In 2017, the Indian government issued a National Health Policy (NHP), almost 15 years after the last one. Per this policy, the budgetary spend on National Health is to be transitionally increased to 2.5 per cent of the GDP by the year 2025. The policy proposes free drugs, free diagnostics and free emergency and essential health care services in all public hospitals in a bid to provide access and financial protection to the financially weaker and at-risk sections of Indian society. What was missing for me and a lot of others was the assertion that healthcare is a fundamental right.
Child mortality statistics (number of deaths per 1000 births) are often held up as a mirror to the state of healthcare in any country. The Indian NHP also uses this statistic but with a different twist – it’s referenced as an ‘increase in life expectancy at birth’. The target is an increase from 67.5 to 70 per cent. UNICEF data for 2016 shows infant mortality rates for India as 31.6 to 37.6.
The problem with statistics is that the numbers are crunched up at different periods, and it’s not easy to show if real progress is taking place. For example, global NGO Save the children, registered in India as Bal Raksha Bharat data suggests that in 2008, 530,000 children under 5 died in the lowest income quintile in comparison to 178,000 among the highest wealth quintile. The rate of decline between 2005-06 and 1997-98 among the lowest income quintile is 22.69 per cent compared to 34.37 per cent among the high-income quintile for the same period.
There is a distinct difference in the percentages between upper strata of society and the underprivileged which isn’t reflected in the overall averages. And this is the real problem that the NHP must tackle aggressively to make any impactful difference.
The broad categories that make up the expenditure in any NHP are primary healthcare, physician’s prescriptions (medicines) and hospitalisation. In each of these categories, the cost of medicines or prescription drugs will be embedded. Under hospitalisation, there are many costs that fall under physician’s prescription like stents, implants and dressings.
In India, we have essential drugs under price control. Since hardly any drug research or innovative new drug has emerged from India, all our medicines are off-patent molecules or generic drugs with Indian brand names. Hence our market is known as a branded generic market. Unlike anywhere in the innovative pharma markets of EU, US and Japan, in India, the same generic drug will have several brands! The quality of each brand may differ depending on which company has manufactured and packed it.
The Indian drug regulatory body is also fragmented. The central apex body is CDSCO (Central Drug Standards & Control Organization), this has 4 zonal nodes and is headed by DCGI (drugs controller general of India). This body oversees clinical trials, issues new guidelines for manufacturers and importers to follow and licenses certain category of drugs including imports. Regulatory oversight of manufacture and sale of drugs is under each state authority, which issues the license to manufacture in that state. DCGI reports into the central Health Ministry whereas the state regulatory authorities report into state health ministries. So in terms of quality of products, well-known pharma companies who operate from well-controlled states are able to command and demand prices at higher price bands whereas the myriad small pharma companies operating from a state that does not have robust regulatory oversight, sell their products at much lower prices.
Government hospitals and pharmacies tend to purchase drugs at the lowest price band whereas the private hospitals and doctors prescribe and buy branded drugs from bigger pharma players. Similarly, a comparison of Government hospitals to the more expensive private hospitals lays bare the standards even in hospitalization!
India’s new healthcare policy refers to a single purchaser or payer for health – essentially the government will buy the healthcare services for the people. The policy, however, does not promise to purchase services from government or public hospitals but also plans to use private players. The challenge with this approach is that there are huge differentials in the cost. Instead of using the money to pay insurance companies for incomplete services, the government should be investing in and strengthening its public hospitals so there is little or no dependence on private players.
In its present form, the implementation of our National Health policy will be beset by formidable challenges because of the disparate health infrastructure landscape in the country. The policy builds its optimism on the perceived success of NRHM (National Rural Health Mission) which it believes has strengthened the infrastructure and trained thousands of people.
There are several lessons to be learnt from UHC implementations around the world. We would do well to evaluate what works and what doesn’t to strengthen our own.
The UK’s NHS is a rare example of truly socialized medicine. Healthcare is provided by a single payer, the British government, and funded by the taxpayer. Appointments and treatments, as well as almost all prescription drugs, are free to the patient (though paid for through taxes). The maximum cost of any drug prescribed by the NHS is $12. While this may sound like utopia it isn’t always so. There are long waiting lists for non-emergent procedures and NHS patients wait an average of eight weeks for out-patient (OPD) treatments and about two weeks for diagnostic tests. While NHS patients can choose their hospital, they can’t always choose their specialist. Well off patients who can afford to often opt out of the NHS and sign up for private insurance.
The Canadian healthcare system was built around the principle that all citizens will receive all “medically necessary and hospital physician services.” Each of Canada’s ten provinces and three territories finance and run a statewide health insurance program. There is no cost sharing for the healthcare services guaranteed under federal law. In 2009, Canada spent 11.4 per cent of its GDP on healthcare, which puts it on the slightly higher end of countries in OECD (Organisation for Economic Cooperation and Development, an inter-governmental organisation with 35 member countries of high-income economies).
Many in Canada take on private insurance to be able to pay for medication, which does not come free (or at a cut off price), though not as high as in the US. Waiting for treatment in ER is the same as in UK or worse. It depends on the medical emergency. Patients with chest pains, for example, are prioritised over cuts, bruises and broken arms.
Closer home, Thailand began implementing its variant on universal healthcare as recently as 2002, but by 2012 had covered 98% of the population. The rapid scale-up was a result of massive political will and strategic partnerships as well as public and civil society pressure. The scheme, completely government financed through general tax covers nearly 80 per cent of the healthcare needs of the people. In comparison, India’s UHC barely covers 30 per cent.
Thailand’s per capita spending on health nearly four times that of India, but as a share of the GDP, it’s only about 4.1% as against India’s 3.9%. Their secret to optimised costs is that the government mostly uses public hospitals. Since the 1970s Thailand has invested in its health infrastructure.
If the government’s intention is to protect the underprivileged and at-risk sections of our society through the NHP, it will have to do a lot more than pay lip service to the healthcare rights of our citizens. To actually makes a difference, we need a policy backed by political will, a robust healthcare infrastructure and strategic partnerships. There is documented proof when people are healthy and feel safe and secure, productivity rises. If we have the will, it can be done.