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Resource centre on India's rural distress
 
 

For a quantum leap to deliver primary medical care -Meenakshi Datta Ghosh & Dr. Prasanta Mahapatra
-The Hindu

The primary health-care system in India, intended to enable affordable health care, has not delivered on its promise. Rural, public health facilities are unable to attract, retain and ensure the regular presence of trained medical professionals. Health centres and hospitals in the public sector have proliferated but they are distributed inequitably. India may have one government hospital bed for every 1,833 people, but the reality is that while in Goa there is one bed for 614 people, in Bihar it is one for every 8,789 people (The Lancet, November-December, 2015).

On average, a poor household spends 14 per cent of its income on health care; the figure varies from 1.3 per cent in Tamil Nadu to nearly 37 per cent in Jalore, Rajasthan (Iyengar and Dholakia, 2012). Wherever State governments have increased the coverage and outreach of reliable primary medical care, for instance in Tamil Nadu and Kerala, these States have health outcomes which are on a par with those in Sri Lanka and China.

News reports indicate that Budget 2016 is set to unveil the “mother of all health schemes”. A health protection plan at Rs.800 per family (Rs.500 as Central assistance and Rs.300 as the State’s share) is being envisaged for eight crore families defined by socio-economic and caste criteria. This will entitle each family to a health insurance cover of up to Rs.50,000 per annum, with a Rs.30,000 top-up for senior citizens in this group. The insurance cover will be redeemable at private secondary and tertiary health-care hospitals. The health cover in the Rashtriya Swasthya Bima Yojana (RSBY) will be enhanced to Rs.50,000 from the current Rs.30,000 per family per year. A national health agency is being considered for effective implementation. It is said that the Centre will spend Rs.4,000 crore annually, with States’ contribution of Rs.2,600 crore.

However, this current model of health insurance is structurally flawed. Merely enhancing covered medical expenses and adopting persuasive labelling and semantic changes does not in any manner alter the distinguishing feature of the RSBY. It is essentially a catastrophic, health insurance scheme that promises access largely to specialist medical care at the secondary and tertiary levels. What happened to that first and most critical building block for universal health care, i.e. primary medical care? Expanding health insurance devoid of organised and accountable primary medical care services is like putting the cart before the horse.

A wish list

In Budget 2016, we are looking for a quantum leap in the allocation for primary medical care. We recommend a community health insurance programme (CHIP). For the same premium targeting a family of three persons, we recommend as the core scheme, a family health protection plan (FHPP) in the domain of primary health care, which will cover comprehensive ambulatory medical care and hospital access.

CHIP will build on the existing health-care infrastructure, with a view to stimulating demand-driven growth. It will strengthen primary medical care at primary health centres (PHC) and introduce competition among ambulatory care providers by recruiting non-profit and for-profit private providers. Clinics, polyclinics, nursing homes and hospitals, in public, non-profit and for-profit sectors will participate. Clinics set up by practitioners of Indian systems of medicine can also partake in this. PHCs must participate and compete with other providers. A participating clinic must satisfy the required quality of service standards. This will help build a robust foundation for primary health care.

CHIP will be feasible only if subsidy entitlements and premium obligations are equitable, based on a person’s paying capacity rather than medical need. Most social security programmes in the country rely on the poverty line, which is appropriate only for food subsidy. Thus, many families with income marginally above the poverty line, when faced with high medical and health expenditure, end up below the poverty line. It is well known that the lower middle class is unable to afford the cost of medical care. Health and housing are the next in order of need of families as their income goes above the poverty line. Hence it is necessary to fix a separate income line for health and housing. The monthly income limit for employees’ state insurance (ESI) eligibility and low-income housing finance should be synchronised.

These must also be thought of: setting up a technical group on income lines for health and housing (it can be done jointly by Niti Aayog, the Ministries of Health, Housing and Labour) to develop the technical basis for computation of these income lines and periodic updates; adopting for the low income group (LIG) an income figure around the current official low income limit for housing finance and salary limit for ESI coverage. In that event, the middle income group (MIG) would include families with a monthly income more than low income limit, but with marginal taxable income. The remainder would constitute the high income group (HIG); grading the subsidy on the premium for FHPP in a way that below poverty line (BPL) families get 100 per cent subsidy, LIG 75-90 per cent subsidy, MIGs 50 per cent subsidy and HIGs entitled to a health insurance premium subsidy enjoyed by income tax-paying families through income tax concessions.

With the government failing to deliver the goods, the private sector health-care provider is now the new normal, despite being known for dispensing aggressive and unaffordable treatment. Rural households do not have too many options. Data from the National Sample Survey Office corroborate the finding that RSBY does not provide financial protection equitably. Without primary health care, there is little hope of achieving equity. But will Budget 2016 make primary care happen?

Meenakshi Datta Ghosh is former Secretary, Government of India. E-mail: mdattaghosh@gmail.com

Dr. Prasanta Mahapatra is Dean of The Institute of Health Systems. E-mail: pmahapat@gmail.com