India is different. In most democratic countries discussions on healthcare have gone sideways as there is a great rift between the Right and the Left with a divider in between. In India, however, there is no Left or Right as nobody is challenging the private market in healthcare.
Contrarily, in the West, the conservatives on the Right want the state to pump the brakes when it comes to spending on health as that interferes with the market. Predictably, those on the Left disagree blaming precisely the market for the high, unaffordable price of healthcare.
Challenging or accepting the market in health become important debating points only when the issue of quality of health delivery comes up. Without that the arguments will primarily be about how to stick the taxpayers to fund a programme that does not offend commercial interests in health.
This is how it is in India and this is the principal reason why there is no Left and Right in our discussions on healthcare, only UPA versus NDA! Should it be five lakh rupees per family, or less, or more? How much can the state afford without seriously questioning the market?
No party wants to be like a gawker at a traffic wreck when it comes to health. At the same time, the supremacy of private healthcare is acknowledged by all.
In the 1950s, private health costs were just between 5% to 10% of the total health bill of the country. Today, the position is reversed and the change has not been in slow motion. There has been an eight fold increase in the number of private hospitals between 1980 and now.
This is why, as the National Sample Survey records, as many as 24% of rural households and 18% of urban households fall into the debt trap on account of medical expenses. Two out of five cancer patients lack the finance required for their treatment. This is what has given money a medicinal smell.
UPA’s Rashtriya Swasthya Bima Yojana only promised Rs 30,000 per year for five members of every Below Poverty Line (BPL) household. This looks like a frail paper boat compared to NDA’s pledge to give, through the Pradhan Mantri Jan Arogya Yojana (PMJAY), five lakh rupees for every poor household (no limit on size) per year for healthcare.
Illnesses, sadly, don’t abide by financial discipline or threshold. A cardiac ailment, or cancer, can wipe out even relatively prosperous families. This is why quality of health delivery and not financial upper limits should be critical.
Once that happens, the Left and the Right would emerge in the debate. There will now be a straight confrontation between state and private run health services on who can do a better job.
European public hospitals have always matched, often bettered, private ones, so why can’t we? In Europe, out of pocket expense is 10% roughly, but ours is 63%.
So far in India, the quality of curative care has not been axial. The total number of hospitals, private and public, number about 79,000 nationwide.
Unfortunately, just 700 or so meet the standards of the National Accreditation Board for Hospitals and Healthcare Providers (NABH). This is less than 1%!
Without quality control, most hospitals will fail to arouse trust in people. This benefits a handful of private hospitals who hesitate to join PMJAY because of its regulatory regimen.
These are the ones that will always remain crowded, even if people can’t afford them.
With drugs and pathological tests as well, patients seek quality. Estimates from different sources suggest that about 80% of out of pocket expenses are for privately purchasing medicines and pathological tests, most of it for outpatient care.
Yet, all our state health policies have leaned heavily all along towards inpatient cost reimbursement, once again, mostly private.
Health policy discussions in our country have come a long way. Earlier, we spoke of primary health and taking preventive steps. Today, the accent is on hospitalisation and curative care.
This is why the WHO-sponsored “Health for All” Alma-Ata Declaration of 1978 – that promoted preventive and community health – now appears like an old photograph of dead relations.
While we recognise curative care today, even overvalue it, we don’t quite treasure the quality of delivery. Consequently there is no political pressure to upgrade our public hospitals to effectively compete against private ones.
When this happens, if it ever does, it would bring the Left and the Right bang in the centre of the debate. Then we will know what really works, and what doesn’t, in the Indian setting. Can public hospitals match up, or not?
Till such time we will be firing ideological blanks at one another.
DISCLAIMER : Views expressed above are the author’s own.
Dipankar Gupta taught for nearly three decades in the School of Social Sciences, Jawaharlal Nehru University.