From the ramparts of the Red Fort on August 15, the Prime Minister once again kept to form and announced a big-bang programme. It was the Pradhan Mantri Jan Arogya Abhiyaan or the National Health Protection Mission (AB-NHPS) or ‘Modicare’, scheduled to be rolled out on September 25 this year. It is grandiose in size. More than 10 crore families or about 50 crore Indians are targeted with a hefty medical cover of `5 lakh.
Healthcare has got a pride of place in our pronouncements, but on the ground, it gets short shrift. Sample this: This writer was part of a massive re-housing programme in 2007 of shifting over 12,000 families of poor and displaced slum dwellers in Mumbai from the borders of the Sanjay Gandhi National Park to a rehabilitation layout in Powai, where they were to get pucca homes. As the monsoons began to lash the city, the newly settled community was hit hard with a wave of epidemics – dengue, malaria, typhoid. Many children died.
Suddenly, it was realised that not enough had been done to set up medical facilities before moving such a large community. It was only after diseases and deaths sparked local agitation that a small makeshift health centre was opened by the municipal corporation; for a proper Primary Health Centre to be set up, it took nearly two years.
REPORT CARD
Healthcare has been central to the NDA government’s thinking; but the report card has not been great. For those with short memories, the National Health Protection Mission (NHPM) – the first ‘Modicare’ – was announced in 2016 Budget with a `1 lakh cover; but it never really got off the ground. It has now been dovetailed into the new AB-NHPS programme with a `5 lakh cover.Among other targets, the government had announced that its action plan would eliminate Kala-Azar by 2017, but the deadline has been missed. The spread of malaria too is of serious concern, with the World Malaria Report claiming that in India, the malaria surveillance mechanism detects a mere 8 per cent of cases, among the lowest in the world.
In respect of the AB-NHPS, identifying those qualifying for the medical cover is going to be a nightmare. The scheme is not open to all citizens, but only to the ‘poor’ identified through the Socio-Economic Caste Census database. The criteria for inclusion is catch-all and subjective. For those in rural areas, some of the conditions listed are: Families living in only one room with “kuchcha walls and a kuchcha roof”; a female-headed family with no adult male member in the 16-59 age group; landless households deriving a major part of their income from manual casual labour; and destitutes and those surviving on alms. Certification of many of these categories is near-impossible and will lead to corruption and mismanagement.
INSURANCE-BASED MODEL
The other big question mark is whether an insurance-based model for achieving universal healthcare in India can succeed. A large part of medical care is achieved through outpatient clinics, where expenses build up and can never be compensated. Therefore, a better strategy perhaps would be through public expenditure on building a more robust public healthcare system, and more doctors to cover the remotest corners.
The AB-NHPS programme currently relies in a big way on the existing private sector network of hospitals and insurance companies, which is both expensive and inaccessible. Associations of private hospitals and the Indian Medical Association (IMA) have been complaining of poor packages, and eight states are still to sign up. Whether the private sector will finally cooperate or not will depend on whether the profit margins are going to be to its liking.
The AB-NHPS programme hides the fact that India is among the poorest spenders among developing countries. Prime Minister Modi declared in 2017 the government’s intent to raise healthcare spending from the current 1.15 per cent to 2.5 per cent of GDP by 2025. But a “bare minimum” budget of around `65,000 crore demanded by Health Minister J P Naddafor 2018-19 — about 33 per cent higher than last year — was trimmed down to `52,800 crore, just 5 per cent higher than the previous year.
Sri Lanka spends about four times as much as India per capita on health, and Indonesia more than twice. As a percentage, India spends 1.15 per cent of GDP compared to an average of 1.4 per cent by low-income countries. The Maldives’ spend is 9.4 per cent, Bhutan’s 2.5 per cent and Thailand’s 2.9 per cent. More money and will need to be put where the mouth is.