A reading of the BJP election manifesto 2014 on health reads much like a wish list and a restatement of the policy of the earlier government. The only new idea was the National Health Assurance mission that sought to use insurance as a means to ensure universal coverage. The former health minister, Dr Harshvardhan, was faced with an ailing health sector and proceeded to rightly diagnose its major drawbacks. He drew attention to the weakness of the public sector, the unethical practices of the private sector, the poor regulatory structures and the corruption in the Medical Council of India.
Harshvardhan also pushed for anti-tobacco initiatives such as the increasing the size of pictorial warnings on cigarette packets and restrictions on the sale of loose cigarettes but the powerful lobby of the industry ensured that their interests were protected. Each of his diagnoses incurred wrath from diverse constituencies connected to the health sector. All this snowballed against him and he was removed as Union health minister within less than six months of his appointment!
During this period, the Prime Minister’s programme of Swachh Bharat Abhiyan gained a great deal of media hype and attention. While hygiene and environmental sanitation are important, there are other important determinants of health that get eclipsed. These include food insecurity – resulting in high levels of under nutrition among children – livelihoods, access to safe water supply, health services and housing.
The neglect of the social sectors was visible with the spending cuts in the 2015 Union Budget. Public spending on health in India is around 1 percent of the GDP, which is the lowest when compared to other low and middle income countries. It certainly is much lower than the 5 percent recommended by the World Health Organisation. The squeeze on central funding on health meant that the National Health Assurance Mission could not take off and decisions were taken to shelve the free drugs and diagnostic schemes. The provision of accessible, affordable and effective health services to all, therefore, remains an empty promise.
The budget squeeze has affected the status of several national health programmes. Many of them have now been merged with the National Health Mission, which has also not received adequate funding. Apart from the Health Ministry, other schemes like the Integrated Child Development Scheme under the Women and Child Welfare Ministry, received only half of the required allocation. It is significant that the Parliamentary Standing Committee on Health in April, 2015 observed the negative consequences of budgetary cuts for the National Programmes and health services:
“The Committee notes that due to broad budgetary cuts imposed by the Ministry of Finance, fifteen important Health Schemes of the Ministry of Health & Family Welfare have been left without any budgetary provisions for 2015-16…
“The Committee views with serious concern the sharp reductions in allocations of funds for Health and NHM in the Central Plan in 2015-16 and feels that huge assumption has been made that 42 per cent transfer of Central Taxes to the States in the form of untied funds would compensate for the shortfall in Central funds for Health and if this assumption is not validated, then there will be a very severe shortfall of health expenditure in several backward States which fare poorly in terms of various health indicators and are, therefore, required to increase their health expenditure, but are unable to do so due to various reasons. The past experience shows that if the spending is left to the States, contractor-intensive sectors takes priority over non-contractor intensive sectors and Health, not being a contractor intensive sector, will take a backseat in such circumstances…
“Keeping all these factors in view, the Committee apprehends that in the financial year 2015-16, targeted health outcomes would be seriously jeopardised if the Central Government does not move quickly towards shouldering a bigger share in overall public spending on health. The Committee, therefore, recommends that instead of depending on the States for additional resources for health, in the year 2015-16, the Central Government should enumerate a fiscal roadmap for generating and allocating more financial resources for health so that the vision of moving towards universalization of affordable healthcare is translated into reality.” (emphasis added)
No political vision on policy front
On the policy front, the government has come up with a draft National Health Policy 2015 in January. This health policy document was drafted hurriedly and there was a lack of engagement and wider consultations. Several sub groups were constituted and were asked to give their inputs within a week! As a member of one of the sub groups, I tried disassociating myself but was unable to reach the concerned bureaucrat in the ministry despite several efforts to contact him.
It is now common knowledge that the ministry requested a few senior public health experts to draft the NHP. As a result, the National Health Policy 2015 has been widely criticised as a document that lacks vision and reads more like a UN document. The drafting of any policy cannot merely be reduced to a bureaucratic exercise. It requires a political vision, and should be able to provide directions for health services strengthening and development.
In earlier instances, several consultations were held in the Ministry of Health, the Planning Commission and the Prime Minister’s Office. For example, in UPA-I, consultations took place to design the National Rural Health Mission with active engagement between the government, NGOs and academia. This kind of engagement has been missing in the last one year of the Modi government. However, the Prime Minister has been meeting NRI doctors, business groups and representatives of multilateral organisations to get ‘expertise’ to further commercialise the health sector.
Since we are not privy to these discussions that have taken place behind the closed doors of the Prime Minister’s Office, we have to take a closer look at the trajectory of health sector development in Gujarat during Modi’s tenure as Chief Minister. Broadly, during his tenure the private sector was strengthened, a variety of public- private partnerships were initiated across levels of care and public insurance schemes were implemented. What one can expect with the cuts in budget is the further weakening of public institutions and national health programmes, and a rapid, unregulated commercialisation. If one were to judge Modi’s first year in office, then clearly the health sector is its underbelly. There is a policy paralysis in health and little political will to bring about any serious reform.
(Rama.V.Baru is Professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi)