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 CMP’s 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 WHO’s 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 CMP’s 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 Reddy’s 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 government’s 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 government’s 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 CMP’s 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 unacceptable—it 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 government’s 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 government’s 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 CMP’s 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.