Health versus wealth

Poornima Joshi, Hindu  Jul 26, 2012

Health issue:The packaged care model may not work as it deters an integrated health system.

Health issue:The packaged care model may not work as it deters an integrated health system.

Current deliberations in the Planning Commission about actualizing universal health care in the Twelfth Five Year Plan, have invited concerns. There has been a marked thrust on state-funded insurance as opposed to a genuine effort on the government’s part to rebuild public health systems, something that has been a globally time-tested system to ensure health for all.

The ongoing discussions are based on reports of the Planning Commission’s steering committee and High Level Expert Group (HLEG). The contentious theme in the definition of the Universal Health Care (UHC) coined by HLEG, excluding the promise of ensuring “affordable, accountable, appropriate health services of assured quality to all Indians”, states the role of government as a “guarantor and enabler” and not necessarily the “only provider” of health and related services.

The HLEG makes two critical recommendations that have raised objections from health experts and activists alike. A crucial recommendation that is being contested is the “purchase” of insurance schemes by the government. “Purchase of all health care services under the UHC system should be undertaken either directly by the central and state governments through their departments of health or by quasi-governmental autonomous agencies established for the purpose,” says the HLEG report. The other contentious suggestion is the proposed “contracting in” of the private sector. “Develop effective contracting-in guidelines with adequate checks and balances for the provision of health care by the formal private sector,” HLEG report adds.

At a seminar organized by the Council for Social Development in the Capital in July, health experts opposed this proposed roadmap towards UHC even when there was near unanimous approval of the proposal to raise health expenditure from the abysmally low, that is, 1.2 per cent of the GDP, to at least 2.5 per cent of the GDP by the end of the Twelfth Plan, and to at least 3 per cent of GDP by 2022.

According to Prof. Imrana Qadeer, formerly of the Centre of Social Medicine and Community Health (CSMCH) in JNU, improvement of health care has to be accompanied by enhancing the efficiency of public sector. “There is a need to go back to the Bhore committee and delve into economic and social structures in the country to if access to health care has to be universalised. We have to talk of equality not equity. The steering committee separates health from health services,” said Prof. Qadeer. “What do terms such as ‘contracting-in’ of the private sector mean when the corporate sector is actually leading reforms in the health sector?”

The HLEG envisages a “managed care” model with a thrust on an increase in government expenditure. By increasing public spending on drug procurement, availability of free essential medicines is to be ensured. General taxation, as per HLEG, is the principal source of health care financing – complemented by additional mandatory deductions for health care from salaried individuals and tax payers. It proposes introduction of specific purpose transfers to equalize the levels of per capita public spending on health across different states level of essential health care. Most importantly, the HLEG proposes universal and cashless access to an Essential Health Package (EHP) including essential medicines.

These ideas are further consolidated in the steering committee of the Planning Commission. “To begin with, core components of the EHP must include all the preventive, promotive, curative and rehabilitatory services in routine and emergency settings available under RCH and national health programmes,” says the steering committee report.

There are problems with this “packaged care” model, pointed out Dr Amit Sengupta of the Delhi Science Forum (DSF). How do you spend the money—do you use it to build a system or use it to provide UHC as a package? Who provides health care is important because fragmented provisioning of services does not allow for development of integrated health systems.

“Advancing the logic of fragmentation, an attempt is made to promote segregation of health systems into primary care by the public sector and tertiary care by the private sector. As the private sector grows to fill the vacuum, a loud noise is made about ‘catastrophic payments’. The state then steps in and asserts that a ‘minimum package’ would be ensured. The argument for this is lopsided because private sector, despite being a ‘partner’ in providing tertiary care, is then financed through public funds, that is, through ‘minimum packages’ ensured by the state,” said Dr Sengupta.

There is enough evidence, said Dr Sengupta, to prove that the best performing systems are those that are publicly financed and provisioned. “Public provisioning needs to be located in a range of other social protection measures while public financing has to be located in a progressive taxation system that is premised on the notion of equity.” Clearly, it will take far more than insurance packages to ensure health for all. Time-tested global models in Cuba, Costa Rica and neighbouring Sri Lanka prove that the government has to necessarily be the “provider” and not just a “guarantor” to actualize universal health care.

The Planning Commission’s perspective on universal health care causes concern

Immediate Release-Jan Swasthya Abhiyan Calls For National Debate for ‘Universal Health Care’

Press Statement on the occasion of World Health Day – April 7th 2012

Jan Swasthya Abhiyan Calls For National Debate On Design Of Proposed System For ‘Universal Health Care’

Ensure quality, free health care for all as a right: Give priority to expansion and improvement of Public health services, regulate Private medical sector

Over the past year there has been a lot of interest in and visibility of the concept of Universal Health Care. The Planning commission had set up the High Level Expert Group (HLEG) on Universal Health Care (UHC) which has submitted its recommendations in Nov. 2011. The Planning Commission is now considering implementation of Universal health care in some form during the XIIth Five year plan. JSA welcomes this interest and commitment to Health care for All by the Government of India. On the occasion of 7th April, 2012 World Health Day, JSA would like to set out clearly our views on the issue as well as express serious concern with the direction in which the discourse on Universal Health Care seems to be taking.


The JSA welcomes a number of key aspects of the HLEG-UHC report. Most importantly we appreciate:

 The emphasis on the concept of “universal”, of including every citizen, unlike the currently dominant approach of “selective” approach of targeting the poor

 Clear emphasis on tax-based financing of the health system, rejection of insurance in the financing and provisioning of universal health care.

 Recommendation to abolish user fees in the health system.

 Definite commitment to “Free Medicines for ALL” in the Public Health System.

 Recommendation of strengthening and the expanding the public sector

 Recommendation to establish Urban UHC system.

Defining the need and urgency of private sector regulation, as well as outlining a potential regulatory structure.

 Bringing Community based accountability mechanisms to the center stage.

More recently the Steering Group on Health of the Planning commission finalized its report which incorporates (interprets) the findings of the HLEG into the Planning Commission process. However the Steering committee report contains recommendations that would defeat the purpose and spirit behind any evolving process of Universal Health Care.

 The reduction of the comprehensive Essential Health Package suggested by the HLEG into just RCH and National Health Programes. This is NOT a Universal health care entitlement.

 The concept of giving financial and operational autonomy of the public health facilities is also very problematic. Financial autonomy means leaving the public health system to “fend for themselves”. This will be very damaging to any hopes for a Universal System.

 The concept of “provider choice” to choose between private and public providers is also unacceptable. Especially during last 20 years, the public health system has been neglected and made sick whereas the private sector has received encouragement for un regulated growth.

 JSA believes that the private sector should play a complementary / supplementary role, on the terms defined by a strengthened public health system accountable to the people.

 Steering Committee report suggests that one district in each state pilot this concept in the first year of the plan. We would strongly suggest that the unit of pilot should logically be the state, and more over that such pilots be initiated only after full discussion and public debate.


We firmly believe that the public health system has to be the back bone of any universal health system. Our emphasis should be on strengthening of the Public Health system, especially the primary level of care. The public sector should be brought up to its full functional capacity and expanded.

The private sector needs to be involved in the UHC system only on the terms of public good. Integration of the public and private sector is to be seen in terms of an integration of the “logic” of the health system. Corporate profits should not be allowed to lead or define health provision. The health system has to be effectively and transparently regulated with its primary goal being the people’s welfare rather than private profit. It is only under such circumstances that we can develop a UHC system that will truly serve the needs of the people equitably.

UHC system should be based on tax based financing. Present models of publicly financed commercial insurance (such as Arogyasri scheme in Andhra Pradesh) have proved to be highly problematic in terms of scope and rationality of care, and become financial drain on the exchequer without delivering anything like Universal health care.

The governance of the whole UHC system must be firmly people centered and rights based, with a community led and focused process. We visualize institutionalizing a process of community based monitoring, planning and action for health which is evolved based on experiences in a number of states of the country in which JSA partners are involved.

Jan Swasthya Abhiyan call for action on Universal Health care

Given this situation the JSA calls for the following:

 A national public debate on the contours of the proposed universal health care system. Such an important issue cannot be rushed through and its various strands need to be understood, discussed and commented upon widely by the people.

 Definition of a clear, transparent and time bound road map for strengthening and expanding the public health system while improving its functioning and accountability; this must include allocation of adequate, enhanced budgets.

 Enactment of adequate laws guaranteeing the right to health, including National and State Health acts, which would lay down the framework for regulation of the health system, particularly relevant for private medical providers. Providing entitlements must be accompanied by a clear framework for accountability and grievance redressal.

 While developing and operationalising the universal health care system, highest priority must be given to significant expansion and improvement of public health services. Regulated private providers should not be competing with public providers for common resources, rather they may be in-sourced to provide services, but never as a substitute to the public sector.

 Ensuring forums for participation of community members, community based groups and civil society organizations along with elected representatives and public health functionaries at various levels, for planning, monitoring and reviewing the functioning of the universal health care system.

We must be aware that the direction of developing universal health care in India must be towards strengthening the public health system and socialization of health care, rather than promoting further expansion of unregulated, profit-oriented private medical care. Hence a national debate is essential and there should be no haste in rolling out these concepts – even the looming large of the General elections should not become an excuse for the government to short circuit and distort the concept of Universal Health Care for narrow political gains.


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