‘Take care’ means more than ‘get well’
What is the mandate that society gives to a health ministry? Is it to provide some level of clinical care and limited financial support after people get very sick or to keep people as healthy as possible for as long as possible? The duties of a modern state require it to provide both health protection and illness care, with greater investment in the former. However, health ministries often tend to see the latter as their main task. It is not surprising, therefore, that the finance ministry sees a few disconnected benefactions to sick people as evidence of a ‘health-friendly’ Budget. How can it project a ‘big picture’ plan for health financing when the draft National Health Policy is lying untouched for over a year?
We must thank the finance minister for some good things he offers for health, both within that sector and through other sectors. Increased investment in pulses production signals an overdue recognition that the scarcity and high prices of these protein sources are depriving millions of Indians, especially children, of essential nutrition. The pledge to provide clean cooking gas and electricity to all villages dovetails well with the prime minister’s call to the affluent to surrender their gas connections in favour of the poor. Universal access to clean energy will help free millions of women and children from the kitchen’s curse of indoor air pollution from solid fuels, and reduce the threat of several associated diseases. While the sight of the finance minister wielding his (t)axe on cigarettes is welcome, the absolute immunity that beedis continue to enjoy makes his claim of shielding health from tobacco’s harm sound untenable.
Within the health sector, what catches the eye is the fillip to dialysis centres across the country. It certainly will help many patients with a chronic kidney disease. However, where is the vision to strengthen primary health services for an early detection and effective treatment of high blood pressure and diabetes? Failure to do so will result in ever-growing numbers of persons seeking dialysis and cardiac repair, when many of them could have been effectively protected from reaching an advanced stage.
In 2008, Thailand included dialysis in the programme of universal health coverage on grounds of equity even though it did not meet the cost-effectiveness criterion. While professional groups argued for hemodialysis, the less expensive option of peritoneal dialysis was chosen for government funding and trained nurses have been providing this service even at patients’ homes. At each stage, the decisions were guided by health technology assessments (HTAs).
The choice of health technologies to be prioritised for government funding is guided, in many countries, by a formal process of HTA, which combines evidence of clinical effectiveness with considerations of comparative cost-effectiveness, affordability and equity. In Britain, this function is performed by the National Institute for Health and Care Excellence (NICE), which guides the National Health Service. In Thailand, the HITAP (Health Intervention and Technology Assessment Programme), an autonomous arm of the ministry of public health, performs this role. In India, we do not have any institution that provides such analytic support to the health ministry, which in turn should appropriately advise the finance ministry. Ideally, the Indian Council of Medical Research (ICMR) should establish a multi-disciplinary expert group analogous to NICE or HITAP. Recent cuts in the budget of the ICMR do not bode well for that.
Who will bear the cost of recurrent dialysis and on what scale? The cost of supporting dialysis rose from 0.2% of the Thai health budget in 2008 to 3.4% by 2012. Thailand launched a massive programme screening for hypertension and diabetes to provide effective early care that can curtail the demand for dialysis and contain escalating health care costs. Such coupling of preventive and palliative care has not been strategically signalled in our Budget.
Lowering financial barriers to accessing health services and providing financial protection against health care-related impoverishment are the objectives of the Universal Health Coverage, to which the government is committed. Will the proposed insurance cover of Rs 1 lakh per family meet these objectives? While the poor will have greater access to hospitalised care, insurance will not cover the cost of outpatient care and drugs, which account for 70% of out-of-pocket expenditure. Jan Aushadi stores will help increase access to low-cost generic drugs for the middle class but will they assure unimpeded access to essential drugs for the poor?
The claim that the insurance programme will reduce catastrophic financial shocks due to hospitalisation is only partly true, since the over-limit in-hospital costs and post-hospitalisation expenses will be out of pocket. More important, the cumulative burden of recurrent expenses on common ailments and continuous spending on chronic conditions are what drain the health and savings of many Indians. Insurance does precious little for that. Weak primary care services will land more people in hospitals and health care costs will progressively escalate beyond the reach of government budgets.
A universal insurance scheme for acute hospitalised care will succeed only if it is part of an integrated system that seamlessly connects essential basic services for disease prevention and early clinical care with referred advanced care when needed, and ensures efficient follow-up on return to primary care. In essence, it calls for the marriage of an expanded National Health Mission and all government-funded health insurance schemes to create an integrated system of service provision and financial protection. When will that happen? Why is the urban health mission still on the drawing board? Will the central insurance scheme compete with or assimilate the state-funded health insurance schemes, which selectively target hospitalised care? Some questions to ponder, as we prepare for the Budget of 2017.
(K Srinath Reddy is president, Public Health Foundation of India. The views expressed are personal)