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Vol.
XXVIII No. 52
December
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Misplaced
Initiatives In The Health Sector
Amit
Sen Gupta
THE
Common Minimum Programme announced by the UPA government had a number of
portions that addresses issues related to health care in the country. Six months
after the CMP was announced, it is time to take stock of the direction in which
the government has moved as regards some of the commitments made in the CMP.
The
new National Health Policy was announced in 2002, and after a change of
government in the country hopes of a change in direction were stoked by some
positive declarations of intent in the Common Minimum Programme. It stated, for
example, that: The UPA government will
take all steps to ensure availability of life-savings drugs at reasonable prices.
The CMP also underlined its commitment to focus on primary health care. The
UPA government will raise public spending on health to at least 2-3 per cent of
GDP over the next five years with focus on primary health care.
Unfortunately, the hopes raised by such positive commitments have been belied in
the ensuing months.
BUDGET
FAILS TO HONOUR COMMITMENT
The
first budget by the UPA government provided no additional budgetary support for
health care, thereby rendering meaningless its commitment to increase public
spending on health. The CMPs commitment to raise
public spending on health to at least 2-3 per cent of GDP over the next five
years is indeed welcome, though it still falls short of the WHOs
recommendation that public spending on health should be around 5 per cent of the
GDP. However, even in order to achieve the target of 3 per cent, yearly targets
need to be formulated for the public health budget, with assured central and
expected state contributions. It would require a major increase in budgetary
support, as the present public expenditure on health care is just 0.9 per cent
of the GDP. It is unfortunate that the 2004-05 budget failed to set any kind of
a trend in this regard. If the CMPs commitment is not to remain on paper, a
plan for incremental increase in budgetary support for health has to be worked
out. This would mean a minimum 30-35 per cent increase each year, and an
additional strategy to ensure enhanced budgetary support for health from state
budgets.
DRUG
PRICE CONTROLS NEEDED
The
ministry of chemicals and fertilisers has initiated steps to consider ways in
which drug prices can be controlled, but as yet there have been no concrete
moves to impose price controls in order to bring down the spiralling rise in
drug prices. In the mean time drug companies have begun lobbying intensively to
prevent any new price control mechanisms from being announced. The hollow claims
of the industry, that drug prices are low in India, have been laid bare by a
study commissioned by the ministry. The study, which looked at three drugs
Nimuselide, Cetrizine and Omeprazole concluded that companies have huge
margins of profits in such commonly used drugs. The
study showed, for example, that while the wholesale price of generic Nimesulide
100 mg is only Rs 1.20 for a 10 tablet strip, its MRP is as high as Rs 30 in
case of one company. At the same time, the MRP of Dr Reddys brand, Nise, is
Rs 38.61.
A
committee (Sandhu Committee) has been constituted by the ministry under the
chairmanship of the joint secretary of the Department of Chemicals and
Fertilisers with representatives from the health and law ministries to
compile a list of drugs that would be brought under price control. The final
report of the committee has not yet been received. It is hoped that the present
government will not, like previous governments, succumb to pressures from the
industry and would impose price controls on essential and life saving drugs.
RURAL
HEALTH MISSION:
UNDESIRABLE FEATURES
The
governments commitment to primary health care is now being sought to be
implemented through the proposed Rural Health Mission. However, a reading of the
initial drafts of the proposed Mission raise many disturbing concerns. The
scheme proposes to hand over large parts of the public health system to private
providers and NGOs. It lays emphasis on the need to levy user fees in order to
maintain the infrastructure. It is not committed to strengthening the public
health infrastructure, but instead proposes to fill the gaps in the
infrastructure through private sector participation. An impression is being
created that the non-functioning of the public health system is a legitimate
reason for resorting to privatisation of the structure. The move towards
casualisation and privatisation is evident from the fact that the central
government has recently advertised for district level posts of district managers
and other personnel in six states of India to manage activities of SCOVA
(autonomous organisations or societies registered by the state governments.
under the direction of the central government). These personnel are to ensure
increasing participation of NGOs and other private institutions in health care.
In essence, thus, there appears to be a trend towards moving further away from
any commitment in providing comprehensive health services by the government.
The
Rural Health Mission is being tomtommed as evidence of the governments
commitment to providing primary health care. While any initiative to promote
larger coverage in rural areas is welcome, the scheme as it stands now is by no
means adequate. Even the finances that are sought to be committed to the Mission
falls far short of what would be required to put in place a comprehensive health
infrastructure. We understand that the government proposes to spend something
like Rs 8,000 crores on the Mission over the next five years. This works out to
about 0.3 per cent of the GDP per year in other words just one-tenth of the
committed 3 per cent of GDP expenditure on health that the CMP promises. If the
Rural Health Mission is to be the only matching action to the CMPs
commitment, it is obviously too little.
The
lynchpin of the Mission is going to be the Accredited Social Health Assistant (ASHA),
who would be at the centre of the Mission. She is to be paid on the basis of the
cases she brings in whether for immunisation, institutional deliveries or
sterilisations. Any such proposal, which does not make provision for adequate
and regular remuneration for the health worker at the village level is clearly
unacceptableit is tantamount to providing poor health care for poor people.
The proposed linkage to population control targets is worrying and raises the
suspicion that the primary target of the Mission would be to further the
governments stated agenda of a targeted population control programme.
As
discussed earlier, the other problematic feature of the proposed Mission is its
attempt to privatise health care delivery by soliciting the participation of the
private sector. India already has the most privatised health sector in the world
with 84 per cent of health expenditure being paid for by the people. Any
initiative that seeks to further skew this balance between public and private
expenditure needs to be reconsidered. The proposal to set up autonomous State
Health Societies at the state level will only open the floodgates for
privatisation as these societies would start seeking private funding to keep
them going. In essence this would mean the government withdrawing from its role
as a health care provider and becoming a mere regulator. We are seeing this
happening in areas like the power and telecommunications sectors already.
The
Rural Health Mission, thus, needs to consider the above and locate itself in a
framework that reaffirms the governments commitment to providing
comprehensive health care to all those who require it. This would require
adequate resources, and strengthening of all tiers of the Primary Health Care
infrastructure through government funding. Unless the Mission is designed to
address the concerns stated above, it will amount to mere tokenism and would
further pave the way for privatisation of the health care system. We hope the
government will not act in haste to put in place a sloppy mechanism in the name
of providing health care to rural areas.
POPULATION
PROGRAMME: CAUSE FOR CONCERN
It
is also a matter of deep concern that the Common Minimum programme refers to sharply
targeted population control programmes in 150 districts This amounts to
providing tacit clearance to coercive measures to control population. Not only
are such measures violative of basic human rights, they have also been shown to
be almost entirely useless in stabilising population.
The CMPs position on this stands in clear variance with the National
Population Policy 2000, which had been formulated on the basis of a wide
national consensus.
A
strategy paper commissioned by the ministry of health and family welfare
proposes a target of 50 lakh sterilisations a year in the next four years in the
five high-fertility states of Uttar Pradesh, Jharkhand, Bihar, Madhya
Pradesh and Rajasthan. This goes far beyond the current national levels 48
lakh sterilisations a year are reported from all over the country, of which only
around 13 lakh are from these five states. In the paper a much greater role is
envisaged for the private sector. The scope of the programme, the paper says,
will be increased to add another 150 high-fertility districts. It further
proposes a compensation package for sterilisation to cover the costs of the
procedures in public and private health facilities; a professional indemnity
insurance cover for doctors conducting sterilisation operations against legal
and financial costs of possible consumer cases; partnerships with the private
sector through accreditation; and suitable higher payment to doctors nearer to
basic market costs are envisaged to attain the goals in the CMP districts.
Clearly, this proposal is a complete reversal of the non-targeted approach that
the NPP 2000 had proposed.
One
is tempted to repeat an old adage: the more things change, the more they remain
the same. The first six months of the UPA government seems to prove this. One
only hopes that there will be some major changes that we shall see in the coming
months.
