Debt ridden Health

It is the role of the State to ensure adequate investment in public healthcare, and, if public private partnerships are the elected route, the State must develop the oversight mechanisms necessary to minimise the risks

Laura Keenan Delhi

Under the Common Minimum Programme (CMP), the government promised to provide quality education and healthcare for every Indian citizen. As per the 2001 population norm, there is a shortage of 21,983 sub-centres, 4,436 primary health centres and 3,332 community health centres. In rural areas, the ratio of hospital beds to the number of people is 15 times lower than in urban areas. On top of that is the rising per capita expenditure on health: India is home to one of the most privatised health economies in the world, and estimates suggest that over 80 per cent of outgoings on health are out of one's own pockets. Inevitably, it is the poor who are most affected by this drain on households resources. According to 2002 World Bank statistics, hospital costs results in a quarter of all the people, who take ill, to fall below the poverty line. Nearly half the rural households that are in debt are due to the loans that they had to take to finance their hospital expenditure. It may be ironic, therefore, that the government is attempting to eradicate farmers' debts while simultaneously perpetuating a situation that has the potential to cripple its rural poor economically.
The current government has nominally ackno-wledged the urgency of the situation and committed to increases in expenditure on health to two-three per cent of the GDP. In 2005, the National Rural Health Mission (NRHM) was launched, with the intention of providing effective healthcare to the rural population with a special focus on the 18 states with the weakest public health indicators and/or infrastructure. The UPA resolved to increase allocations to NRHM by 30 per cent each year. As of now, the government has been criticised for merely redistributing funds for pre-existing programmes, and the latest budget concedes an increase of just 11.4 per cent over 2007-8 with a sustained level of investment of 0.9 per cent of GDP.
Given these meagre commitments, it is not surprising that people are reluctant to use public services. One study in Udaipur revealed that not one of the assessed sub-centres had access to water supply; just seven per cent had a toilet and eight per cent electricity. Although temperatures cross 50 degrees C at the height of summer, only three per cent had a fan, while almost half the rooms leaked when it rained. Of the 898 people who stated that they could not remember using government facilities, the most common reason cited was that there was "no proper treatment" available there. And it is hard to disagree: up to one in three doctors' posts remains vacant in rural India. Of those that get filled, around two-third may be absent at any one time. And when they do turn up, research suggests that treatment is cursory and delivery poor - examinations are performed 28 per cent less often than in the private sector, although cases are often more serious, and amongst the poorest of the population, public sector doctors spend an average of just two minutes in consultation with each patient. Private practitioners, in contrast, spend 4.5 minutes.
The question the government has seemingly asked itself is whether to focus first and foremost on improving the public system and strengthening the infrastructure, or whether to make more effective use of the private sector. The taskforce report, that fed into the 11th Five Year Plan, explicitly recommends partnerships with private and non-profit organisations and NGOs - particularly where the partner supplies capital investment and delivers the services under contract with the government. The question civil society and interest groups need to ask themselves is whether private sector involvement will compensate for a severe lack of primary care infrastructure, or merely exacerbate existing problems in securing access to treatment and medicines.
Contrary to popular perception, Public Private Partnerships (PPPs) are already being implemented formally and informally within the Indian healthcare system. Reference can be made to the splitting of investigation charges, or the contracting out of the management of medical colleges to specially constituted registered societies in Uttar Pradesh. Through the NRHM, the process of primary health centre handovers has already begun in Bihar and the Northeast. Recently, the Rashtriya Swasthya Bima Yojana scheme (RSBY) rolled out to four lakh households in Delhi and will reach 20 lakh in Rajasthan. Initially trialled in four districts, the government proposes to extend the programme to all Below Poverty Line (BPL) families over the next five years. It works by providing health insurance cover to BPL workers in the unorganised sector, offering a fingerprinted cashless smartcard worth Rs 30,000 per family per year for a one-time cost of Rs 30. The Union government is meeting 75 per cent of the total cost and state governments will cover the remaining 25 per cent. Unlike failed projects in Karnataka, where premiums were not established or linked into enrolment numbers, the RSBY multiplies the premium by the number enrolled in the scheme. Logically, it is therefore in the interest of the insurance company to enrol as many BPL families into the scheme as are in the district. From the government's perspective, the beauty of the programme is in the minimal amount of effort required.
Where health insurance schemes have failed in the past, this could be attributed to problems such as adverse selection, cream-skimming (catering to the young and healthy) and high administrative costs. Preliminary evidence suggests that the RSBY scheme is better thought out than many of its predecessors. However, health insurance will improve access to quality healthcare only when it will draw from sustained investment, motivated and well-paid staff, established and integrated audit and regulatory systems and educated citizens. With these provisos, there may be space for private interventions at the tertiary level. Studies show that contracting out works when it comes to preventative care. The Janani project, which operates in Bihar, Jharkhand and Madhya Pradesh, is a case in point. It provides family planning and reproductive health services to 203 million people through 40,000 rural health providers and 663 medical clinics. The organisation works by negotiating subsidies due to the extensive numbers of people it deals with and then providing large-scale service delivery. This also gives them the leverage to enter into dialogue with major companies. Since preventative care has little financial viability, this is difficult territory, but as an intermediary, Janini, can redirect the energy of the private sector towards the poorer sections of society. Given Janini's success, it is surprising that this model has not been replicated elsewhere.
In terms of curative care, however, the private sector is notoriously slow at responding to gaps in the market. Also, there are only a few models to follow for primary care interventions. In the ideal situation, collaboration between providers allows sharing and redistribution of resources, but this will be incompatible with a competitive health economy where providers must market themselves to attract the most profitable patients or, alternatively, government investment. After all, the private sector has vices of its own and the interests of private practitioners are not always symmetrical with the interests of patients or more general public health concerns. According to a recent study, up to half of prescriptions made by private doctors are unnecessary; surgeries and expensive aftercare are performed where there is no need. Inadequate information about treatment and medication is routine, and unlicensed and unqualified doctors are relatively ubiquitous. The problems (familiar ones) are currently the lack of monitoring and accreditation procedures and implementation, pervasive corruption, along with the inability of the government to enforce existing regulations.
Ultimately, it is the role of the State to ensure adequate investment in public healthcare, and, if PPPs are the elected route, the state must develop the oversight mechanisms necessary to minimise the risks. Accreditation, for instance, would enable the stakeholders - government, private partners, and consumers - to reach a consensus on appropriate practices within a given climate. The poor cannot be handed over to the blind forces of the market without the paternal protection of the State that contributes in repeating the debt cycle once again and turning the old deal into a "new deal."

The writer is a researcher with the Centre for Legislative Research and Advocacy (CLRA), New Delhi.