February 29, 2016 was the day of high expectations for many, especially to get to know the focus areas of public resource allocations of the incumbent governments in its third year of office. Healthcare sector too awaited eager to see something substantial in the resource allocation, that would make a fundamental difference in the public health systems and services in India.
The general expectation was high, as its main ruling party had promised to deliver a robust healthcare reform in its Election Manifesto 2014, when it will be voted to power. Some of those critical promises are as follows:
- “India needs a holistic health care system that is universally accessible, affordable and effective and drastically reduces the out of pocket spending on health.
- NRHM has failed to meet the objectives and will be radically reformed.
- The Party accords high priority to health sector, which is crucial for securing the economy.
- The overarching goal of healthcare would be to provide, ‘Health Assurance to all Indians and to reduce the out of pocket spending on health care’, with the help of state governments.
- The current situation calls for radical reforms in the healthcare system with regards to national healthcare programs and delivery, medical education and training and financing of healthcare.”
- The manifesto then went into the details of each reform areas, after stating, “the last healthcare policy dates back to 2002; India now needs a comprehensive healthcare policy to address the complex healthcare challenges, keeping in view the developments in the healthcare sector and the changing demographics. The party will initiate the New Health Policy.”
Over three years have passed since then, unfortunately even the new and comprehensive healthcare policy is not in place, just yet.
In that backdrop, we all witnessed in the budget presentation, a well-wrapped package for healthcare in India. The ‘attractive’ packaging label, listing each element of its broad content, was outwardly impressive and attracted almost instant eulogy from a number of industry commentators.
In this article, I shall first present before you, the healthcare measures announced by the Finance Minister Mr. Arun Jaitely in his Budget speech (2016-17), and then would unwrap the package to discuss briefly the implications of each of these three key elements, and the possible impact.
Union Budgetary Proposals on healthcare:
While proposing his Union Budget Proposal (2016-17), the Minister mostly covered ‘healthcare’ in points 52, 53, 54 and 55 of his speech, as follows:
A. Improving access to healthcare:
While proposing a key measure to improve access to healthcare, the Minister acknowledged before the Parliament:
- Catastrophic health events are the single most important cause of unforeseen out-of-pocket expenditure which pushes lakhs of households below the poverty line every year.
- Serious illnesses of family members cause severe stress on the financial circumstances of poor and economically weak families, shaking the foundation of their economic security.
In the above backdrop, the Minister proposed that, in order to help such families, the Government will launch a new health protection scheme, which will provide health cover up to Rs. One lakh (Rs. 100,000) per family. For senior citizens, age 60 years and above, belonging to this category, an additional top-up package up to Rs. 30,000 will be provided.
B. Availability of quality medicines at affordable prices:
Acknowledging the fact that making quality medicines available at affordable prices has been a key challenge for the country, the Minister reiterated that the Government will reinvigorate the supply of generic drugs. Moving towards this direction, 3,000 Stores under Prime Minister’s Jan Aushadhi Yojana will be opened during 2016-17.
C. Addressing an important need of end-stage renal disease patients:
The Minister informed the Parliament that around 2.2 lakh new patients of End Stage Renal Disease gets added in India every year, resulting in additional demand for 3.4 crore dialysis sessions. With approximately 4,950 dialysis centers in India, largely in the private sector and concentrated in the major towns, the demand is only half met. Every dialysis session costs about Rs. 2,000 – an annual expenditure of more than Rs. 3 lakhs. Besides, most families have to undertake frequent trips, often over long distances, to access dialysis services, incurring heavy travel costs and loss of wages.
To address this situation, the FM proposed to start a ‘National Dialysis Services Program’. Funds will be made available through PPP mode under the National Health Mission, to provide dialysis services in all district hospitals. To reduce the cost, he proposed to exempt certain parts of dialysis equipment from basic customs duty, excise/CVD and SAD.
Unwrapping the healthcare budget proposal:
Let me hasten to add at this stage that I have not seen the fine prints of each of these proposals, as yet. My analysis is solely based on the budget speech.
A. Improving access to healthcare:
At Rs. 19,037 crores, the budgetary allocation for the ‘National Health Mission (NHM)’ remains almost the same as the previous year. Overall investments to improve healthcare infrastructure still remaining absolutely meager, the ad hoc strategy of the Government to improve access to healthcare is an insurance-centered, rather than universal, free and cashless health services, as was earlier suggested by the ‘High Level Expert Group (HLEG)’ constituted earlier by the Government.
According to the analysis of National Sample Survey (NSS) data for 2014, published in the Economic&PoliticalWeekly dated August 15, 2015, only 13.1 percent of rural and 12 percent of urban residents are covered by government-funded insurance schemes, though the official data states 25 percent coverage. The NSS data also shows an increase in the out-of-pocket expenditure in these areas.
This has happened, even after the promotion of the Governments own insurance-based schemes, such as, the RSBY by the Central Government and also similar schemes by the State Governments, such as, Arogyasri in Andhra Pradesh, over a decade.
Additionally, there are many other reports, which clearly highlight that just pushing for increased insurance coverage, does neither help the poorest of the poor of society, nor does it ensure better and more efficient financial protection.
A paper of October 9, 2013 titled, “Universal Health Coverage – Why health insurance schemes are leaving the poor behind” reiterates that funding through progressive taxation is the key to achieving ‘Universal Health Coverage’. Even the poorest countries can raise more revenue for health through taxes. Oxfam estimates that improving tax collection in 52 developing countries could raise an additional US$269 billion, which is enough to double health budgets in these countries.
The world over, and mostly in the OECD countries, serious doubts are still being expressed about the effectiveness of targeted insurance-based health schemes, instead of public funded focus on ‘Universal Health Care’.
Looking in isolation, while the measure of incremental health insurance coverage, as proposed by the Minister, seems to be a good intent to improve access to healthcare to some people, but is devoid of a clearly charted holistic pathway, based on the lessons learnt from the past. Just the announcement of intent may, therefore, not be effective on the ground.
Currently, India has the Rashtriya Swasthya Bima Yojana (RSBY), launched by the Labor and Employment Ministry on April 1, 2008, to provide health insurance coverage to ‘Below Poverty Line (BPL)’ families. RSBY coverage extends to five members of a family-head of the household, spouse and up to three dependents, who are entitled to hospitalization coverage of up to Rs 30,000 for most diseases. In this insurance scheme, the beneficiaries require to pay only Rs 30 as registration fee, while Central and state governments pay premium to the insurer.
It is still not clear to me, whether, the newly announced insurance coverage is a separate scheme all together with details to be announced later or a part of RSBY initiative.
Besides all these, the fundamental question, however, that would still keep haunting, how would the existing mostly rickety rural brick and mortar healthcare infrastructure; non-availability of right medicines at the right time and at the right places; acute shortages of medics and paramedics, satisfactorily address the incremental needs, thus created?
B. ‘Pradhan Mantri Jan-Aushadhi Scheme’:
This does not seem to be a new initiative, at all. Jan-Aushadhi is an ongoing campaign launched by the Department of Pharmaceuticals in 2008, in association with Central Pharma Public Sector Undertakings (PSU), to provide quality medicines at affordable prices to the masses. Jan Aushadhi Stores (JAS) are being set up to provide generic drugs, which are available at lesser prices, but are equivalent in quality and efficacy as expensive branded drugs.
The Department of Pharmaceuticals had proposed to open at least one JAS in each of the 630 districts of the country, so that the benefit of “quality medicines at affordable prices” is available to at least one place in each district of India. If the initiative becomes successful, depending on the cooperation of all stakeholders, the scheme was to be extended to sub divisional levels as well as major towns and village centers by 2012. However, after 5 years, i.e. up to February, 2013, only 147 JAS were opened, and out of those only 84 JASs are functional.
More recently, according to a June 02, 2015 report, “under the new business plan approved in August 2013, a target of opening 3,000 Jan Aushadhi stores during the 12th plan period i.e. from 2013-14 to 2016-17 was fixed. As per the Standing Committee on Chemicals and Fertilizers report in March 2015, till date only 170 Jan Aushadhi stores have been opened, of which only 99 are functional.”
The tardy progress of the scheme was largely attributed to:
- A lackluster approach of State governments
- Poor adherence to prescription of generic drugs by doctors,
- Managerial/ implementation failures of CPSU/ BPPI.
- Only 85 medicines spread across 11 therapeutic categories were supplied to the stores and the mean availability of these drugs was found to be 33.45 percent, with wide variations across therapeutic categories.
With all the available information, it appears that the same old and unsuccessful scheme, even during the tenure of the present Government, since the last 3 years, has been repackaged and announced with a new name “Pradhan Mantri Jan Aushadhi Scheme” in the Union Budget 2016-17.
There is no doubt, however, the intent of ‘Pradhan Mantri Jan-Aushadhi Scheme’ of 2016 is as laudable as the “Jan-Aushadhi Scheme”, launched by the Department of Pharmaceuticals in 2008, was at that time, but will it start working now, all of a sudden, despite sustained failure?
Besides strong support required from the State Governments, and other factors as enlisted above, making the doctors prescribe drugs in generic names would be a critical factor to make the “Pradhan Mantri Jan-Aushadhi scheme’ a success and primarily to extend desirable benefits to a sizeable section of both the urban and rural poor. The question, thus, remains, how would the Government ensure that the doctors prescribe drugs in generic names?
C. National Dialysis Services Program:
The proposal for the ‘National Dialysis Services Program’ to provide dialysis services in all district hospitals, especially, due to a staggering number of around 2.2 lakh patients of ‘End Stage Renal Disease’ in India every year, is yet another laudable intent in isolation, though it emerges just as an ad hoc measure in the healthcare space of the country, sans the new National Health Policy.
In my article last week titled, “Healthcare In India (2016-17): Whither Goest Thou?”, I wrote, as the new ‘National Health Policy’ is still not in place, we may, at best see in the Union Budget Proposals (2016-17), some ad hoc measures for healthcare.
While unwrapping this budget speech of the, it appears that on a broader perspective the measures proposed in the budget have turned out exactly that way.
Nonetheless, the proposal of the Finance Minister for a special patent regime with a 10 percent rate of tax on income from worldwide commercialization of patents, which are developed and registered in India, is an excellent one, by any standard, for the innovators.
With frugal public health expenditure of just around 1 percent of GDP, as compared to 3.5 percent of China and 5 percent of Brazil, with larger GDP base, successive Governments of India has been blatantly neglecting public healthcare, for far too long, which continues even today.
At a time, when the Government is mulling making health a fundamental right for Indian citizens, similar to education, and making denial of health an offense, besides its earlier other promises, these budgetary measures are disappointing to many.
Overall, the Union Budget Proposals, made by the Finance Minister for 2016-17, falls far too short of reasonable expectations of any deserving citizen of the country. Neither does any such healthcare measure appear holistic to me, besides being sustainable, as I unwrap the Minister’s healthcare package and take a closer look at it.
By: Tapan J. Ray
Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.