Lack of social or political demand for good health care in India: Impact on unfolding universal health coverage

A few months back, the erstwhile deputy chairman of the planning commission (now dismantled) spoke at an event. Planning commission used to be the most powerful body setting up various developmental agendas for the country. The planning commission has now been replaced with Niti Aayog (Policy Commission)! The planning commission ex official indicated that the political representatives often do not seek resources for health care. Other sectors such as industry, agriculture, trade, and infrastructure take up the priority on the demands list. The sporadic demand in health sector is mostly limited to the tertiary care hospitals for the respective political constituencies. It appears that as a fall out of this situation the policy making for health care has minimal political accountability as well as least alignment to the needs of the people. As a matter of fact, India is going through a massive restructuring in health care in the present times. Universal health coverage is being brought to the reality. However, there is no public debate on this issue. Issues such as women safety and corruption consume a significant space of public discourse in lay media. Except for the scattered trivial media coverage, there is hardly anything above the table. This leaves space for back channeling, negotiations, and politicking by the lobbying groups. International funding agencies, pharmaceutical companies, tertiary care industry, and their representatives are predominant force in these negotiations.[12] India has the capacity and resources to build up a comprehensive, person cantered and excellent quality health care systems for her citizen based on the principles of primary health care. However this opportunity is likely to be lost. There seems to be an inclination towards maintaining a week primary care system. In spite of the talks of comprehensive care; fragmentation of public health services into several disease linked vertical programs is likely to be continued with focus on diseases such as Polio, tuberculosis and HIV. The vertical programs reflect wilful and wasteful public health spending. Projects are driven by pressure to spend (financial targets) instead of specific health indices as outcomes. There is strong interest towards developing and maintaining tertiary care services through public health funds which is likely to result in industrial consumption of medical goods. There is talk about strengthening of traditional systems of AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy) but the focus appears to be at developing legal framework for expansion of prescriptions for allopathic pharmaceutical products by nonqualified practitioners. Shortage and regional imbalance of physicians is a widely publicized issue. However, in spite of the public outrage, policy makers are politically refraining from bringing medical education under rightful regulation, transparency and accountability. Unregulated over the counter sale of pharmaceutical products continues. Price regulation of drugs and medical devices seems to be a distant dream. The issue of regulation of the private health care industry is being altogether declined. By perpetuating ignorance about clinical gate keeping of secondary and tertiary care services and by proposing to allow the financial instrument of universal health coverage as a cover for the purchase of drugs, diagnostics and secondary & tertiary care services; the subsidy raised from general taxation is being designed to be indirectly transferred for the benefit of the tertiary care industry. The insurance schemes supported through public funds shall cover hospital care only. There is no talk of use of insurance funds for the provision of health maintenance, prevention and promotion thereby reducing the expenditure on tertiary health care; which even the richest countries in the world are finding difficult to bear. This is unusual for a Universal Health Coverage program for a country like India with high disease burden. The proposed model has little resemblance with the models of other developed countries such as Canada, Australia and UK; who have achieved UHC several decades back. Unless low cost, high quality and equitable healthcare become a political demand and an electoral issue, the situation is not likely to change. Health care is projected to be a booming industry and likely to grow many folds in the near future. Should the public health policies be synchronized with the growth of health care industry? There is a general mood for economic development in India. But do economic development of a country and growth of health care industry are meant to be in alignment? As a country shouldn’t India be saving on unnecessary unregulated health care spending? With a huge population to cater and profound morbidity in the undeserved; shouldn’t India be targeting on cutting down the sickness levels thereby down regulating the spending incurred due to preventable causes of death and disability? A relatively young population is our dividend, but how are we going to benefit from it if the same population is crippled with disease, illness, and sickness and simultaneously burdened with low quality or costly healthcare? India must strive to develop a vision to reap economic benefits of a healthy citizenry rather than focusing all public health policies on growth of health care industry. The first priority of public health policies should be an alignment with the public interest. It is healthy to keep public health policies noncontaminated from the interests of health care industry.[3] Corruption in healthcare is not limited to the practices of the individual medical practitioners. It has a wider international and national perspective. By signalling out the professionals only, general public is left out with little leverage in negotiation with dominant industry forces; while the wider malaise goes unnoticed from the public scrutiny. Political leadership should be pragmatic enough to respond to this crisis and should not wait too long for health care to become an electoral political demand; thereby saving decades for Indian democracy.

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