The finalised chapter on health in the 12th Plan document envisages a large role for the private sector in health care.

A CHAPTER on health prepared for the draft 12th Five Year Plan Document in July received a lot of criticism for its limited understanding of universal health care and its diluted commitment to increase public expenditure on health. If the revised version is any indication, there has not been much change in the official mindset.

Claimed to be prepared on the basis of the recommendations of a High-Level Expert Group (HLEG) on Universal Health Care constituted by the Planning Commission, both the draft version and the finalised one display a tilt towards the involvement of the private sector in health care. The only substantive change is a slightly enhanced commitment of public spending, from 1.58 per cent of the gross domestic product (GDP) mentioned in the draft chapter to 2.1 per cent, by the end of the 12th Plan. This, too, is way below the demand for 5 per cent of public expenditure on health. The document seeks to hand over health care to a network of public and private providers rather than increase substantively the public provisioning of health services through an enhanced health budget. The inevitability of the private sector playing a large role in health care is thus taken for granted.

The belief inherent in the present document as well as the previous one is that public services are intrinsically inefficient and designed for failure. Apparently, the very idea of Universal Health Coverage (UHC) touted by the government aggressively owes its genesis to a renewed emphasis several international agencies laid on facilitating and promoting the private sector in health care. While the draft and the finalised chapter wax eloquent on the need to address out-of-pocket (OOP) expenditure, it is baffling that the remedy is seen in regulating the private sector and not in widespread public provisioning of health services.

In the finalised chapter, there is a slight dilution of the approach to reducing OOP expenditure. Concerns were expressed in the draft to lower OOP expenditure to affordable levels in the 12th Plan period; the finalised chapter says “the 12th Plan measures will also aim to reduce out-of-pocket spending as a proportion of private spending on health”. There are no targets or time frame set. In fact, the chapter takes solace from the HLEG report which admits that “the transformation of India’s health system to become an effective platform for UHC is an evolutionary process that will span several years”.

There is a tacit admission that OOP expenditure is very high, at about 4.1 per cent of the GDP in 2008-09. Public expenditure on core health (Plan as well as non-Plan and taking the Centre and the States together) pales in comparison: 0.96 per cent of the GDP in 2007-08 and 1.06 per cent in 2011-12. “It needs to increase much more over the next few Plan periods,” the revised chapter observes without making any substantive commitment as to how much is needed to cut down OOP.

While reviewing the progress of health infrastructure in rural areas, the final chapter is as candid as the draft was in admitting that the creation of infrastructure has been slower in high-burden States and that most of the facilities did not match the standards set by the Indian Public Health Standards.

Health insurance schemes

Although shortcomings have been acknowledged, there is no clear-cut commitment on strengthening public health care and its infrastructure. For instance, notwithstanding the concerns expressed in the document over the Rashtriya Swasthya Bima Yojana (RSBY), the flagship health insurance scheme introduced for the poor in 2007, there is noticeable advocacy of handing over public funds to the private sector through the insurance route. The document acknowledges a general problem with any “fee for service” payment financed by an insurance mechanism—that it creates an incentive for unnecessary treatment which in due course raises costs and premiums. It speaks about evidence that this has been happening and about the necessity to devise steps to minimise it.

The revised chapter concludes that some groups oppose insurance schemes on the grounds that they are not realistic. But the paragraph goes on to say that the beneficiary is able to choose from alternative care-givers covered by a common insurance scheme and that experiences with the RSBY and other State-specific insurance schemes need to be studied thoroughly so that suitable corrective measures can be introduced before integrating these schemes into a framework of UHC.

The chapter also includes a critique of the RSBY but does not advocate a complete review of the same or a discontinuation of the scheme. It says: “The shortcomings of the RSBY noted so far include high transaction costs due to insurance intermediaries, inability to control provider-induced demand, a lack of coverage for primary health care and out-patient care. Fragmentation of the different levels of care can lead to an upward escalation towards the secondary level of patients who should preferably be handled at the primary or even preventive stages. The RSBY also does not take into account State-specific variations in disease profiles and health needs.” Health groups like the Jan Swasthya Abhiyaan (JSA) have been demanding a rejection of the scheme.

The JSA has been insisting that public expenditure on health should not be less than 5 per cent of the GDP. It maintains that secure access to quality health care can only be guaranteed by a well-resourced and accountable public health system. Additionally, the implementation of insurance schemes also needs to be comprehensively inquired into, especially the financial sustainability of the schemes, the health outcomes, and the financial risk production of the households.

The JSA has also pointed out that there is enough evidence internationally to show that the utilisation of large, networked private care-providers to give insurance outcomes leads to high costs and poor health outcomes. It has demanded the gradual dismantling of the current public-financed health insurance schemes and the integration of those schemes into a universal and comprehensive system to provide health care for all.

In a significant change, the title of the subsection “Key elements of the 12th Plan Strategy” in the draft has been done away with in the finalised chapter. However, what is more significant here is that in the finalised chapter, the key elements of the new strategy are described as part of a longer plan to move towards UHC, which the HLEG points out is a process that may unfold over two or three Plan periods. The draft clearly laid the time frame as two Plan periods. One of the key strategies involves the expansion and strengthening of the public sector health care system to meet the health needs of rural and even urban areas.

As if making a strong case for good and affordable public sector health care, the document says that increase in supply in the public sector will cause a shift towards public-sector providers and free the vulnerable population from dependence on high-cost and often unreachable private sector health care. Clearly, it does not make the causal link between public expenditure on health and supply of public sector health services. Perhaps reacting to criticism, a line in the draft chapter, “that private sector will of course continue as an option to those who can afford it”, has been removed.

The introductions to both the draft and the final chapter are more or less the same, but nutrition as a key component of health is absent from the list of other determinants. There is no reference to universalising the public distribution system (PDS), a long-standing demand of activist groups.

Rural health

In the section on the National Rural Health Mission (NRHM), a commitment to provide 30-50-bed community health centres (CHC) per lakh population is missing from the main text. Whether this is an oversight or a deliberate omission is not clear. Further, in the draft, 3.47 lakh accredited social health activists (ASHAs), or less than half of the total number of them, were said to have received training up to the fifth module. In the final version, this figure becomes 72 per cent.

The section on gaps in human resources is drafted flippantly. It says that “lack of skilled human resources is a major constraint on any effort to upscale health service delivery and serious efforts were made to address this problem in the Eleventh Plan. An important initiative was the addition of 8.66 lakh ASHAs under the NRHM to facilitate accessing of health care services by the community. ASHAs have been very active in and effective in promoting institutional delivery and immunisation and to some extent in increasing access to sterilisation services.”

ASHAs would be required also to deliver contraceptives at the doorstep for a “nominal” amount. A new incentive-based scheme, the Home-Based Newborn Care, has been launched as a key intervention to reduce infant mortality rate, and once again, through ASHAs. Depending on how successful they are in improving newborn care practices at the community level and early detection and referral of sick newborn babies, ASHAs would be paid Rs.250 a case.

First, to describe ASHAs as skilled human resources and then deny them a decent wage is one of the biggest stories of denial in the grand architectural correction of the health system currently under way. It has been rather easy for the government to recruit lakhs of poor women, who are dependent on meagre family incomes, to work as ASHAs. But it has been unable to recruit doctors, nurses and specialists, the actual “skilled force” component of the health system. Payment to ASHAs continues to be incentive-driven. In fact, the actual shortage in skilled personnel is striking. At the end of the 11th Plan, the gap in staff position was 53 per cent for nurses, 76 per cent for doctors and 88 per cent for other specialists.

The conclusion of the chapter is telling. There is a mention about expanding the NRHM into a National Health Mission, but without the corresponding increase in budgetary expenditure.

The document also talks about putting in place a basic architecture for health security for the nation, incentivising State governments to do what is needed to improve the public health care system while “effectively regulating the private health care system, so that the two together can work to address all possible threats to health and manage the delivery of essential preventive, promotive, curative and rehabilitatory interventions”. This task, it says, cannot be completed in one Plan period but will “take two or three Plan periods, with experimentation, to put the basic health infrastructure in place”.

Finally, the chapter does not display any urgency in addressing the very issues it poses in the beginning, including those relating to OOP expenditure. The approach continues to be ad hoc and non-serious and at the same time appearing to be self-critical.