Right to health? Govt of India 'coercing' beneficiaries into clutches of private players

By Raghav Agarwal* 
The Covid-19 crisis has laid bare the Indian public health system and brought it to its knees. Visuals of patients and kin desperately searching for bed, life-saving oxygen or critical medical supplies have hogged international headlines. After decades of neglect and underinvestment, the unfolding human tragedy has taken the veil off the problems plaguing India's public health system.
"For a long time since its independence in 1947, public health was neglected and was not viewed as an economically productive expenditure in the country -- unlike investments in manufacturing, services, and agriculture," says Amulya Nidhi, national co-convener of Jan Swasthya Abhiyan (Peoples' Health Movement).
"For many decades, health systems in India have not received the respect and resources they deserve. Central and State public financing of health stagnated around 1-1.5% of GDP, and outof-pocket expenditure (OOPE) on health was increased drastically to over 60% even in recent years," he adds.
India's expenditure on health as percentage of its GDP is much lower than other developing countries and its neighbours such as Brazil (9.2%), South Africa (8.1%), China (5%), Bhutan (2.5%), and Sri Lanka (1.6%).
The Bhore Committee report in 1946 declared in the very beginning of its preamble that 'No individual should fail to secure adequate medical care because of inability to pay for it.' In 1983, India enacted its first National Health Policy (NHP) establishing comprehensive primary health care services to reach the population in the country's remote areas.
However, the policy failed to meet its objective due to its selective applicability based on age, gender, ethnicity, thus preventing access to health care surveillance. NHP – 2002 was an extension to NHP-1983, focusing on public-private partnerships in public health to overcome the government's shortcomings of infrastructural and workforce deficit. 

NHP 2017 builds on the NHP 2002 in the context of progress towards 'Universal Health Coverage.' NHP 2017 stresses that making available good quality, free essential and generic drugs and diagnostics at public health care facilities is the most effective way for achieving the goal.
Ayushman Bharat, a flagship scheme of the Government of India (GoI), was launched in 2018 as recommended by the NHP 2017 to meet Sustainable Development Goals (SDGs) and its underlining commitment to "leave no one behind." Under the scheme, GoI announced the creation of 1,50,000 Health & Wellness Centres (HWCs).
The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PM-JAY as it is popularly known. It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India. Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits.

Universal Health Care vs Universal Health Coverage

While the pandemic has highlighted the structural weaknesses in India's public health system, those issues have always existed, says Amulya Nidhi. It has allowed the private health sector to grow by leaps and bounds, while the public sector has remained underfunded and underperforming. India's private hospitals are broadly commercialized and profit-driven focused on treating disease.
What makes the matter worse is that most Indians do not have health insurance and pay for health care out of their own pockets. According to the Fitch report, more than 80% of India's population still does not have any significant health insurance coverage, and approximately 68% has limited or no access to essential medicines NHP 2017 has failed to meet its expected goals of delivery, accessibility, and affordability of primary health care and insurance.
This is fundamentally ingrained in the conflict of universal health care vs universal health coverage. The two ideas are interchangeably used. According to World Health Organization, Universal Health Care means that 'all' individuals and communities receive the health services they need 'without suffering financial hardship or discriminating based on economic, social, cultural, ethnic, religious strata or gender .' 

Amulya Nidhi and Jan Swasthya Abhiyan underscore that there is a rudimentary difference between 'care' and 'coverage.' Universal Health Care provides 'Right to Health' for 'all'. In contrast, Universal Health Coverage offers benefits only to a specific population segment while depriving the majority others of the benefits. 

Amulya Nidhi

As per the RTI filed by Vivek Pandey, only 605,308 citizens could avail the benefits of PM-JAY scheme for Covid19 treatment up to first week of June 2021, with about 5 lakh beneficiaries belonging to only three states (Karnataka, Maharashtra, Andhra Pradesh). Further, only about 20,000 HWCs have been constructed to date.
This underscores the diabolical side of Universal Health Coverage, which only provides partial health services while coercing the beneficiaries into the clutches of private players to receive complete treatment. Under the pretext of Universal Health Care and lack of incentives for the government to invest in public health, NHP 2017 has accelerated the transformation (or degeneration) of public health services into an oligopolistic profiteering health industry.
It took just about 15 months and two waves of Covid-19 to expose the debauchery of the current National Public Health System and its over-reliance on private health services. "The fundamental issue remains that the commercially-driven private hospital system does not look to provide long-term ongoing care to people with the aim of preventing and controlling disease", says Amulya Nidhi.
Data from the National Sample Survey (2017-18) shows that out-of-pocket expenditure in private hospitals is almost six times that in public hospitals for inpatient care and two or three times higher for outpatient care. "A policy shift in purchasing of care from private providers is thus more likely to lead to increasing levels of health inequity and exclusion of the poor and marginalized from essential health services," he adds.
It is worth noting that even during the pandemic, private players resorted to immoral profiteering by overcharging human desperation for beds, and denying admission to those who could not meet the exorbitant costs of treatment.

Decentralised healthcare

The pandemic has relayed the focus back on the importance of public health services. Mumbai was at the epicenter of the second Covid-19 wave, with daily positive cases elapsing 10,000. The State government ramped up the free Covid-19 beds in the city to about 20,000+ in less than a month, with 80% beds in public hospitals and makeshift Covid jumbo centres.
Ramawatar Agarwal, age 63 years, was a co-morbid Covid-19 patient. Despite spending Rs 50,000 to book a bed at Mumbai's Kokilaben Dhirubhai Ambani Hospital, he was not administered any medicines, temperature or oximeter checks, or even provided drinking water for about eight hours from the time he entered the hospital. Worried about his well-being, he quickly shifted to a Mumbai Municipal Corporation-run Seven Hills Hospital. In about seven days, he cheated death and returned home without spending a penny.
Amulya Nidhi and Jan Swasthya Abhiyan believe that there is an urgent need to promote the decentralization of health care and build integrated, comprehensive, and participatory health care approaches that place "Peoples Health in Peoples Hands". They seek to make the private players more accountable, with greater government regulation and standardization of health services.
The care of public health is the first duty of the State. It should be our unflinching goal to reclaim our right to well-being and to establish the Right to Health and Health Care as Basic Human Rights inscribed in the constitution.
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*PGP 2020-22 Indian Institute of Management (IIM) Bangalore