World Bank President Jim Kim calls user fees ‘unjust and unnecessary’ #healthcare

World Bank President Jim Kim today at World Health Assembly called these fees ‘unjust and unnecessary’

 

‘The issue of point-of-service fees is critical.  Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services.  This is both unjust and unnecessary.  Countries can replace point-of-service fees with a variety of forms of sustainable financing that don’t risk putting poor people in this potentially fatal bind.  Elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage.’

World Bank Group President Jim Yong Kim’s Speech at World Health Assembly: Poverty, Health and the Human Future

World Bank Group President Jim Yong Kim

World Health Assembly

Geneva, Switzerland

May 21, 2013

As Prepared for Delivery

Poverty, Health and the Human Future

Mr. President, Director-General Dr. Margaret Chan, Excellencies, colleagues and friends:

We stand at a moment of exceptional possibility.  A moment when global health and development goals that long seemed unattainable have moved within our reach.  A moment, also, when dangers of unprecedented magnitude threaten the future of humankind.  A moment that calls us to shed resignation and routine, to rekindle the ambition that has marked the defining chapters of global public health.

A generation must rise that will drive poverty from the earth.  We can be that generation.

A generation must rise that will end the scourge of inequality that divides and destabilizes societies.  We can be that generation.

A generation must rise that will bring effective health services to every person in every community in every country in the world.  We will be that generation, and you—members of this Assembly—will lead the way.

Yes, I’m optimistic.  I’m optimistic because I know what global health has already achieved—what you have achieved.

In 2011, global average life expectancy reached 70 years, a gain of six years since 1990.  The global child mortality rate has fallen 40 percent in the same period.  In the ten years since Dr. LEE Jong-wook announced WHO’s commitment to support countries in scaling up antiretroviral treatment for AIDS, 9 million people in developing nations have gained access to this life-saving therapy.  These are just a few of the milestones of recent progress.

I have another reason to be optimistic.  I know global health is guided by the right values.

Thirty-five years ago, the Alma-Ata Conference on Primary Health Care set powerful moral and philosophical foundations for our work.  The Declaration of Alma-Ata confirmed the inseparable connection between health and the effort to build prosperity with equity, what the Declaration’s authors called “development in the spirit of social justice.”

Alma-Ata showed the importance of primary health care as a model of health action rooted in the community; responsive to the community’s needs; and attuned to its economic, social and cultural aspirations.  Alma-Ata set the bar high.  But we continue to struggle to provide effective, high-value primary health care to all our citizens.  Unfortunately, none of WHO’s 194 Member States has yet built the perfect health care system.  We can all get better and we know it.

But in the grand spirit of Alma-Ata, we must focus again on the link between health and shared prosperity.  And, this time, we must turn our loftiest aspirations into systems that build healthier, more productive, more equitable societies.

For what Alma-Ata did not do was provide concrete plans or effective metrics for delivering on its admirable goals.  In many cases, frontline efforts inspired by Alma-Ata lacked strategy; evidence-based delivery; and adequate data collection.  This shouldn’t have been surprising, and I’m certainly not criticizing global health leaders of that time.  Indeed, many of the architects of Health For All are my heroes to this day.

Today, we have resources, tools and data that our predecessors could only dream of.  This heightens our responsibility and strips us of excuses.  Today we can and must connect the values expressed at Alma-Ata to strategy and systems analysis; to what I have been calling a “science of delivery”; and to rigorous measurement.  And we must actually build healthier societies.

The setting for this work is the growing movement for Universal Health Coverage.

The aims of universal coverage are to ensure that all people can access quality health services, to safeguard all people from public health risks, and to protect all people from impoverishment due to illness: whether from out-of-pocket payments for health care or loss of income when a household member falls sick.

Every country in the world can improve the performance of its health system in the three dimensions of universal coverage: access, quality, and affordability.  Priorities, strategies and implementation plans will differ greatly from one country to another.  In all cases, countries need to tie their plans to tough, relevant metrics.  And international partners must be ready to support you.  All of us together must prevent ‘universal coverage’ from ending up as a toothless slogan that doesn’t challenge us, force us to change, force us to get better every day.

The good news is that many countries are challenging themselves, measuring outcomes and achieving remarkable progress.  Turkey launched its “Health Transformation Program” in 2003 to provide access to affordable, quality health services for all.  Formal health insurance now covers more than 95 percent of the population.  The health reform is one of a bundle of factors that have contributed to Turkey’s health gains.  Between 2003 and 2010, Turkey cut its infant mortality rate by more than 40 percent.

Thailand’s universal coverage reform dates from 2001.  The program has substantially increased health care utilization, especially among the previously uninsured.  And, as of 2009, the program had already reduced by more than 300,000 the number of Thai people suffering catastrophic health care costs.

And let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution, the World Bank Group.  Thailand’s health leaders were determined to act boldly to provide access for their whole population.  Today the world learns from Thailand’s example.

Many other countries are also advancing.  And the growing momentum for universal health coverage coincides with a new chapter in the global fight against poverty.

Last month, the organization I lead, the World Bank Group, committed to work with countries to end absolute poverty worldwide by 2030.  For the first time, we’ve set an expiration date for extreme poverty.

And we know that fighting absolute poverty alone is not enough.  That’s why we’ve set a second goal.  We’ll work with countries to build prosperity that is equitably shared, by nurturing economic growth that favors the relatively disadvantaged in every society.  We’ll track income growth among the poorest 40 percent of the population in every country and work with country leaders to continuously improve policy and delivery, so countries can achieve economic progress that is both inclusive and sustainable – socially, fiscally, and environmentally.

To end poverty and boost shared prosperity, countries need robust, inclusive economic growth.  And to drive growth, they need to build human capital through investments in health, education and social protection for all their citizens.

To free the world from absolute poverty by 2030, countries must ensure that all of their citizens have access to quality, affordable health services.

This means that, today as never before, we have the opportunity to unite global health and the fight against poverty through action that is focused on clear goals.

Countries will take different paths towards universal health coverage.  There is no single formula.  However, today, an emerging field of global health delivery science is generating evidence and tools that offer promising options for countries.

Let me give just one example.  For decades, energy has been spent in disputes opposing disease-specific “vertical” service delivery models to integrated “horizontal” models.  Delivery science is consolidating evidence on how some countries have solved this dilemma by creating a “diagonal” approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system.  We’ve seen diagonal models succeed in countries as different as Mexico and Rwanda.

Whether a country’s immediate priority is diabetes; malaria control; maternal health and child survival; or driving the “endgame” on HIV/AIDS, a universal coverage framework can harness disease-specific programs diagonally to strengthen the system.

As countries advance towards universal health coverage, there are two challenges we at the World Bank Group especially want to tackle with you.  These two areas are deeply connected to the goals on poverty and shared prosperity I described a moment ago.

First, let’s make sure that no family, anywhere in the world, is forced into poverty because of health care expenses.  By current best estimates, worldwide, out-of-pocket health spending forces 100 million people into extreme poverty every year, and inflicts severe financial hardship on another 150 million.  This is an overwhelming form of affliction for people, as the anguish of impoverishment compounds the suffering of illness.  Countries can end this injustice by introducing equitable models of health financing along with social protection measures such as cash transfers for vulnerable households.

Second, let’s close the gap in access to health services and public health protection for the poorest 40 percent of the population in every country.  Improving health coverage and outcomes among the poorer people of any country is critical to building their capabilities and enabling them to compete for the good jobs that will change their lives.  We have to close health gaps, if we’re serious about reducing economic inequality, energizing countries’ economies and building societies in which everyone has a fair chance.

The issue of point-of-service fees is critical.  Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services.  This is both unjust and unnecessary.  Countries can replace point-of-service fees with a variety of forms of sustainable financing that don’t risk putting poor people in this potentially fatal bind.  Elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage.

Now let me tell you five specific ways the World Bank Group will support countries in their drive towards universal health coverage.

First, we’ll continue to ramp up our analytic work and support for health systems.  Universal coverage is a systems challenge, and support for systems is where the World Bank Group can do the most to help countries improve the health of your people.

I was recently in Afghanistan, where the Bank Group has been working with the government and other partners to rebuild the country’s health system.  In Afghanistan, this abstract term ‘health system’ quickly becomes personal.  Let me tell one story. Several years ago, Shakeba, a young woman from Parwan province, gave birth at home, because there was no health center she could go to.  She developed complications and lost her baby.  Earlier this year, Shakeba gave birth to another child—in the delivery room of a recently-opened health center, with modern equipment and skilled personnel.  Shakeba and her new baby are thriving.  Improving health systems literally means life or death for many mothers and children.

The number of functioning health facilities in Afghanistan grew more than four-fold from 2002 to 2011.  During this time, the country reduced under-five mortality by more than 60 percent.

Middle-income countries may face very different challenges.  Many middle-income countries I visit are suffering from an epidemic of hospital-building.  In some countries, I’ve seen brand-new, ultra-sophisticated emergency facilities where specialists are preparing to treat, for example, complicated emergencies like diabetic ketoacidosis.  But when patients are released from these facilities, they can’t get adequate support in the routine, daily management of illnesses like diabetes, because the primary care system has been starved of financing.  It makes no sense to pour resources into responding to downstream complications, without investing in upstream prevention and disease management that could often keep those complications from happening in the first place.

When countries anchor their health systems in robust primary care and public health protection, health care costs can be controlled.  We will work with all countries to do just that.

Our second commitment is that we will support countries in an all-out effort to reach Millennium Development Goals 4 and 5, on maternal mortality and child mortality.

Reaching these two MDGs is a critical test of our commitment to health equity.

We must continue to focus on the MDGs, even as we prepare for the post-2015 development agenda.  The MDGs have given energy and focus to everyone in the global development community. We have not finished the job.  Now is the time to do it.

Last September at the United Nations General Assembly, I announced that the World Bank Group would work with donors to create a funding mechanism to scale up support for MDGs 4 and 5.  Since then, we have been expanding our results-based financing for health, focusing on the maternal and child health goals.  Our results-based financing fund has leveraged substantial additional resources from the International Development Association, IDA, the World Bank Group’s fund for the poorest countries.  This has been an unquestioned success: the trust fund has multiplied resources for maternal and child health.  Over the past five years, we have leveraged $1.2 billion of IDA in 28 countries, including $558 million for 17 countries since last September alone.  Now we are working with Norway, the United Kingdom and other partners to expand this effort.

Results-based financing is a smart way to do business.  It involves an up-front agreement between funders and service-providers about the expected health results.  Payment depends on the delivery of outcomes, with independent verification.  Results-based financing also allows citizens to hold providers accountable.  It puts knowledge and power in ordinary people’s hands.

These programs all have rigorous impact evaluations. In Rwanda, the impact evaluation showed officials that performance incentives not only increased the coverage and quality of services, but also improved health outcomes.  The study found that babies were putting on more weight, and that children were growing faster.

Our third commitment is that with WHO and other partners, the World Bank Group will strengthen our measurement work in areas relevant to universal health coverage.  In February, the Bank and WHO agreed to collaborate on a monitoring framework for universal coverage.  We’ll deliver that framework for consultation with countries by the time of the United Nations General Assembly in September.

We don’t have enough data.  For example, we don’t yet measure the number of people forced into poverty by health expenditures in every country each year.  We will work with countries and partners to make sure we get better data so countries can achieve better outcomes.

Fourth, we will deepen our work on what we call the science of delivery. This is a new field that the World Bank Group is helping to shape, in response to country demand.  It builds on our decades of experience working with countries to improve services for poor people.  As this field matures, it will mean that your frontline workers – the doctors and nurses, the managers and technicians – will have better tools and faster access to knowledge to provide better care for people.

Distinguished ministers, as you move towards universal coverage, tell us where you’re hitting barriers in delivery.  We’ll connect you and your teams to global networks of policymakers and implementers who have faced similar problems.  We’ll mobilize experienced experts from inside and outside the World Bank Group, including from the private sector, where much of the best delivery work happens.

Fifth and finally, the World Bank Group will continue to step up our work on improving health through action in other sectors, because we know that policies in areas such as agriculture, clean energy, education, sanitation, and women’s empowerment all greatly affect whether people lead healthy lives.

Mexico has done an impressive job in this respect.  Mexico’s Seguro Popular, for instance, works in concert with the Oportunidades cash transfer program.  Oportunidades has increased poor people’s spending capacity and reduced the depth of poverty.  It has also raised school enrollment and access to health services among the poor.  Meanwhile, Seguro Popular has reduced out-of-pocket health care payments and catastrophic health expenditures, especially for the poorest groups.  All countries can’t match Mexico’s resources.  But promising options for similar types of action exist for all countries.

When ministers of health seek to integrate expanded health coverage with efforts to reduce poverty, the World Bank Group’s policy advice, knowledge resources and convening power are at your disposal.  For instance, we can help facilitate discussions with ministries of finance.  We saw promising steps in this direction at the meeting of African health and finance ministers in Washington last month.

But specific actions from the World Bank Group must be part of a wider change in how we work together as a global health community.

The fragmentation of global health action has led to inefficiencies that many ministers here know all too well: parallel delivery structures; multiplication of monitoring systems and reporting demands; ministry officials who spend a quarter of their time managing requests from a parade of well-meaning international partners.

This fragmentation is literally killing people.  Together we must take action to fix it, now.

Aligning for better results is the approach of the International Health Partnership, or IHP+.  And it’s gaining momentum.  Earlier today, Director-General Margaret Chan and I took part in an IHP+ meeting.  It’s inspiring to see more and more countries taking charge, setting the agenda based on strong national plans, and making development partners follow the lead of governments.

We are reconfirming our shared commitment to IHP+ as the best vehicle to implement development effectiveness principles and support countries driving for results.   But, honorable ministers, we must hold each other accountable.  We all have to be ready to pound the table and demand that we stop the deadly fragmentation that has hindered the development of your health systems for far too long.  The stakes are high and the path will be difficult, but I know we can do it.

My friends,

Together, we face a moment of decision. The question is not whether the coming decades will bring sweeping change in global health, development and the fundamental conditions of our life on this planet. The only question is what direction that change will take:

Toward climate disaster or environmental sanity;

Toward economic polarization or shared prosperity;

Toward fatal exclusion or health equity.

Change will come—it’s happening now. The issue is whether we will take charge of change: become its architects, rather than its victims. The gravest danger is that we might make decisions by default, through inaction. Instead, we must make bold commitments.

Since the turn of the millennium, we have experienced a golden age in global health, shaped by the achievements of the leaders in this hall. But will history write that the golden age expired with its hopes unfulfilled, its greatest work barely begun? That it sank under the weight of economic uncertainty and leaders’ inability to change, to push ourselves beyond our old limits?

We know what the answer must be. The answer that the peoples of all our nations are waiting for—those living today and those yet to be born.

We can do so much more. We can bend the arc of history to ensure that everyone in the world has access to affordable, quality health services in a generation.

Together, let’s build health equity and economic transformation as one single structure, a citadel to shelter the human future.

Now is the time to act.

WE MUST BE the generation that delivers universal health coverage.

WE MUST BE the generation that achieves development in the spirit of social and environmental justice.

WE MUST BE the generation that breaks down the walls of poverty’s prison, and in their place builds health, dignity and prosperity for all people.

Thank you.

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• #India – Unhealthy Health Governance (kractivist.wordpress.com)

Prominent US Modi supporter Dr. Akshay Desai in hiding, running from law in $25M defrauding case

Federal agents raid Universal Health Care headquarters Dr. Akshay Desai goes into hiding; investors lose $25 million

By A Correspondent, Indiatribune.com

St. Petersburg, FL: Indian American physicians and entrepreneurs, who invested over $25 million in Dr. Akshay Desai’s Universal Health Care Group, Inc., are seething in anger after the company filed for bankruptcy. The Surat-born 55-year-old Dr. Desai, a high profile entrepreneur in Florida, who was a luminary of the Republic Party for his fundraising abilities and was closed to presidential contender Mitt Romeny, has gone underground according to report.

Dr. Desai, in an interview six months ago, had claimed: “My company is now doing business in 20 states and this year we are expecting revenue of $1.5 billion.”

The state documents portray Universal, as a company in deep financial distress and badly mismanaged. Universal Health Care executives overstated assets and submitted “misleading financial statements” to the state and a major creditor, according to state documents released on March 28 by the Office of Insurance Regulation.

After Federal Bureau of Investigation agents on March 28 raided the headquarters of Universal Health Care Group Inc, in St Petersburg, Florida, which has gone belly up and filed for bankruptcy throwing over a 1,000 employees out of work, the Department of Justice has called on the bankruptcy court to appoint a trustee for this major Medicare provider.

Guy G Gebhardt, a DOJ official and a US Trustee in Florida, in court documents filed on April 3, in the wake of the search-and-seizure warrant executed by the FBI as part of an investigation that federal laws may have been violated and criminal indictments are likely, reiterated that it was imperative that a trustee take over the reins of Universal.

He said he strongly believed there are grounds to suspect that the hierarchy of the company has committed fraud through false statements amounting to criminal conduct in its financial reporting.

The Miami investment group led by Miguel “Mike” Fernandez earlier had expressed interest in buying Universal, but backed away two days later without comment after seeing the presentation.

Universal listed its Medicare Advantage membership as 90,000, Medicaid enrollees as 64,000. About 43 percent of the HMO members in Florida are patients, who require extra care — and bring in higher premiums from Medicare — because they have diabetes, lung disease or dementia.

A chart shows the company has brought in more than $1 billion in premiums a year, most of it from Medicare. Yet, according to another chart, the company lost $61 million in 2011 and $3 million last year.

Among some of the major investors in Universal were doctors Zach Zachariah, another longtime major Republican Party fundraiser, who had ploughed in over $6 million, and Raj Gupta, who had invested over $4 million.

“He is going to pay for his mistakes because something is not right,’’ Dr. Gupta, a Fort Lauderdale physician, said. “He told me he can do whatever he wants and does not have to listen to me or any other investor.’’

Several other Indian American physicians, including Dr. Raghavendra Vijayanagar, founder and former chairman of the Indian American Republican Council, and several entrepreneurs, and even some academics had invested anywhere from $250,000 to $1 million each, and among them there was an overriding sense of deep disappointment and despondency, with one of them saying, “All the investors have been right-royally screwed.”

“Who the hell knows what he did with all the money,” one said. “Hundreds of millions of dollars and God only knows where the money went,” this investor said, adding, mockingly, “He was living larger then life, flying in private jets and talking big to Romney and all those people, and of course, nobody wants to talk to him now, and all the politicians have washed their hands of him.”

According to its Web site, Universal provided federal- funded entitlement insurance programs such as Medicare and Medicaid to nearly 200,000 customers in 19 states and had 40,000 Medicare and 60,000 Medicaid members in Florida alone, who were now in a quandary regarding the future of their health insurance.

The Tampa Bay Times reported that when the FBI agents raided the Universal headquarters on March 28, employees were ordered out and told to immediately get away from their computers.

The FBI raid was carried out during the same week that the bankruptcy court trustee had alleged “a pattern of dishonesty or gross mismanagement,” including “side deals” that benefited insiders, and had cited examples where more than $18.3 million had been transferred to a Universal subsidiary also founded by Dr. Desai and $2.2 million in “bonuses and other compensation” to company officers Desai, Patel and Ludy in addition to their salaries, also in 2012.

The trustee said that even as Universal was knee-deep in financial trouble, Desai had continued to draw a $900,000 salary and another $2.5 million or more in bonuses and other compensation in 2012.

After the FBI raid, Desai, who was easily accessible, couldn’t be reached and Zachariah, Gupta and others who had invested in Universal, said they could not reach him either and believed he had gone underground or may have left the country.

Starting in 2006, Universal’s Any, Any Any plan — members purportedly could see any doctor anywhere at any time — drew thousands of members but also complaints of false advertising, poor customer service and denied medical treatments. The company temporarily suspended enrollment, and in 2008 signed an agreement with state regulators to beef up reserves to handle the swelling volume of claims.

Over the next few years Universal continued to grow, eventually expanding to 23 states and serving 140,000 members. In 2010, it spent $9 million for a new headquarters on Central Avenue in St. Petersburg and another $750,000 for renovations.

It paid more than $500,000 for a 28th floor condo in nearby Signature Place, known for its sleek architecture and sweeping views of the waterfront. Employees joked that Universal needed the condo as temporary housing for the many executives who cycled through — the company had five chief financial officers in six years.

For the past three years, Medicare officials hammered Universal for poor quality, urging potential members to use caution before selecting it.

The first public notice that Universal was in serious financial trouble came in November when it agreed to stop selling Medicare policies in Georgia. That state’s insurance commissioner cited Universal’s net loss of $22.1 million in the first six months of the year as reason for the halt.

On Feb. 4, the Florida Office of Insurance Regulation deemed Universal nearly insolvent and accused executives of a broad pattern of financial mismanagement — including fraud and diversion of funds — under Desai’s leadership.

Two days later, Universal Health Care Group filed for bankruptcy, listing $50 million to $100 million in assets and $10 million to $50 million in liabilities. Among those to whom the company said it owes an “undetermined’’ amount: Desai and his wife, Seema.

The Tampa Bay Times also said that Desai could not be reached and that “no one answered the door at his $2.6 million bay front Snell Isle mansion. A burgundy SUV and a dark silver Audi R8 sports car sat in the driveway, but the gates to the property were closed.

 

#India– Tea Gardens death and disease

Dhiren Malpaharia had a burn injury from before Durga Puja. The skin was gangrenous- so Pradipan (pradipan.slg@gmail.com) took him with Janaki Malpaharia to NBMCH for treatment. After the gangrenous skin was excised in early November he came back to the closed Dheklapara Tea Estate. The Rs 35 a day his relations earned was not enough. He was given Burnol for the ulcer. He died on the night of 4th December at Birpara State General Hospital. He deserved Universal Health Care. He deserved 100 days work at minimum wages. He deserved to be protected from his unjust employer by the courts and the administration. Mal Paharias are a sub group of the Paharia Community- only 100,0000 of whom survive in “Santal” Parganas. Some 25 Paharia families live among the 350 tea labourer housesn Dheklapara (Main Division)- a tea estate closed for 11 years. Another 250 tea labourer families live at Niparnia Division of the same TE. The neighbouring Bandapani TE is also closed

Dheklapara (Madarihat-Birpara, Jalpaiguri)
Visit 25th November 2012- They survive on Rs 35 a day!

Siliguri Welfare Organization and Peoples Health Forum organized a camp at Dheklapara Tea Estate Main Division from 11am to 3pm on Sunday 25th November. Uttar Banga Sambad and another organization had arranged for around 350 blankets and mosquito nets for the labourers. The Tea Workers Cooperative helped and a UTUC representative attended. There were around 25 volunteers from SWO and 4 doctors. We passed Sulkapara, Binnaguri and Ethelbari on our way (since we traveled via Sevoke and
Odlabari). Dheklapara is 9 km from Birpara. Niparnia is 3 km away from the Main Division.

Dr Debashis Mukherjee, Dr Prakash Baag and Dr Anita Mazumdar saw around 250 patients. Weight, height, age and names of all patients were recorded and BMI of all adults will be calculated. 4 health volunteers- one girl from Niparnia Division, Kunu Malpaharia, Rajib Malpaharia
and one other male volunteer from the Main Division- were identified. If
trained and supplied an infant weight machine they could (with the help of
Salter scales from the Anganwadis) take the weights of all children. There are an estimated 250 under 5 children in Niparnia and estimated 350 in the Main Division. The ANM attends the Dheklapara Dispensary on Fridays, Record keeping is excellent. Immunization is given, BP of pregnant women is taken.

This Tea Garden is in Bandapani Gram Panchayat (GP).
Recently the Bandapani Tea Estate also closed down. Earlier many worked in the Stone “jhalna”- sorting and loading at Rati River.
They earned Rs 250 or more there. The Cooperative gives them Rs 35 a day for Tea Plucking. Joy Birpara Tea Estate is functioning. The Health sub Centre is at Joy Birpara. Dim Dima Tea Estate has a CNI Primary School and Fatima High School run by catholics.

There are 25 Malpaharia families here.
There are also Malpaharias at Chunabati, Raipur,
Rayabari, Kathalguri, Totabari (near Banarhat)

Janaki Malpaharia is wife of Kunu. Her maiden name was Kahar.  She has an 11 year old daughter. She had 2 miscarriages. Most recent delivery was a girl 2 months ago who died and was not breastfed. Since then she can not walk and has “some irregularity in her periods”. After the MRI at AMRI (PPP connected to NBMCH) she was found to have narrowed spinal spaces. She has recovered to the point of sitting up. The treatment with Phenytoin has helped her. Apparently she has epilepsy. No CT scan done to look for tuberculoma or cysticercosis. Her Hemoglobin is 6.9 gm% and Total Count WBC is 3800/cu mm. No enlargement of spleen however. She has cough for one month. We advised Sputum for AFB. Maybe Gp Rh and VDRL need to be done later. She was given a mouth wash for halitosis.  She had urinary tract
infection as well.

Dhiren Malpaharia is 60 years old. He
fell and burnt himself before Durga Puja (October). There was near gangrene- his dead skin was removed at NBMCH. The large ulcer covers half his forearm and most of the upper arm. His elbow is stiff in a flexed position. The raw area is red and clean- but the piece of shirt covering it has marks and may not be clean. Advised silver sulphadiazine in preference to Burnol. Also clean gauze or other light cotton cloth to be changed every day.

Rajib Malpaharia who cycles to school at Birpara is in class 11. He had phimosis and was also operated at NBMCH.

We met the father of Jarain Nayek 23/F, unmarried, who died after 3 days of fever. They are originally from around Mayurbhanj/ Jamshedpur.

We visited the home of Urvashi Bedia daughter of Pradeep. She is 12 years old. They are originally from near Hazaribagh. About 4 months ago she stopped walking. This continued for 2 months. Now she can walk again. She is quite thin. She studies in class 6. She had pus discharge from her ears (CSOM). Her eyesight was also affected. Now she has swelling of the right knee for a week.

On the way back we stopped for lunch at Sangam Line Hotel. They have a stone sorter machine.

The Dheklapara Tea garden is closed for 11 years. There are around 700 families living here.

An old lady and her grand child live alone

Indo Tanti had Hemoglobin of 5 gm %.
She had her ECG taken. Death Certificate says Congestive Cardiac Failure. No X-Ray. Possibility of TB does not seem to be ruled out.

There has been Dengue recently in the area. There has also been proven Chikungunya.

Malaria is rampant.

Stone related work could lead to Silicosis in future- urgent need for Spirometry and follow up. At least 5 patients were referred for Sputum AFB.

Niparnia has a problem of elephants attacking houses

Debijhora Tea Estate (Chopra, U Dinajpur)
Visit 19th November
Break in Tea Gardens here is between 11.30 am and 1.30 pm. BMOH, second ANM Augustina Kullu and ASHA Sugandhi Baraik took me to meet 6 year old Prima Beck of Bohura Line who has Kala Azar on 20th November. Another family with a treated KA patient has relations in Manjha/ Betbari in Naxalbari Block (where PHN Krishnamoyee Bala is now posted). We heard that the first case was diagnosed by doctors in Kishanganj. There were 72 Oraon tribal patients (largest group in Bohura Line) last year out of 106 in Chopra. There were 74 more cases in the other 8 blocks of U Dinajpur. Bohura Line is on the border with Bangladesh and frequent cattle thefts occur. Only one family- from Azamgarh (near Gorakhpur) and Jaunpur (husband and wife) – still have cattle. Some people are working in Kakarvitta in Nepal and many in other areas (Rajasthan, Tamil Nadu, and Delhi) especially in plywood factories. There were a lot of pigs- but this has been done away with following
pressure from health workers. In another KA patient’s home we found a dehydrated old gentleman with one day history of diarrhea. We suggested he go to the Tea Estate dispensary for re-hydration. This family brews alcohol using gur [molasses]. Yesterday I read that there is cholera in one tea garden [probably in Jalpaiguri]

On the 16th October members of SWO, Forum for Peoples Health, APDR and Binayak from PUCL went to Gulma Tea Estate. Here 160 acres of common land- used for subsistence farming in the past- had been fenced off by the Tea Estate. They claimed that this land had been rented to them 30 years ago- though they had not used it in this period. Now they plan to turn it into real estate- possibly taking advantage of the river, rail line, and view of the mountains to build a tourist site or upper class residential colony (like Ambuja). They were harassing workers who opposed this land grab. We spoke to a worker Mr Samad and his wife (a nurse) who was cooperating with NAPM.

 

by- prabir chattreji

 

#India- Appeal to PM -launch a national scheme of ‘free essential medicines to all’

 

November 05^th 202

 

Dr. Manmohan Singh,

Prime Minister of India,

South Block, Raisina Hills,

New Delhi 110 011

 

Appeal to launch a national scheme of ‘free essential medicines to all’

 

Dear Prime Minister:

 

As you may well be aware, citizens of India spend exorbitant amount of money out of their pocket to seek health care, pushing every year more than 30 million citizens below poverty line.  An expense on a single hospitalization is an enough ground for 40% patients to sell assets or be indebted. About 70% of this expense is on medicines.   According to the CES 2009, about 29% patients cannot afford to seek any kind of medical care and expenses on a single hospitalization is an enough ground for 40% patients to sell assets or be indebted. Cost of medicines is the biggest slice in out of pocket health spending more for ambulatory but significantly to hospitalized patients. In addition, spiraling rise of prices of medicines is keeping away vast number of people out of reach to essential medicines. About 65% countrymen do not have access to essential medicines while India exports drugs to about 200 countries.

In the Independence Day speech of 2011, you had mentioned that the 12^th Five Year Plan will be the ”Health plan” and you mentioned “A scheme to provide free medicines to all in public hospitals is being formulated” in your address to the nation on Independence Day 2012. But, unfortunately both of your announcements have yet to see the light of day even when the 12^th Five Year Plan period has begun from 1^st April 2012. Notwithstanding the fact that the ultimate solution to burgeoning health problems of the majority of India’s citizens

 

lies in “Universal health coverage through state funding” as recommended by the Planning Commission instituted High Level Expert Group (HLEG) and various working groups constituted to formulate 12^th FYP, but even the implementation of any national scheme for free medicines to all is uncertain. Statements of many senior officials of the Union Ministry of Health & FW at various platforms imply that the Central Government has no plans to initiate a scheme of free medicines to patients but will promote this concept by persuading state governments to carry it out by seeking additional funds and incentives under the NRHM from the Centre. The Central Government has released a budget of Rs. 1300 crores for it which is grossly insufficient in contrast to the recommendation of the Working Group on Drugs and Food Safety of the Planning Commission for the 12^th FYP. This group has suggested an annual budgetary contribution from the Centre of Rs. 5500 crores to ensure free medicines to all the patients accessing health care in the Public Health Facilities. It may be noted that this is much less than Rs. 30,000 crores suggested by the HLEG. Yet, even this smaller amount is not being budgeted!

 

In the absence of any national scheme, the objective of universal access to essential medicines is lost. At the moment, barring the states of Tamilnadu, Rajasthan and Kerala, all other states have very truncated schemes in which either some medicines are provided free from limited categories of health facilities or families of certain socio-economic categories are eligible for all kinds of free medicines. This has resulted into no qualitative or quantitative improvement from the previous state of affairs. In fact, previous experiences convince us that till universality of access is not ensured, patients who require free medicines will be deprived the most.

 

We the undersigned, therefore, appeal to you that a national scheme of ‘free essential medicines to all ‘ is immediately initiated with an annual budget of Rs. 5500 crores  & allocation  of required human resource & facilities without any further delay. If it is not launched  throughout India,  ‘free essential medicines to all ‘ which is the easiest of the components of UHC (Universal Health Care), then citizens would legitimately question any official talk about  UHC. We hope, the Government of India will abide by your pronouncements and send a message to all citizens.

 

It is important that while launching a national scheme, elements of transparent methods of procurement, quality assurance, promotion of essential drugs and rational drug concept as adopted by Tamilnadu and Rajasthan would be followed.

 

Best regards.

 

Yours sincerely,

 

 

(Dr. Narendra Gupta)

On behalf of all National Organisers , Jan Swasthya  Abhiyan

Prayas, 8, Vijay Colony, Chittorgarh 312 001

Convenor: JSA

B. Ekbal

­­Jt.Convenors/National Organisers

Ab­hay Shukla

Ajay Khare

Amit Sen Gupta

Amitava Guha

Joe Varghese

N.B Sarojini

Narendra Gupta

Renu Khanna

T. Sundararaman

Thelma Narayan

Vandana Prasad

 

 

National Co-ordination Committee:

 

All India People’s Science Network (AIPSN)

All India Drug Action Network (AIDAN)

Asian Community Health Action Network (ACHAN)

All India Democratic Women’s Association (AIDWA)

Association for India’s Development (AID)

Bharat Gyan Vigyan Samiti (BGVS)

Breastfeeding Promotion Network of India (BPNI)

Catholic Health Association of India (CHAI)

Centre for Community Health and Soc. Medicine, JNU

Christian Medical Association of India (CMAI)

Community Health Cell (CHC)

Forum for Creche and Child Care Services (FORCES)

Fedn. of Medical Representative Assns. of India (FMRAI)

Health Watch Forum

Joint Women’s Programme (JWP)

Medico Friends Circle (MFC)

National Alliance of People’s Movements (NAPM)

National Federation of Indian Women (NFIW)

National Association of Women’s Organisations (NAWO)

SAMA

SATHI-CEHAT

Voluntary Health Association of India (VHAI)

 

Participating Organisations:

 

Over 1000 organisations concerned with health careand health policy from both within and outside

the above networks.

 

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Evidence, Consensus and Policy: curious case of changes proposed in India’s public health policy

English: National Rural Health Mission of India (Photo credit: Wikipedia)

SEPTEMBER 27, 2012

tags: National Rural Health Mission, Planning Commission of India,Planning Commission XIIth Plan, Public Health India

by Shivam Vij

Guest post by KAVERI GILL, at  kafila.org

The world of development is as prone to fashions as any other. In recent times, ‘evidence-based policy’ has become the new gold standard, following hot on the heels of participation and ownership of policy processes and outcomes by academics, activists and civil society groups. This applies within nation states, especially of the global South. India today epitomises such objective and bottom-up democratic largesse in favour of the ‘aam admi’- for largesse it is, make no mistake – with a near constant refrain of the avowed aim of ‘inclusive growth’. And yet, does it really?

Or is politically correct discourse and seemingly open decision-making processes in the social sector sphere merely dangerous fig leaves for seismic and opaque shifts in policy, which have very little to do with evidence and even less to do with broad-based consensus? Rather, they are an outcome of fixed ex-ante views – which may be termed as a distinct partiality to the Chicago School of Economics – about the path to a fictitious endpoint of a mainstream development paradigm, which itself is faith-based. It is not justified by theory or a heterodox reading of the empirical experiences of presently developed countries, let alone latecomer developing nations which are, for various exogenous and endogenous reasons, likely to have different trajectories altogether. I refer here to the hackneyed line about faster growth being pursued as a necessary, if not sufficient, condition for eventual trickle down, no matter that the ‘dur khaima’ of an equitable society is never arrived at!

In his address to the nation last Friday, the Hon. Prime Minister mentioned ‘the common man’ twice in the opening lines, as a straw man in whose name and interests all ‘difficult’ second-stage reforms are being undertaken. On p.1 of the Planning Commission of India’s Approach Paper to the XII^th Plan [1], it is argued that high growth during the XIth Plan was seen as instrumental to achieving two ends: to create income and employment opportunities for better living standards for the majority, and to generate resources in order to finance social sector programmes, aimed at “enabling inclusiveness”. It goes on to define the latter: “…inclusiveness is a multidimensional concept. Inclusive growth should result in lower incidence of poverty, broad-based and significant improvement in health outcomes…” (ibid., p.2). A wish list of the Left liberal’s ideal social contract follows, in the Rawlsian sense of justice, and quite far from Nozick’s Libertarian minimal nightwatchmen role of the state. The discourse could not be better.

But let us unpack the ‘inclusive growth’ jargon – with particular reference to public health care – as an illustrative exercise of evidence, and its selective and biased use to derive unwarranted policy prescriptions in the social sector sphere in recent times. Quickly, to recap a refresher undergraduate course in economics, health care is not a routine commodity, rather more of a public good [2], exhibiting externalities and marked information asymmetries of moral hazard and adverse selection. In layman’s terms, because of these and other characteristics, the state remains heavily involved in this sector even in advanced countries, through public financing, and provision or regulation or both, for the market is bound to fail. When returns to large investments accrue over the time horizon of many generations – and admittedly many governments – then it is only a progressive state that has the gumption to invest in such sectors.

Judging by its expansive discourse and promises, one could be forgiven for thinking this is precisely what the present government in India means to do. For structurally, the ‘demographic dividend’ advantage of a relatively young population, that it  also constantly waxes eloquent about, can only be realised if we have achieved decent health (and education) outcomes for the majority. It is the briefest window of time which, given the present dire state of malnutrition amongst children, and the fact that India is far from attaining any of the numerous health-related goals of the MDGs [3], lead many to suggest it is closed off already. Even discounting this view as needlessly grim, the Approach Paper to the XIIth plan itself concedes that health outcome indicators, such as infant mortality rates and maternal mortality rates, are weaker than they should be at this level of development (cf. Footnote 1).  So what does it propose to actually do, in its Health Chapter of the Approach Paper to the XIIth Plan ^[4]?

India has averaged 8% p.a. GDP growth rates over the XI^th Plan period. And yet, its public spending on (core) health – combined Centre and State, plan and non-plan– has hovered around an abysmal 1-1.2% of GDP [5], one of the lowest in the world [6]. Where the XIth Plan still ostensibly aimed to increase this (core) amount to 2-3% by the end of plan period, the Approach Paper to the XIIth Plan settles for an avowed increase to only 1.58% by the end of the plan period. Why should this be the case, given that higher growth rates for the country are justified time and again as being necessary for fiscal room to spend more on social sector programmes?

And how is this possible, given the government has recently vocalised a desire to move towards universal health care for all, in which connection the Planning Commission of India constituted a High Level Expert Group (HLEG) of respected academics and practitioners, to deliberate and come up with the best way forward [7]. The logistical ‘how’ is threefold in the Health Chapter (August draft).

First, the Centre expects individual States to contribute increasingly to the funding of public health, which over the XIth Plan was roughly in the ratio of 1:2. The previous sharing formula for Centrally Sponsored Schemes, such as the National Rural Health Mission (NRHM), was largely in the form of a self-regulated MOU, which States progressively lived up to over the course of a plan period, depending on their fiscal capacities and levels of development. Such contributions would now be mandatory, in that a large part of the Central funding is conditional on higher investments by States.

The proposed new formula to determine the quantum of the flexible ‘incentive fund’ to each State still takes into account its health lag versus that of the national average. In so doing, it gives some weight to its developmental and poverty levels. But linking this amount to its own contribution, and to “agreed parameters of performance and reform in previous year’s sector wide MOU with the MoHFW” (p. 32, Health Chapter (August draft)) – whatever the latter refers to – penalises the worse off States, which are most likely to be cash-strapped and  have less room for manoeuvre for additional fiscal spend. In a federal system, States are in any case reluctant to own Centrally Sponsored Schemes, such as NRHM, because they are conceived of elsewhere and the political credit for them accrues to the government in power at the Centre.

In recognition of externality and equity issues in the provision of basic health care services at the national level, HLEG recommends “a substantial proportion of financing of these services can and should come from the Central government, even though such services have to be provided at sub-national levels” (p.11, HLEG 2011). Yes, States should not use Central contributions as a substitute for their own spending, as many have done so in the recent past, rather to complement it. But this peculiar form of forced ‘incentivisation’ coming out of a misplaced desire to straighten negotiation between Centres and States on the distribution of funding is likely to result in a poverty trap for poorer and less well governed States, and their hapless populations.

More confounding, given the evidence, is the proposal to follow the ‘managed-care’ model of health care provision, the beacon for it being the USA model. The latter is universally derided for being highly inequitable in provision, extremely expensive, and leading to relatively poor health outcomes, compared to other advanced countries. This despite the fact that the private sector is regulated to a far higher degree in that country and patients have recourse to expensive law suits in case of transgressions in delivery by them. What this model would mean in India is that large corporate networks would compete with public health institutions for public funds, to deliver packages of services (most outpatient care and hospital services) at cost to patients. If they cannot compete, as hitherto poorly funded and supported public sector health institutions are unlikely to be able to do so, they do not survive the Darwinian game. The public sector’s role in delivery of health care will be restricted to a minimal essential package, made up of basic child and reproductive care, as well as prevention and promotion roles. In short, the spectre of the private sector is to be unleashed on the public health delivery system.

Strong critiques of the proposed structural ‘privatisation by stealth’, including indisputable international evidence to show how such managed care models work over time to reduce choice in the range of (free) services on offer, and quality of care, have emerged from committed researchers and practitioners working in the public health sphere, so I will not repeat what they have said far better [8]. Indeed, the Health Chapter (August draft) itself admits the following: “…the system creates strong incentives for whoever is managing the network to minimise total cost… there is limited patient choice, and as such the quality of medical care provided has to be carefully regulated” (p.29, ibid.). I would like to focus instead, in conjecturing what could be the objective intellectual motivations for such a shift in policy, and in so doing, make some observations about public sector performance, quality, regulation and finally, rights and justice, in the Indian social sector context, and health care sphere in particular.

Is the shift driven by an argument about poor public sector performance in delivery in health care? If a researcher is objective and without ideological bias, they cannot deny that it has been lacking, which reflects in the dismal health outcomes in the country (noted previously), as well as the flight of those who can and who cannot afford it from the public delivery systems in health (and education). At 67%, the proportion or private out-of-pocket spending on health is sky high, and research has established that health expenses is one of the primary reasons for pushing households below the poverty line. But how can we best read this voting with one’s feet – or in this case – wallet?

Cross-country data on health expenditures show that a higher level of government spending on health is frequently associated with lower levels of reliance of a country’s health system on private out-of-pocket expenditures [9]. So if the quest is eliciting better performance, isn’t the answer to strengthen the public health care system after decades of below-minimal (forget-optimal) spending by the government on this sector? To completely emasculate and demolish it, on the logic that the private sector will force it to perform better or die out, reeks of rather strong ideological proclivities (of the Chicago School of Economics variety).

Is the idea that frontline providers in the public health care system, be they doctors or paramedical staff, are completely unaccountable and therefore, need the stick of private sector discipline to get in line? Again, any open-minded researcher and practitioner would be foolish to dispute widespread doctor absenteeism in public health care centres, especially in rural India, the system’s de facto privatisation through corrupt medical functionaries diverting patients to their ‘private clinics’ in the same compound, charging a fee for consultation and medicines etc. Indeed, I myself found that to be the case in 2008-09, when working on an evaluation of NRHM, as an independent researcher for the Planning Commission of India [10])!

But in the public health system’s defense, what do we expect from a huge cadre of contract and not regular employees, such as are currently employed in NRHM.  I refer here to doctors and paramedics, not even the accredited social health activists (ASHAs), itself a large cadre of underpaid and overworked ‘voluntary’ women workers, on whom the system exploitatively and cheaply depends [11]. The next question to ask is whether private sector employees would be more accountable? Specialist and super-specialist services in public health centres in rural Bihar are already contracted out to the private sector, and their employees behave as badly, if not worse, than their public sector counterparts. We come to the vexed question of asymmetrical geographical power and monetary incentives in a fully corporatised medical sector, because of course highly well-paid doctors in urban centres have to perform, in terms of showing up and working long hours, to the tune of profit-maximising payroll masters (and broke patients!)

If the idea behind this shift in policy really is to guarantee good performance and high quality in public delivery, a far better idea is to tie powerful people to the public health system in the country, and ensure they have a stake in its doing well, as we have all read and absorbed Hirschman’s classic 1970 treatise on ‘Exit, Voice and Loyalty’. A good beginning would be to somehow link CGHS benefits for all public sector employees – from the most junior to the most senior, as they are all relatively powerful in their own tiers and domains – to the public health care system alone. It will be remarkable how quickly we see an improvement in performance and quality of provision, were such a move undertaken. Additionally, legislation ought to be passed that the private costs of health care, as well as foreign costs of health care, for government and political functionaries, is not underwritten by the Government of India. This will countervail, to a significant extent, the argument that there is no fiscal room for additional social sector spending in these recessionary times, since the amount saved will add to the ability to do so (cross-subsidisation of sorts, always a decent redistribution tool).

Further, is the government willing and able to rein in and regulate the private sector in general? For as the Health Chapter (August draft) itself acknowledges, any kind of privatisation in the provision of health care, such as the managed-care model, has to be carefully and heavily regulated by the government. So far, it is unable to stem empanelled doctors and hospitals from gaming the system and performing unnecessary hysterectomies, in rural and small-town India, the costs of which are reclaimed through the Rashtriya Swasthya Bima Yojana insurance scheme (which we will come to shortly). In subaltern India, it will also find it hard to enforce necessary emergency caesareans be performed, in a managed-care model whose financial imperative act to cut free services over time, especially those of a more expensive nature. Moral hazard and adverse selection are going to be rife in this system, as is the complexity of information and understanding needed sidestep them. Such information asymmetry problems are known to be much worse for poorer and illiterate women, and other subordinate groups, so it will be the government’s duty to safeguard their rights if it is the one foisting this market on them.

What about the argument that the public delivery of health care is irrevocably interwoven with large-scale corruption, such as recently publicised about NRHM in Uttar Pradesh, and therefore, what is the harm in trying the private sector alternative? First, this is not universally true across states of India, as anyone with a passing knowledge of Tamil Nadu and other well performing states’ social sector programmes will counteract. Second, a sophisticated understanding of corruption as also including unilateral power to behave with impunity, especially in today’s India, suggest the  private sector will be allowed to get away with ‘corruption’ on an equally, if not larger, scale than the public sector. In Delhi itself, the post-Imperial capital, the government is unwilling or unable to ensure that powerful private hospitals, who have obtained government land on the condition that they admit a certain percentage of patients from economically weaker sections (EWS), actually do so. It is also turning a blind eye to the hidden but increasing private medical trials industry that is mushrooming in the country.

Privatisation of an entire system is not something that can be easily – or at all – rolled back, in our Age of Capitalism. How hard it is to stuff the genie back in the bottle, in the face of greedy corporates and powerful lobby groups, is something the NHS is set to find out soon in the United Kingdom, just as numerous Presidents of the USA did when trying to reform its deeply flawed system, and ironically, as Obama has fought hard to do in recent times. So before this massive step is taken, let us think very carefully as a nation, especially as our levels of development and health achievements are far worse than that of these countries.

Finally, if privatisation and PPPs are something the government needs for faster growth, as signals to attract FDI and keep the stock market bullish, why not fully privatise numerous other sectors, such as large-scale infrastructure, construction, airlines operations etc.? Let these be riven with ‘efficient corruption’, in the Shleifer and Vishny sense, or not, in which case they can keep rooking on cost, quality and timing, with need for repeat delivery at short intervals etc. (it will keep the aggregate demand high, in any event!) Let the opportunity to earn supra-normal profits, via monopolies and even natural monopolies, be with the private sector alone (not even PPPs). For they matter – relatively – little to the social contract of the state, with its citizens, other than cutting the government’s revenues in earnings.  If something has to be ceded from the public sector portfolio in the India of 2012, to keep it on the conveyor belt of growth, let it be these areas. In lieu, ring fence public spending and the public provision of basic needs, such as health care (and education), for not only are these instrumentally important to achieve ‘inclusive growth’, if we really mean to, but they are constitutively important, to ensure the majority of citizens in a democracy have capabilities to lead a flourishing life.

The less said about the third ‘how’ of financing universal health care, via insurance, in the Health Chapter (August Draft), the better. International evidence is overwhelmingly of the view that this is not possible, and numerous early academic and evaluation studies of the Rashtriya Swasthya Bima Yojana (RSBY) insurance scheme show its many flaws. These are acknowledged by the Planning Commission: “They [HLEG] have also noted the problems with reliance on a market oriented, “fee for service model”, based on insurance in which the premium is paid by the government. This creates incentives for unnecessary curative care and a consequent spiraling of costs (p. 29, Health Chapter (August draft)). And still, it proposes to expand it across the entire BPL population of the country, to numerous other unorganised sector worker groups and so on.

If all these suggestions and the associated policy push are not coming from theory or empirical evidence, then where are they coming from? Unless one were party to inner policy formulation deliberations, it is hard to say. The Health Chapter (August draft) places the full onus on the origin of the managed-care model recommendations with the HLEG. The HLEG 2011 does suggest a networked system at the district level, leaving itself wittingly or unwittingly open to such misinterpretation, as activists feared. If news reportage is correct, there is an on-going debate and disagreement between the Ministry of Health and Family Welfare, and the Planning Commission of India, on the proposed changes. As an outsider, it is again hard to keep track of the exact nature of the differences, and how they are being negotiated, day by day. Therefore, the broader political economy ‘how’, of the eventual form of the Health Chapter (August Draft) in the final approved Approach Paper to the XIIth Plan, is still an open-ended one.

As Buchanan and Tullock (1962) famously noted, government and the bureaucracy is not a monolithic, uniform black-box of an actor, and is rather made up of individuals, their idiosyncracies, their failures, their incentives, their propensities to act in certain ways. So we are yet to see where the chips eventually fall on the policy front, as regards proposed changes to the public health care system. But I will appeal to the higher selves of those determining the final version of the Health Chapter, in the Approach Paper to the XIIth Plan, whomsoever they be, to rather act to strengthen its many good ideas, some drawn from bright  people working within the government and others from HLEG 2011, on the expansion of regional AIIMS-like institutions across the country, medical education in the public sector, the provision of free essential generic medicines, the regulation of private sector quacks through accreditation and so on. This is your and our moment, this country’s moment, if it really aspires to being just, fair and ‘inclusive’.

To remind public sector naysayers, within and outside the government, health care is not a normal commodity in many respects (neither is education). Both are linked to fundamental needs and aspirations of the people, what it means to be human, in essence, and as a social animal, a community. A catastrophic illness in the poorest family will compel them to spend all their money, even money they do not have, on the slim chance of survival for one of its members. The desperation of the poor to better their situation and become upwardly mobile – though that is semantically a misleading gradient, too opulent at that standard of living – is what compels families to enroll their children in schools, as they are doing in droves at present in India, against every socio-economic odd and every geographical constraint of vast distances between remote hamlets and providers. Such aspiration is only going to grow in our country today, because of what the media and every single sensory source in our Age of Information Overload is consciously projecting as our country’s shining future.

If the judiciary is increasingly recognising and legislating on rights in the social sector sphere, surely the government ignores them at its own peril in a democracy? And if it is going to do so, let us forget all this humbug about faster growth being pursued to better the lot of ‘the common man’. Let us openly acknowledge that evidence-base and ownership by academics, activist and civil society groups matters not a whit to eventual policy formulation. Let us not attempt to co-opt all dissenting voices, by soliciting their views in endless committees and platforms, while proceeding exactly or even worse than before (such as a supposed desire to move towards universal health care, disguising all sorts of sins of omission and commission), for it is more cynical an act than never having consulted them at all. And let us be prepared politically for the consequences of systematically and knowingly ruling out the possibility of the majority ever being able to participate in a democracy’s so-called ‘success story’, of growth alone. Pursued for its own sake, it is to be a private celebration for an exclusive few.

(Kaveri Gill is an independent academic and researcher based in Delhi. The views expressed in this piece are the author’s own and are independent of any professional institutional affiliation she holds, past or present).

---

[1]http://planningcommission.nic.in/plans/planrel/12appdrft/appraoch_12plan.pdf(last accessed 24 September 2012).

[2] So is education, especially elementary education.

[3] On the primary education side, too, there has been an increase in enrollment and fall in drop-out rates in recent years, but grave questions remain about the actual learning levels and quality of education.

[4] I allude in this piece to an August draft of the proposed Health Chapter of the Approach Paper to the XIIth Plan, which is at present being finalised by the Planning Commission of India. It shall forthwith be referred to as the Health Chapter (August draft). Since there are many drafts and it is a work in progress, figures may differ slightly in citations of different versions by various authors.

[5] These figures vary by source, but the range remains as stated. Public spending increases marginally, if spending on co-determinants of health, such as water, sanitation etcetera, is included.

[6] At 19%, public spending on health as a percentage of total health expenditure is also lower in India (WHO 2007 & 2008) than all South Asian countries, except Pakistan (Sri Lanka: 46.2%; Bangladesh: 29.1%; Nepal: 28.1%; Pakistan: 17.5%), let alone China (38.8%) and Brazil (44.1%). Interestingly, Europe (Germany: 76.9%; France: 79.9%; UK: 87.1%) – with its tradition of welfare states – far outshines the USA (45.1%) in this respect.

[7] It produced, “High Level Expert Group Report on Universal Health Coverage for India” (November 2011), forthwith referred to as HLEG 2011.

[8] Inter alia, “Dangerous Drift in Health Policy – Jan Swasthya Abhiyan Action Alert” (August-September 2012) maybe be accessed at: http://www.scribd.com/doc/103888531/Jan-Swasthya-Abhiyan-Action-Alert; “Setting up Universal Health Care Pvt. Ltd.”, Rakhal Gaitonde and Abhay Shukla, op-ed in The Hindu, 13 September 2012).

[9] Much also “depends upon the specific way the additional public spending is pooled and spent. Prepayment from compulsory sources (i.e. some form of taxation) and the pooling of these revenues for the purpose of purchasing healthcare services on behalf of the entire population is the cornerstone of the proposed universal healthcare…[it] is essential for ensuring that the system is able to redistribute resources and thus services to those in greatest need…both theory and evidence [shows] that no country that can be said to have attained universal coverage relies predominantly on voluntary funding sources (p. 9, HLEG 2011).

[10] “A Primary Evaluation of Service Delivery under the National Rural Health Mission (NRHM): Findings from a Study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan”, Gill 2009, Working Paper 1/2009 – PEO, Planning Commission of India.

[11] This trend for contractual employment to do the same job, in the public and private sector in India (the distribution of regular to contractual workers in Maruti Suzuki’s factory in Manesar is a good example of the latter), can also be traced to the many labour market perils of unfettered globalisation and capitalism.

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27th Ramanadham Memorial Meeting: Public Health, Inequality and Democratic Rights

The late sixties marked the first major crisis of independent India at all levels of its
economy and polity. This crisis gave birth to radical movements. Among these
were the tribal and peasant struggles led by Marxist Leninist parties. Brutal state
repression was launched on these movements. Regional civil rights
organisations arose as a response to the various illegal modes of repression. Thus in
1974 Andhra Pradesh Civil Liberties Committee [APCLC] was founded in
Andhra Pradesh.

Those were the times when A. Ramanadham, a medical doctor by profession,
founded one of the district units of APCLC in Warangal town.
Born in Mustikuntla, a small village in Khamman district in 1933, he started his
career as a government doctor. Dissatisfied with the unethical medical practices, he
left his job and set up his own Children’s Clinic in 1968 in Warangal. That year
marked the beginning of his involvement in various social issues. The clinic was to
become, perhaps, the only democratic centre in the entire town.
In June 1975, Emergency was imposed institutionalising the ongoing repression. Dr.
Ramanadham, along with other activists, were arrested. After lifting of
Emergency APCLC was able to function again. Dr. Ramanadham became its
Vice President.
Civil rights organisations that had earlier been confined to their own regions and
histories, began to share information and experiences. Joint investigations into
repression on worker and peasant struggles and joint campaigns on repressive
laws. In this process of building fraternal relations PUDR came to know the work of
Dr. Ramanadham. And to appreciate his gentle friendliness and modesty

Dr. Ramanadham’s involvement with civil liberties was inseparable from his
professional role as a doctor. In fact, his professional role helped the civil rights
movement which, in turn, made him a better doctor. It helped him to understand
the social origins of the diseases of his patients He did not confine himself to
giving medicines but tried to spread a scientific outlook. Out of this came his
famous book in Telugu, Medical Guide which was addressed to the people and not
to health workers.
Dr. Ramanadham tried to create a space for democratic values wherever he went
and in whatever he did. Struggling against corrupt medical practices in a health
centre in Husnabad, helping friends to bring out a revolutionary literary journal in
Warangal, helping a young girl and conducting her marriage against the will of her
influential parents, organising a people’s clinic with the help of doctors on strike in
front of Warangal -Government Hospital, are examples of Dr. Ramanadliam’s
involvement and initiative in democratic concerns

In the late seventies peasant struggles for higher agricultural wages and against
landlord repression spread in Warangal and other districts Police was given extensive illegal powersto repress these struggles. Governments kept changing  but state violence continued. With APCLC, Dr. Ramanadham was actively involved in investigating fake encounters, custodial torture and deaths. This earned  them the wrath of the police

On 2nd September 1985, at Kazipet railway station, SI Yadagiri Reddy was shot
dead by unidentified assailants, believed to be naxalites. Next morning his body
was carried in a funeral procession in which a number of armed policemen
participated. The procession was led by the district Superintendent and the Deputy
General of Police. When it neared the Children’s Clinic, a group of policemen
broke into the clinic. They ransacked the clinic and assaulted the compounder and
waiting patients. Then they went into the neighbouring shop, Kalpana Opticals,
where they found Dr. Ramanadham and shot him at point blank range.
Immediately after, a neighbouring doctor took him to Mahatama Gandhi Memorial
Hospital, about two kilometres away. Soon after he was declared dead. With his
death the Warangal unit of APCLC” ceased to function
Four days after his death, police filed a second FIR in the Yadagiri Reddy murder
case, the first murder case to be registered under TADA in Warangal. Dr
Ramanadham was named as accused. However, in the case of the murder of Dr.
Ramanadham, no accused were named. Police maintained that naxalites were
responsible and they had used snatched police revolvers. Two policemen were
suspended for dereliction of duty as their revolvers had been snatched
Barely a year later J. Laxmareddy, President of the Karmmagar unit of APCLC
was killed by police on 7 November 1986. The Warangal unit was revived with
the efforts of N. Prabhakar Reddy who became its convenor. A lawyer by
profession, he was instrumental in obtaining bail for hundreds of rural youth
charged under TADA. On 7 December 1991, police came to his house and shot
him dead.
The murders of civil rights activists are not random acts of violence by a few
deviant policemen. These are part of a larger political policy of the government
against the people. Perhaps the only meaningful way of remembering Dr
Ramanadham is by committing oneself to the movement for democratic rights
and affirming our faith in people’s struggles to implement and extend these
rights.

People’s Union for Democratic Rights (PUDR), Delhi

Invites you to attend

27th Ramanadham Memorial Meeting

Public Health, Inequality and

Democratic Rights

Speakers:

Dr. Yogesh Jain

Jan Swasthya Sahyog

Topic: Social Inequality and Public Health

Dr. Jacob Puliyal

St. Stephens Hospital, Delhi

Topic: Immunization Programmes and Public Health

Dr. Amit Sen Gupta

People’s Health Movement

Topic: Drug Policy, Pricing and Public Health

Chair

Dr. Ritu Priya Mehrotra

Centre for Social Medicine & Community Health, JNU

8th September, 2012

5 pm – 8pm

Conference Hall

Indian Law Institute

Opp Supreme Court

Bhagwan Das Road

New Delhi

Anybody ill here and seen a doctor yet?

 

KRISHNA D. RAO,  The Hindu

 

The Hindu

GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana

Addressing the scarcity of medical practitioners in rural India is fundamental to achieving universal health care in the country

The Planning Commission’s draft 12th Plan for health has attracted much debate and controversy. Critics have been quick to direct their attention at two issues in it — the proposed increase in government health spending from one per cent to 1.58 per cent of GDP, and the “managed care model.” The spending increase was rightly felt to be grossly inadequate to move India towards achieving universal health care. The “managed care” model was expected to relegate the government’s role to a purchaser of services and undermine its role in the service provision. By focusing on these two issues, the debate on the 12th Plan for health, and indeed the Plan’s approach paper itself, ignores some of the more fundamental obstacles to achieving universal health care in India. For one, the scarcity of rural doctors currently prevents the delivery of even basic clinical services to needy citizens. Simply spending more or changing the way health services are purchased will not solve this problem.

Urban-rural divide

People deliver health services. Urban Indians can be forgiven for thinking that there are enough doctors in the country. Indeed, our cities are abundant with all manner of clinics, diagnostic centres and hospitals. But having a qualified doctor nearby is a rarity for the vast majority of Indians who inhabit the country’s rural spaces. According to the 2001 Census, there is a tenfold difference in the availability of qualified doctors between urban and rural areas i.e. one qualified doctor per 8,333 (885) people in rural (urban) areas of India. Addressing this rural scarcity is fundamental to efforts for achieving universal health care in India.

There are several notable reasons why doctors are reluctant to serve in rural areas. Fundamentally, the professional and personal expectation of medical graduates is not compatible with the life of a rural doctor. Their ambition lies in becoming medical specialists. Once they specialise, the professional, income, lifestyle, and family life opportunities in cities make rural jobs unattractive. Moreover, with private medical schools and their high fees dominating medical education, it makes little sense for medical graduates to take up jobs that don’t offer them the opportunity to recover their investment.

The scarcity of rural doctors places an important responsibility on the government. However, its efforts to place government doctors in rural posts have been largely unsuccessful. For the hardship that rural doctors have to endure, government service offers relatively little in terms of remuneration, quality schooling for their children and a chance at a decent family life. Human resources in the State health services are also poorly managed.

For instance, there is little transparency about transfers and postings because they are a source of both corruption and political patronage in the health system. Absenteeism is another issue. Indeed, most of the court cases facing State health departments have to do with human resource issues. However, given the professional and personal expectations of doctors, it appears unlikely that large increases in salaries and management changes will attract adequate numbers to government jobs and rural posts.

Situation abroad

Interestingly, many high, middle, and low-income countries also face a scarcity of rural doctors. Many of them have ameliorated this problem by using non-physician clinicians to deliver basic health services. In the United States, the United Kingdom, many countries in Africa, and even in South Asia, individuals such as nurse-practitioners or medical assistants, who have some years of basic clinical training, perform many of the clinical functions normally expected of fully qualified doctors. In sub-Saharan Africa and many parts of Asia, clinical services in rural areas are possible only because of these non-physician clinicians. They provide a range of clinical functions, including basic clinical services, manage deliveries, caesarean sections and abortions. Importantly, assessments from a variety of settings have shown that they perform as well as doctors.

Clinician cadre

India, however, has had an uneasy relationship with mid-level clinical cadres. At the time of India’s independence, licentiate medical practitioner (LMP)s, who underwent three years training, comprised nearly two-thirds of the qualified medical practitioners (the other one-third being doctors) and they mostly served in rural areas. LMPs were abolished after Independence but doctors never really occupied the space that LMPs vacated. Now, the shortage of rural doctors has forced some States to look towards non-physician clinicians for relief. Clinicians with around three years of clinical training currently serve at government rural health clinics in Chhattisgarh and Assam. Importantly, assessments of their performance in Chhattisgarh have shown them to be as competent as doctors for delivering basic clinical care. And because their training focuses on serving as rural clinicians and their career ambition is to have a government job, these clinicians, as the Chhattisgarh experience shows, have a greater likelihood of staying and serving in rural areas. The Central Health Ministry has proposed to expand this clinician cadre nationally through the Bachelors of Rural Health Care (BRHC) course. Unfortunately, expanding this cadre has met with considerable opposition and a former health minister even labelled them as “qualified quacks.”

The road to universal health care in India necessarily requires a serious assessment of basic problems that afflict the health system like the lack of human resources in rural areas. While this piece has focused on doctors, the rural scarcity of other health worker cadres such as nurses, lab technicians and pharmacists is equally acute and equally deserving of serious attention.

Higher government spending on health or how health services are purchased will do little to ensure that all Indians have health care if there are inadequate numbers of trained health workers with the right skill mix. The experience of other countries and two States in India show that non-physician clinicians, whether they are three-year trained clinicians or nurse-practitioners, can be part of the solution.

(Krishna D. Rao is senior health specialist, Public Health Foundation of India, and visiting faculty, Department of International Health, Johns Hopkins University, U.S. The views expressed are solely his and not of his affiliated institutions.)

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Don’t take the wrong pill- Universal Health Coverage

 

 

 

Editorial, The Hindu 

 

The Planning Commission must not make the mistake of letting short-term fiscal concerns overturn the national aspiration for Universal Health Coverage (UHC). Some elements of the draft Twelfth Plan on health have caused alarm, as they run counter to key recommendations of the Commission’s own High Level Expert Group. The Plan panel wants to reduce out-of-pocket spending on health from 71 per cent to 50 per cent during the Plan period, to mitigate the biggest factor that leads to impoverishment of many families. But that will be impossible without substantial fiscal support. Regrettably, there appears to be a quiet attempt to peg targeted public spending on health at 1.58 per cent of GDP, ignoring the HLEG recommendation for an increase to 2.5 per cent over five years, and to 3 per cent by 2022. Among comparable nations, India brings up the rear in public spending on health at 1.2 per cent of GDP.

 

English: Manmohan Singh, current prime minister of India. (Photo credit: Wikipedia)

 

It is now crucial for the Centre and the States to come together and launch a UHC model funded by general taxation that meets the essential health requirements of all people. The success of legal reform in the United States to regulate a socially disconnected, for-profit health industry, and the remarkable equity achieved by other welfare-oriented countries should persuade Indian leaders on launching a national plan.

At the polio summit in February, Prime Minister Manmohan Singh emphasised the need to strengthen public health systems, and accelerate efforts to achieve universal access to care. It would defeat this idea if UHC were to rely on for-profit providers of care and insurance under a ‘managed care’ model. The Planning Commission would do well to steer away from the siren songs of corporatisation, and focus on the core challenge: the need to set up an independent regulatory framework at the national and State level for all types of care institutions, regulate drugs to lower costs and promote generics, identify standard treatment and management guidelines, and provide resources to fund the essential health package. It is of course encouraging that the Commission has distanced itself from reports of reliance on corporate providers, but it is essential to state the vision clearly in the Plan. Also worth pointing out is the potential of UHC to create a large number of jobs and spur economic growth. India needs many more professionals to achieve the ideal norm of one doctor for 1,000 people, and three nurses and midwives per doctor. Here, the HLEG provides a useful roadmap for expansion of teaching institutions, which can quickly raise the capacity of many remote hospitals.

 

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Immediate Release-Planning Commission of India to hand over Health Care to Corporate Sector

 

English: Montek S. Ahluwalia, Deputy Chairman, Planning Commission, India, speaks at the closing plenary of the World Economic Forum’s India Economic Summit 2008 in New Delhi, 16-18 November 2008 (Photo credit: Wikipedia)

 

 

 

 PRESS STATEMENT

 

 

Planning Commission of India to hand over Health Care to Corporate Sector

 

The draft health chapter of the 12the Five Year Plan document is being discussed for final adoption by the Planning Commission by the end of August, 2012. The Jan Swasthya Abhiyan (Peoples Health Movement – India) expresses concern regarding the present recommendations and plans outlined in the draft chapter. The chapter fails to build on the recommendations of the High Level Expert Group (HLEG) set up by the Planning Commission, misquotes the Group’s recommendations in many places and ends by proposing a plan for restructuring the country’s health system that would effectively hand over health care to the corporate sector. It is particularly problematic that the plan document invokes the concept of Universal Health Care, while actually proposing a strategy that is far removed from the basic tenets of Universal Health Care.

 

The Plan document recommends increase in public expenditure on health from the present 1% to 1.58% of GDP. This is in sharp contrast to the HLEG recommendation of increasing this expenditure to at least 2.5% of the GDP and also at variance with the earlier pronouncements by the Prime Minister. Secondly it proposes that the Central government’s (which collects most of the taxes ) share in the additional health expenditure would be less than half of what states would contribute and that Centre’s contribution would be conditional on states’ contribution!   The Planning Commission seems to have decided thatIndia will continue to be among the bottom 10 nations in terms of percent GDP spending on health.

 

What is of even greater concern is the strategy proposed for restructuring of the country’s health system in the document. The Plan document proposes a transition from: “….the present system which is a mixture of public sector service provision plus insurance, to a system of health care delivered by a managed network”. There is, thus, a road map envisaged where the Government will abandon its central role of providing health care and become primarily just a ‘manager’ of the new system envisaged.

 

The document’s vision of ‘universal provision of public health care’ includes two components.  “..preventive interventions which the government would be both funding and universally providing” (see annexure) and  “clinical services at different levels, defined in an Essential Health Package, which the government would finance but not necessarily directly provide”. What, in essence, this formulation proposes is that the Government would, over time, confine itself to providing a small package of services and would be primarily just a purchaser of virtually all clinical services from the  corporatised private sector. The Government would thus finance (with public money), strengthen and bolster an already resurgent corporate sector providing medical services. On the face of it, this appears an almost diabolical ploy to hand over the profit-making clinical services sector to corporate hospital chains. It would also decisively halt and eventually reverse the moderate achievements of the National Rural Health Mission, in expanding public health infrastructure and services in parts of the country.

 

The public health system will now be asked to compete with the private sector to attract patients. A system is envisaged where: “each citizen family would be entitled to an Essential Health package in the network of their choice. Besides public facility networks organized .. private and NGO providers would also be empanelled to give a choice to the families”. Even this truncated role of the public system is qualified by the proviso that” “..public facilities will have to be strengthened, networked, and their managers provided sufficient autonomy to purchase goods and services to fill gaps as per need”. In other words, public only in name, but would be vitiated by the logic of the market and by the incorporation of private players into its fold.

 

The HLEG had, in its report, commented that: “…since there is virtually no focus on primary level curative, preventive, and promotiveservices and on long-term wellness outcomes, these traditional insurance schemes often lead to inferior health outcomes and high health care cost inflation”. Yet the Planning Commission’s document repeatedly talks about expansion of the health insurance scheme called RSBY and its vision of Universal Health Care is nothing but a more expanded version of the RSBY scheme.

 

The document announces another bonanza to the corporate medical sector in the form of grants to set up hospitals and private medical colleges. It says: “Health has now been included with other infrastructure sectors which are eligible for Viability Gap Funding up to a ceiling of 20% of total project costs under a PPP scheme. As a result, private sector would be able to propose and commission projects in the health sector, such as hospitals and medical colleges outside metropolitan areas, which are not remunerative per-se, and claim up to 20% of the project cost as grant from the Government”. It may be noted that the only eligibility requirement is the location, and not any contribution to public health goals.

 

This document proposes that  public health facilities will have “flexibility” to raise their own finances. The Plan document says: “Tertiary care facilities would have an incentive to generate revenues if they are provided an autonomous governance structure, which allows them flexibility in the utilization of self-generated resources within broad policy parameters laid down by the Government”. There are several ways in which such flexibilities can be misused, including in the form of levying of user charges and arrangements with private entities that seek to extract benefits that conflict with the public health goals of public institutions.

 

The HLEG  had recommended : “enforcement of price controls and price regulation on essential and commonly prescribed drugs”. However, this document does not even  mention drug price regulation, in spite of a pending Supreme Court directive that the Government should expeditiously put in place a system to control the prices of drugs. Neither is the recommendation of the Expert  Group, that the production of drugs and vaccines in the public sector be incentivised, reflected anywhere in this  Planning Commission’s chapter.

 

The ideological bias of the Planning Commission’s report is clear when it says: “A pure public sector delivery system involves funding a large public sector health system, with little incentive for the service providers to deliver a quality product”. Such an assertion flies in the face of global evidence that the best performing health systems are those that are publicly financed and where health care is provided either almost entirely by the public sector or by a combination of the public sector and non-corporate  providers. Neighbouring Sri Lanka has been long held as an example of such a system, where over 90% of in-patient care and over 50% of out-patient care is provided by the public sector. Mortality and morbidity rates in Sri Lanka are far better than in India, in spite of the country having a lower per-capita GNP. Thailand, in recent years, has made rapid strides in providing universal access to health services by increasing public finances and by significantly expanding public provisioning of health services. In contrast, the United States, provides ‘choice’ between public and private providers but is by far the worst performing health system among all developed countries, in spite of spending over 8% of GDP on health care.

 

The Planning Commission’s recommendations, perhaps make some sense if seen purely in the context of neoliberal economic policies. Injection of public funds into a floundering economy through the financing of the private, corporate controlled, hospital sector may seem attractive in such a context. But the strategy is disastrous in public health terms, and is designed to finish of the vestiges of a public health system that still survives in the country.

 

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Plan panel wants govt to retreat from healthcare #Goodnews

 

Nitin Sethi & Kounteya Sinha, TNN | Aug 8, 2012, 02.17AM IST

NEW DELHI: In a move that has angered the health ministry, the Planning Commission has asked for reversal of the long-standing public health policy from the 12th plan onwards ending governments’ dominant role in providing health services and transiting to greater privatization of the health sector, something along the lines of the ‘managed care’ system which is followed in the USand Mexico.The health ministry has taken a tough stance against what is referred to as “corporatization of health care” and will send a strong reply on Wednesday to plan panel deputy chairman Montek Singh Ahluwalia arguing that “the first priority should be to strengthen the public health system and involve the private sector only for critical gap filling”.

The letter from health minister Ghulam Nabi Azad says that “the private sector should not substitute but actually supplement the public sector”.

TOI accessed a draft, finalized at the end of July, of the 12th five year plan‘s health chapter which sketches the dramatic policy reversal that would bring in universal health insurance coverage by allowing a selected ‘network’ of private and other operators to sell their services on competitive basis to the government for which they would be paid on what the health industry calls ‘capitation’ basis or simply on fixed rates for different treatments for every person handled.

The plan panel’s prescription visualizes government’s role in delivering primary healthcare as restricted to mere essentials like antenatal care, leaving more lucrative medical treatment to the ‘managed-care’ system where private players will compete with cash-strapped government-run hospitals to run the ‘networks’.

The commission’s proposal runs contrary to what even its High Level Expert Group (HLEG) on health reforms had said as recently as November 2011.

The HLEG, headed by Dr K Srinath Reddy, had recommended, “Purchases of all healthcare services under the universal healthcare 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.”

In other words, the HLEG recommended that health delivery services should be run by the government and where a need arises, the government can hire private hospitals for which they would be paid on fixed basis. Under this system, the private players would not be competing but filling the gap.

The HLEG went against the ‘managed care’ system that the Planning Commission has now recommended.

“It becomes necessary, therefore, to either explore a completely different approach towards the use of insurance companies and independent agents – more in the ‘managed care’ framework, where they take on explicit population level health outcome responsibilities or invest further in the capacity of the ministries and departments of health to directly provide and purchase services from contracted-in private providers wherever necessary. We favour the latter option,” the expert group had held.

HLEG will meet on Thursday to discuss the commission’s latest proposal.

Dr Reddy told TOI, “We have clearly voted for strengthening of the public sector. We will meet on Thursday to discuss where there is a mismatch between our recommendations and the commission’s proposal.”

He added, “We have clearly said that the public sector needs to be strengthened and should be the main provider of services under the UHC. Where needed, the private healthcare provider could be contracted to supplement these services through a well designed system. Both public and private providers should be monitored by an independent regulator for quality of care so that the entitlement under the UHC is properly delivered through technically competent and ethically correct health care.”

The health ministry, however, is livid. An official told TOI, “We should not forget the exploitation of patients that goes on in the private sector every day through over prescription and over diagnosis. The health challenges in India‘s urban and rural areas are completely different. The private hospital chains have no presence in such backward areas facing the worst health indicators. How will they perform there?”

The ministry is also worried that such a move by the Planning Commission will take away “the few doctors that are still practicing in public hospitals”.

“The National Rural Health Mission needs to be continued. We have invested huge amount of money and planning over the last seven years over it and are finally seeing results. A National Urban Health Mission needs to be floated for the urban poor,” the ministry said.

Sources said at stake in this controversial move is the health sector pie which is set to rise substantially as the government ups its investment in the 12th five year plan to Rs 10,85,369 crore.

At present, almost all health funds provided to states are part of the flexible arrangement to help states set public health priorities.

The Planning Commission has recommended that this be kept to a minimum of 10% of the total funds and the rest be part of an ‘incentive fund’ which will be linked to the state governments undertaking such ‘reforms’ and other targets. This would also effectively reduce the funds that the health ministry controls substantially.

Oddly, the Planning Commission’s report even misinterprets what the HLEG recommended and claims, “The expert group has recommended that we should move towards a system of a network of health service providers at the primary, secondary and tertiary level which is funded on the basis of per capita payment to the network. The system managed as a network of service providers and individuals is registered on payment of a charge per person covered. Once enrolled, the individual’s health problems are handled by the network as a whole, with proper regard to the need for preventive care and a sequence of care from primary to the higher level as needed.”

Times View

India’s healthcare system is already among the most privatised in the world and the last thing we need is a further retreat of the state in this sector.Far from reducing its role, the government should be focussing on increasing it.

Not only does it need to spend much more on building infrastructure like hospitals and primary health centres, it must ensure that these are adequately staffed and equipped.Of course, ensuring that the money spent is well-utilised is important, which also means constant monitoring of whether doctors and paramedical staff are actually present where they are supposed to be.

The immunisation programme too needs to boosted and urgently. These are not options but necessary steps because, like education, healthcare too must be seen as something all citizens are entitled to.

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