, there is no mention of a strong drug authority and of the urgent need to bring drug regulation into the Central fold. It is a concurrent subject and the State drug authorities are playing havoc in this area. The whole issue of microbial drug resistance is a serious concern. All these are interrelated. I feel the policy ought to have addressed some of these issues more strongly.

But NHP 2017 does recommend institutional reforms as proposed in the National Commission on Macroeconomics and Health Report of 2005 and in the High Level Expert Group Report 2012. For example, establishing an institute for chronic diseases, a national health standards organisation, and so on. Though I do wish they had set up a department for public health. It is a very important and a crying need.

The aspects of prevention and nutrition, and an emphasis on dealing with the increasing burden of non-communicable diseases seem to find mention. That, I suppose, was expected?

Absolutely, India has not been successful in making the epidemiological transition as yet. So we still have a substantial burden of communicable diseases that are normally associated with poverty and low development, and non-communicable diseases that are associated with lifestyles such as rich diets and lack of exercise. So I am glad that the policy does recognise this dual burden of disease that is prevalent in India.

An important aspect that you have spoken about in your book is the rigidity of the bureaucracy to work towards “health for all”. NHP 2017 talks of implementation through “health in all” within various government departments. Is this a welcome addition? Could the churning of India’s mammoth bureaucracy actually help it gear itself towards prioritising health?

Well, all this depends on two factors, political will and policy design. I feel that we as a nation, warts and all, can overcome issues and face challenges. I am optimistic on that front. For example, the battles against HIV/AIDS and polio offer examples of a clear, evidence-based and highly participatory implementation design backed by outstanding political support.

What troubles me is the lack of political leadership and accountability in the system. We also lack clarity in design. We have failed to incentivise the discipline of implementation science and base our policies on evidence. We have failed to incentivise our leading universities and institutions to take up operational research. Even a health module for IAS officers is funded by the Gates Foundation. The fact that we still work on Central and State aggregate data is reason for the confusion that prevails in our health policy.

INTER-SECTORALITY

You have also emphasised that the government is obsessed with meeting targets on specific interventions such as, say, increasing institutional deliveries and reducing maternal mortality, and is losing focus on the holistic approach required, which, as you point out, enables these indices to rise even faster. Does this policy address those lacunae?

It does partly when it recognises the inter-sectorality of health outcomes—the need to link [up] with the efforts of Swachh Bharat or the need to tackle air pollution, and so on. But I think this inter-sectorality is so fundamental that I do wish the policy had spent time in spelling out its approach on how it seeks to achieve it. For example, though we have, after 25 years of sustained and single-minded effort, eliminated polio, we still found wild polio emerge in Hyderabad and in Gujarat. Why are we not able to stop polio campaigns? Because until the causal factors of malnutrition, contaminated water and poor sanitation continue to exist, diseases like polio and diarrhoea will continue to be threats.

This policy should have been more forceful and should have taken the integration of water, sanitation, environmental hygiene, nutrition, education and basic health to a committee chaired by the Prime Minister. This matters. For, after all, the little toilet has finally got some attention only now after seven decades because of the non-negotiable focus the Prime Minister gave it. Convergence of these programmes at the community level is still a problem. The policy does not spell out any approach for resolving these interdepartmental issues. Merely giving a target that all will get access to safe water or sanitation by 2020 helps little unless the requisite investments are made in those sectors as well. I don’t see that. And further, when I say inter-sectorality, I mean, besides budgets, it is about working together. The Guinea worm disease was eliminated by the joint efforts of public health engineers and public health workers working together. That is not happening today.

There seems to be much thrust on integrating and regulating different medical systems. Will that help in better care delivery? For example, the mainstreaming of Ayurveda and yoga.

I think Indian Systems of Medicine [ISM], such as Ayurveda and yoga have huge potential in promoting wellness and in preventing diseases, particularly chronic diseases. If, indeed, we could put all our money in promoting primary care—that, I would hasten to add, must include access to tap water, nutrition, sanitation, clean air, etc.—and integrating ISM in an effective way, we will not really require so many hospital beds, doctors and drugs. Primary care addresses 90 per cent of all ailments and health issues. And that is the most neglected part in India. Actually, India has no option but to avert disease and promote good health. So promoting alternative medicine is a good step, but fraught with huge challenges. It is an opportunity that has not been fully optimised as yet.

An aspect that you have spoken about extensively is the impediments in implementation, from getting clearances from the Finance Department to the constant tussle between States and the Centre, and how often the approach from New Delhi is prescriptive and not participatory. Do you think this policy addresses these problems?

Sadly, no. I am not aware of how this policy has been formulated and the level of consultations between States and the Centre. Impression wise, it does not give me the feeling that this document is based on any “national consensus” as such, though I am aware that a meeting of all State Health Ministers was held to discuss this policy. But when I say “national consultation” I mean that every State has its current status under each target to be achieved and [an assessment of] the resources [needed] to bridge the distance to the national mean. And to bridge the resource gap, the Central government steps in.

A consensus means that every Chief Minister makes it obligatory to ensure universal access to all essential care as the first charge on the State government’s budget. I don’t see that either, as I see a disproportionate focus on hospital treatment. I say this because, if you notice, there is no mention of what the Central share in the resource pool is going to be. In NHP 2002, there was a target that the Central share will be increased from 17 per cent to 25 per cent. And it did under the NRHM [National Rural Health Mission], where the Central share went up to even 29 per cent in one of the years.

Now there is no target. Instead, States are being asked to raise their public spending to over 8 per cent of their revenue expenditures. For some this is doubling their current spending. It is not clear how this could be possible for the fiscally poorer States that also have the highest burden of disease. So, for these States, achieving the vision of “comprehensive health care that assumes tertiary, secondary and primary care for all” by 2025 is almost impossible and also goes contrary to their immediate priorities.

A Central policy can only provide a direction that defines areas that are negotiable and areas that are non-negotiable. In this context, State obligation, in my view, should define the floor not the roof. Given the low resources, priority should be in promoting universal access to comprehensive primary care and strictly targeted secondary and tertiary care for four or five conditions. Remember, even the [United Nations’ ] sustainable development goal is not about full care for all. It is about universal coverage for essential health care.

There is a mention of pro bono service by the for-profit and not-for-profit sectors in underserved areas. Is this just wishful thinking?

Yes, hugely wishful and borders on naivete, quite facetious actually.

There seems to be an emphasis on procurement and several other areas to be served by both not-for-profit and for-profit sectors. Is this an indirect way of encouraging greater private participation and, generally, privatisation?

The private sector in India really grew by default. There never was a well-articulated policy on the role of the private sector in India. The withdrawal of the state and a low public spending of 1 per cent of GDP in an environment of rising effective demand for services is what fuelled the rapid development of the private sector. NHP 2017 seeks to build on this de facto position.

Given the wide market failures in the health sector, further incentivising and strengthening the private sector and its commercial arm in a poor country like India is worrying. As per this policy, the government proposes to purchase services on a “preferential” basis from the private sector for the whole range of services—primary, secondary and tertiary—in urban and remote areas for infectious and non-communicable diseases. And all this for everyone and with a spending of 2.5 per cent of GDP and weak regulation.

Ample data have revealed that any health service in the private sector costs nearly five times when compared with the same delivered by the public sector. At the same time, it [the policy] also says that such collaboration with the private sector is only short-term and in the long run it will be public provisioning. How is this possible? I find the policy confusing. In other words, what is the kind of health system we will have in 2025? Or 2030? For, there are three options: one, a health system where the public sector is the main provider. This option is not available.

The second is the private sector providing services and people paying for them with their own money. This is where we are today, somewhat. And this means that we also have millions getting impoverished on account of health expenditures. This then is unsustainable and is no option either.

The third is a mixed system where the private sector is a provider of services alongside the public sector, with the government paying for private services in order to provide for financial risk protection. This is the model I suspect the policy is seeking to achieve. But this is not clear because in the chain of service delivery I am unable to see how the government seeks to keep control on costs. Cost control in such mixed systems is possible only when the state is a single payer as in the U.K. or Canada. Even in the U.K., the government not only exercises a tight control over the private G.P. [general physician] but also has secondary and tertiary care provided mainly through its own hospitals. In India, we are ceding space to the private sector in all three areas of primary, where we have credibility and are strong, secondary and tertiary.

We also don’t seem to realise that health markets are highly competitive and, because they are not regulated, also highly corrupt. The ground situation in India is far more serious and complex and calls for a far more sophisticated policy than merely assuming that by “strategic purchasing” we can provide access to all. What is needed when we seek to envision the state to be a steward is having tight regulations with the capacity to enforce standards, ensure outcomes and keep a control on prices. The policy is not very clear on how this will be achieved. In the absence of that governance framework, we will be like the car hurtling downhill with no brakes.

What would you like to see different in this policy?

Three things: First, I wish the policy had paid greater attention to the issue of disparities. To continue to deal with aggregates to define goals shows a lack of awareness of the wide inequities that exist in our country—inter-State, among districts and within a district, among population groups and geographies. Large swathes of the country have indicators that are worse than those of sub-Saharan Africa, while some parts of the country are on a par with the developed world.

Second, the policy could and should have paid greater attention to the notion of public goods that then makes it obligatory for the state to assure. It is not clear what as a citizen I can hold the government accountable for. And worrying in this aspect are issues relating to infectious diseases—the fact that despite sincere efforts over the past few decades, we still have a third of mortality due to communicable diseases. Data suggest that by 2022 India will account for 42 per cent of global multidrug-resistant TB. That is serious. Why India is unable to make the epidemiological transition like other countries should have bothered us much more. Making a single line commitment that we will eliminate these diseases in the next few years is being simplistic.

Third, I would have liked to have seen a lot more rigor. Health care is all about money and there is no free lunch. Someone has to pay for it. And of all the financing options, the most expensive pathway is private health care service delivery financed through private insurance and inflationary payment systems. And we seem to be trending towards that. Mere assertions of States spending 8 per cent of their revenues on health or hoping that CSR, sin taxes or pro bono services will help alleviate the issue indicates that we in India are still not serious about health care.