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National Health Entitlement: Should health care be absolutely free?

The National Health Entitlement proposal by the Government of India is under current consideration of the Planning Commission aiming at provision of making health service totally free. It is a novel dream to enable each Indian to avail both in-patient and out-patient public health services without any user-fees. Nevertheless, many dreams do not end in reality. Going by the requirements and expectations of the public at large, the proposal sounds excellent and promising. However, health care can never be free of cost for any service that is provided by health care delivery system directly. For example, good roads can reduce road accident, improved communication system can help reach the injured faster to the hospital….but the drop of betadine put on the injured part has to be borne by the health system in terms of cost! We have to remember someone somewhere has to, somehow, bear some expenses for health! The old saying that “Public health is a purchasable commodity” is still the ‘gold saying’!

Two things are never seen by any one but given importance by all …the God & the Government. Beyond the realms of such a utopic India as envisaged by the health entitlement proposal where there is no rich-poor rift and health care expenses are non-prohibitive, it must be realized that the economic calculations involving public health are delicate. Imagine the levy is paid by none other than the Government. But, who bears the load in real? The surcharges, ultimately, topple down on to the heads of the tax-payers to ensure budget availability for such an ambitious proposal. The envisioning also thus appears easier and announcing aloud to be politically correct! However, the point may still be debated with the stand out question as…..would it really work? It has two unequivocal responses: firstly, the poor tax payer is throttled down with yet another added knot to pay for somebody who does not pay tax (incapable to earn or manipulating the tax payment) and secondly, undue importance is laid on the vote-bank-politicians and not on the constructive ones. Although this might provide cheap popularity to the short-sighted polluticians for a transient period, it would ultimately damage the whole system in the long run. Examples are many….like what has happened in the railways scientifically…. tracks are racking…signaling systems are failing……..leading to colossal rail mishaps. One boasting statement of one health minister that,”we have created one doctor in every 1000 population / each village” some time in seventies completely jeopardized the Community Health Volunteer Scheme …so on !These type of experiences we have faced on many occasions and are afraid, we may not repeat the same this time also.

Let us consider our experiences and views on the determinants of public health services utilization, the need and demand analogy with the logical way out. Health is a State subject. Tax is collected mostly by the Centre, hence distribution of the tax earned finance vis-à-vis the health at the state level becomes a complex matter too. Looking towards the health programmes, the ‘achievements’ of some of them confuse all…the provider, the acceptor, the national outcome as well as on the international slate.

  • The National Nutritional Anemia Prophylaxis Programme, in one form/ name or the other since 1947 till date, has tried providing free Iron-folate tablets to expectant mothers to ward off anemia and even today almost 80% of pregnant women are anemic. The programme has largely been unsuccessful with just 23% of the pregnant women taking the tablets as per the program protocol of 1 tablet a day for 90 days or more (NFHS 3). What have we achieved by free distribution? Iron tabs,distributed are mostly not consumed since its thought to be “Free and will not work”. Probably, if we would have prescribed Iron to those who demanded, at least some, would have purchased and got cured of anemia.

  • Operating for free did not help our ‘family planning’ and we had to incentivize the adoption of permanent methods of sterilization (tubectomy and vasectomy). Scientifically, permanent methods do not check the population as much as the methods for birth spacing. Further, the planners believe that education will improve status of family planning. But this equation is not one to one. Kerala’s birth rate is much less than other states but most reproductive age Keralites stay outside Kerala for different jobs irrespective of whether it is Jammu, Jamshedpur, Jamaica or Jerusalem ! If they add their population to those places… who produces in Kerala? Is it the under-fifteens & over-sixties group? If it is so, we need to relook at Kerala and into our population policies. If situation of Kerala is so good, why there is higher emigration than most other states in India. Statistics are misleading realities…they can’t talk of live situations. Health cannot be achieved by statistical models either. The difference between statistics & health is something like the difference between a Motorcar carburetor mechanic and a heart surgeon, the former deals with a non-living machine whereas the heart surgeon handles a bustling life!

  • Ironically, we succeed in one health programme and damage that programme with another programme introduced without understanding the complexity of inter and intra-programme interactions. For example, while introducing the Pulse Polio Programme we gave two wrong messages to people. Firstly, the common man understood “Immunization means Polio” and secondly, “If they don’t come for immunization, the workers will go for their homes”… so the consumer thought, “why undertake the pain of attending a health centre or booth, when the worker would come home?” Thus, they stayed at homes, waiting immunizations to reach them and “the fully immunized” (immunized against 6 killer diseases including Measles with vitamin A) population tumbled down from 85% to even 21% in some districts in this country and what we lost was “universality of immunization” because of our understanding of providing “everything for free at the door step”. It is believed that sometimes negative statements might attract attention. If we say polio vaccine will be available only to people who pay for it, may be people would agitate against it with probably a revolutionary the slogan “immunize all of us!”

  • The anti-tubercular therapy administered as DOTS is one of the costliest drug regimen (~some where around Rs.10 to 15 thousand per patient) provided absolutely free of cost to the needy. ‘Needy’ is as per our definition… whether actually he needs free drugs or not, no one has ever asked. We have also affixed some incentive for the DOT provider upon successful completion of therapy per patient. So, apart from the medicine, the cost of incentive is another overload on the Government / tax payers. But what are missed in DOTS are two ‘I’s. They are Intensive case follow-up and Integrity of the DOT worker. The programme does not talk on these two issues and we justify “if it’s free, it is accepted by the people”. And expected, the DOTS Programme is failing with the connotation of increased Non-acceptors and Defaulters.

There are so many examples to amply highlight that health service subsidization alone cannot ensure service uptake by the population. Imagine, a vendor starts selling apples at Re. 1/- per kilo, most of us would perceive it as stuff not for human use! And the apples would then really get rotten. Notwithstanding the fact that talking beyond the parlance of a populist agenda is difficult for the government, what is required is a genuine ‘political will’ and not just ‘pollutical’ drama. Why we say it a drama? Let us get into some realities. A man on an average suffers four times a year from acute diseases. Thus, India will have 488 crore acute patients per year or more than one crore patients per day. One might have to add an equal number of Accident cases and probably double that for all kinds of chronic illnesses from tuberculosis to leprosy and what not. This makes Four Crores of people needing health care every day. If one case needs just a minimal of hundred rupees for care {inclusive of transport, medicine, salary of care giver(s) and others}; we need minimum Four Hundred Crores of rupees every day. If we add the cost of expenditure on malnutrition, mental diseases and non-communicable disease cases it might swell up to four lac crores of rupees a day. Can any Government, world over, handle this? Do our polluticians even know about this reality? Hence, it is better not to spread a myth !!

Bhore committee had recommended one Primary Health Centre in every 30 thousand population, in the year 1946–which we have not achieved even today. We need 1 doctor per 3500 population,1 nurse per 5000 population and 1 pharmacist per 10,000 population.(GOI, 2008). While we have 0.7 Doctors & 0.8 Nurses per 1000 population (GOI,2006), they are mostly concentrated in the urban areas with inadequate health staff support to the sick in the rural. While the picture remains distorted, it is for sure, the Government has a mismatched finance to health. The amount of money spent on advertisements of HIV/AIDS could be more than many of our other budgets while AIDS education could be pinned with other heath related subjects. Availability of potable water supply and treatment of sewage & excreta disposal will remove 95% of diseases from India (WHO). And that we do not focus upon!

The Centre imposes a 10 per cent tax on 119 services. Over the years the government has been trying to bring more services under the tax net to meet the deficit caused by generation of just Rs. 82000 crore off service taxation instead of the estimated Rs. 50 lakh crores for 2010-2011. It has been making news that in a concept note promulgated by the Finance Ministry for service tax levying, two options have been given for the health services. One option is to exclude all services provided by clinical establishments with turnover under Rs 4 crore from the tax net. This means that if we avail medical care from a popular private hospital (which, in most cases, would have a higher turnover given its popularity) then apart from the medical bill, we will also have to pay an additional ~10% of the total amount towards service tax. If we look into the health need and demand of the people, 0.1% of the sick need sophisticated health care which is on most occasions life-saving. This format of care is either available at apex public health set-ups like AIIMS or in certain corporate hospital groups. The cost of such care is also, expectedly, high. If the patient has to bear additional service tax, then obviously service affordability and utilization would decrease. Moreover, the scope of such training to doctors would meet a dead end bringing capital and intellect investment in medical services to a chaotic dismantling.

The second option is to keep hospitals, medical care, diagnostic and Para-medical services out of the tax net. The only exception will be in case of health check-up and cosmetic or plastic surgery. The second one is rather better, but will still throttle the taxpayer and the poor may not be benefited. Notably, after the last budget, the government, cornered by public protests led by hospital chains, had decided to defer a tax on most healthcare facilities.

Health is a complex subject with the cob web of causation, and service or utilization by the people are still more complex issues to understand, what to talk of implementation. The process follows the method of ‘Hour-glass factors of health service utilization’ depicted by the diagram below:

The ‘hour-glass factors of health service utilization’ have to be studied and the principles adequately imbibed in this regard. The factors are convergence of health care services, commitment of health and health related teams and community involvement, popularly known as the ‘3 Cs’. The commitment factor is the critical connection between ‘service convergence’ and the ‘community’. It is laudable that our efforts have worked towards health services convergence and building a committed health team through multitudes of training and capacity building sessions. Asking for community involvement in the health provisioning is also praiseworthy. All the three factors carry a dynamic ‘weight’ relationship which gets redefined depending upon the community. However, we are half-done with all the 3 Cs. Our service convergence is not equitably distributed through our health infrastructures. Capacity building is an on-going process with invariable deadline-disrespect. Health worker training and incentivization have not guaranteed commitment given the inadequacies and inappropriateness in the same. Community involvement is still a far cry as marketing an uninteresting ‘product’ like ‘health’ is extremely difficult.

Graduating from a supply driven mechanism to a demand driven system has been more logical through the years of public health practice. Thus, community involvement is perhaps the most important determinant to keep the process viable and community ownership which is a logical outcome of community involvement is essential to ensure health service utilization. Even Bill Gates would use ‘Windows’ instead of any other operating system for his computers! Here lies the essence of levying user fees for patients attending the public health care institutions. All of us would understand that Re. 1/- per patient registration, as is prevalent at some health centres, is not too high, on the other hand cuts down ways out for medicine pilferages. The virtues of affordability, acceptability or accessibility are not compromised thus. Neither is it a replacement for the health expenses incurred by the Government. Rather, the patient perceives the value of such a prescription, and respects and preserves the slip. The patient takes the responsibility of his health and is more concerned!

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