Poverty’s Handmaiden

Since 1991, the private sector has dominated India’s healthcare sector. The government’s systematic withdrawal in acco­rdance with economic liberalisation, and policies like land at concessional rates and import duty waivers  created this situation. As a res­ult, Indians pay a heavy price for the lack of public health infrastructure—around 63 million are pushed below the poverty line every year due to treatment costs, says the health ministry. However, neither does Parli­ament get stalled nor is there any pri­metime discussion on the lack of acc­ess to affordable healthcare. The Centre and the states have responded with various health insurance schemes to eliminate this terrible monetary blow. Evidence suggests that except some marginal benefits, these schemes have little impact, but only enrich private sector hospitals and insurance firms. K. Sujatha Rao, with nearly 20 years of experience in health administration and policymaking, rejects this ill-informed policy response and arg­ues for a proactive role for the government as a provider of healthcare.

The book lucidly explains India’s deepening health system crisis with minimum jargons and endnotes. Apart from the deficiencies in policy formulation, it also provides an account of the successes and failures of the National Aids Control Programme (NACP) and the National Rural Health Mission (NRHM).

Rao narrates the failure of successive health policies to develop a comprehensive approach to India’s health system, even after reports from about 25 expert committees. Priorities are often set to accommodate the agenda of international organisations and donor agencies rather than addressing needs of people. There is a firm belief within the government on the efficiency of the private sector to meet public health needs, allowing it to operate with little regulation, especially on the cost of treatment and ethical care.

Against the WHO’s benchmark of a minimum 6 per cent of GDP spending, the central and state governments have spent only 1.1 per cent of GDP for health. This constitutes only 18.8 per cent of India’s total health expenditure. The share of capital expenditure (building of new infrastructure) constitutes only 7.5 per cent of public funding of health. This has created a huge deficiency in public health infrastructure. Currently, India faces a normative gap of 3,469 community health centres (CHC) (each for 1,00,000 people) and 5,887 primary health centre (each for every 30,000 people). This has led to a situation where almost 80 per cent of tertiary care is given over to the private sector. In the absence of any effective regulation, this dependency undermines the right to health guaranteed under the Cons­titution. The author also states that on many occasions the Centre could not spend the funds allocated for the Union health ministry due to lack of absorption capacity or regulatory requirements on disbursement of funds. The obsession to control the fiscal deficit has resulted in a 10 per cent cut of the Union health budget. Instead of addressing the poor public finance on health, the erstwhile Planning Commission proposed to fund the private sector to provide seamless services of primary, secondary and tertiary care without commercial int­erests. This would have enabled further privatisation of the healthcare sector using public money.

Rao lists five areas that require comprehensive attention to address the health system crisis in India. These are: strengthening the process of decentralisation and cooperative federalism, revamping the health delivery system, strengthening the public sector, expanding the use of technology and acknowledging the value of evidence. To improve the health delivery system the author makes the following proposals: “(a) Universalise access to comprehensive primary care and public goods free of cost; (b) in view of the resources constraints, to ensure fully subsidised treatment in secondary and tertiary hospitals and institute some amount of co-sharing of expenditures by those who have the capacity to pay; (c) to enforce a rule of law to check the current laissez faire environment and ensure that the provider practice is ethical and rational”. It calls for an activist government to make investments in creating its own infrastructure, “to build its institutional capacity to compete with the private sector on quality and price to safeguard its interests and those of the patients”.

Though the book is rigorously resea­rched, Rao makes sweeping statements on issues like the Drug Price Control Order 2013 (DPCO). While discussing the DPCO 2013, she totally ignores the fact that it resulted in the reduction of the growth of the pharmaceutical market from 16 per cent to 8 per cent. However, the data shows that the medicines covered under the DPCO constitutes only 12 per cent of the Indian market share.

The failure of India’s political leadership to fulfil the constitutional obligation of right to health compels the reader to pose a question to our political leaders: “Do you care for the people’s health?”