ECONOMY
JAITLEY'S SICK PLAN
Health, Budget & Politics - Why NHPS is doomed to fail, & what sick India really needs
- DR. PYARA LAL GARG
Health, Budget & Politics - Why NHPS is doomed to fail, & what sick India really needs



WE ALL KNOW that any democratically elected Governments are supposed to provide health and curative services to their populace by state funding. However in India, health care is still not with in the reach of major sections of the society, particularly the most marginalised ones. This leads to high morbidity and mortality and the same results in indebtedness. 70% of the total health care expenses have to be made out of pocket by the people themselves. As such in the race for privatisation of health care delivery system in India, quality  services has been a casualty. Some of the serious ills such as deterioration in quality of health care, teaching and training of the manpower, corruption, sky rocketing prices of treatment and medical education, are a rule than an exception. 
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All the concerned citizens would like to get answer as to the impact of the Budget announcements regarding health in the Union Budget 2018-19 on the common man, impact on the availability of health services to masses, impact on finances and economy of the Nation, impact on GDP, impact on self reliance and the sovereignty of our country. The Budget provisions are required to be analysed and understood holistically in this context.
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We as a Nation are committed to provide quality health care to each and every individual without any discrimination on the basis of caste, creed, religion, region, language, gender, age, education, economic status, job status, rural or urban bias. To this end a vast Government public health system had been created. However there have been frequent news reports on the quantitative as well as qualitative inadequacy in the public health system. At the same time the profit hungery private sector almost totally unregulated, has also been making headlines like the incidence of Gurugram in the recent past and the health care is slipping out of the hands of common man. As such there is an urgent need for the interference at the Government level. In order to achieve our aim of Universal Health Care, let us ponder for a moment, can we depend upon private sector? Can we place health care of the 1300 Million mammoth population, most of which is extremely poor, at the mercy of corporate or private hospitals? No, a big NO.  

A robust web of Government Institutions for primary, secondary and tertiary care, delivering quality services, coupled with price control on the appliances and the drugs, is the answer to the vexing problem. At-least the success story of strong National Health Services of England, exemplary Health Services in Cuba and the health services of our own country prior to liberalisation, stand testimony. Further it is essential that the policy frame of deregulation of medical education be put to rest forthwith. There is a dire need that the unprecedented hike in the fees of the private medical colleges is controlled as per the law laid down by Supreme Court of India. We need a seamless health care delivery system for providing continuous comprehensive health services to 1.3 billion population. The process of framing the Budget for the financial year 2018-19, was an occasion for this turn, in the right direction. However the opposite has happened.

All the concerned citizens would like to get answer as to the impact of the Budget announcements regarding health in the Union Budget 2018-19 on the common man, impact on the availability of health services to masses, impact on finances and economy of the Nation, impact on GDP, impact on self reliance and the sovereignty of our country. The Budget provisions are required to be analysed and understood holistically in this context. This write up is a small attempt to that end. 
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In order to achieve our aim of Universal Health Care, let us ponder for a moment, can we depend upon private sector? Can we place health care of the 1300 Million mammoth population, most of which is extremely poor, at the mercy of corporate or private hospitals? No, a big NO.  
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Finance Minister in his budget speech announced a budget of Rs.1.38 lakh crore for health, education and social protection for the year 2018-19, an enhancement of Rs. 16000 core over the budget of Rs.1.22 lakh crore provided in 2017-18. Out of this, Rs. 85010 crore are for education and for health the provision is of Rs. 52,800 crore with an increase of 11.5% over the amount of Rs. 47353 crore provided last year 2017-18. National Health Mission allocation this year is Rs.30129.61 crore while the expenditure during the previous year was Rs. 30801.56 crore.  
 
National Rural Health Mission gets 9752.82 crore, while Rs. 1004.67 crore  have been allocated for trauma and Non–Communicable diseases. For Health Insurance  (National Health Protection Scheme NHPS) and for 1.5 lakh Health and Wellnes centres Rs. 2000 crore and Rs. 1200 crore have been provided respectively. 

While announcing Health Budget in para 55 to 62 of the budget text, the FM in the opening para 55, quoting from sanskrit texts of Niti Shastera, said "Now I come to the Health Sector. 'All should be happy and free from disease’ is the guiding principle of my Government. Only Swasth Bharat can be a Samriddha Bharat. India cannot realize its demographic dividend without its citizens being healthy.” Mr. Jaitely ended it with the announcement of upgrading 24 District Hospitals to Government Medical Colleges and a scheme of nutritional support to TB patients.

FM has announced two major schemes under Ayushman Bharat; one being the National Health Protection Scheme to cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization and claimed it to be world’s largest Government funded health care programme. Allocating Rs. 2000 crore for the said scheme, under Rashtriya Swasthya Bima Yojana (RSBY) announced that adequate funds will be provided for the scheme. 

For the 2nd scheme of 1.5 lakh  Health and Wellness Centres under the National Health Policy, 2017 , Mr. Arun Jaitely committed  Rs. 1200 crore and claimed that these centres will bring health care system closer to the homes of the populace. In order to provide nutritional support to all TB patients at the rate of Rs.500 per month for the duration of their treatment FM allocated Rs.600 crore. 
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A robust web of Government Institutions for primary, secondary and tertiary care, delivering quality services, coupled with price control on the appliances and the drugs, is the answer to the vexing problem.
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The healthcare industry is happy and welcomed the government’s announcements. The stocks of Insurance companies rose after the announcement and by noon the shares of SBI Life Insurance Co. Ltd, New India Assurance Co. Ltd,  ICICI Lombard General Insurance Co. Ltd,  HDFC Standard Life Insurance Co. Ltd,  ICICI Prudential Life Insurance Co. Ltd and General Insurance Corp. of India were up 5.9%, 5%, 3.37%, 2 .46% 1.03% and 0.94%, respectively, on the BSE.

INCEPTION OF THE TWO MAJOR PLANS OF THE PRESENT BUDGET:

Infact, from the dawn of 90ties the World Bank, by way of loans and by setting up of Health System Corporations, has been betting for and has created pressure for such policy changes in health sector that lead to withdrawal of the Government from providing health services, imposing user charges for secondary and tertiary care, handing over the hopital care to private sector, throwing ill equipped over-burdened Government Hospitals in open competition with private and five star hotel like corporate hospitals and simultaneously limiting Government health services to the low level primary care. Newly introduced twin schemes are nothing but a replica of the policy imposed by World Bank.
 
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"Now I come to the Health Sector. 'All should be happy and free from disease’ is the guiding principle of my Government. Only Swasth Bharat can be a Samriddha Bharat. India cannot realize its demographic dividend without its citizens being healthy.” said Mr. Jaitely 
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REAL PICTURE OF THE TWO SCHEMES UNDER AYUSHMAN BHARAT:

National Health Protection Scheme is to be launched on August 15 or October 2, per family premium, estimated at Rs. 1000-1200 per annum and total annual premium being Rs.10,000-12,000 crore, central and state governments sharing 60:40, shall cover indoor hospital care, hospitals including private shall be empanneled, can be implemented only if states agree to pay 40% premium. Punjab has already expressed reservations. Budget provision of Rs. 2000 crore can meet the  central share of the premium needs only for four months even on the said projected very-very low premium rates. 

The insurance companies after accounting for the managerial expenses, shall take some profit, shall be able to provide care worth Rs. 8000-10000 crore only. Infact, the Government has limited the expenditure on secondary and tertiary health care of 50 crore poor to this meagre amount, for catering to their needs in all serious diseases including cancer, heart attacks, accidental injuries, child birth related services, infants diseases, childhood diseases, female diseases, kidney failure, liver failure, gall bladder diseases, diabetes, chronic obstructive respiratory diseases, infectious and viral diseases, mental diseases, intoxicant addictions, birth deformities, preventable blindness, HIV/AIDS, joint problems and so on. 
 
There has been a wide ranging controversy over the estimates of  the quantum of premium projected by the Niti Aayog. The figures given are too low. They have compared the NHPS to Rashtriya Swasthya Bima Yojana (RSBY) which is for 7 crore BPL Families of up to 5 members each (husband, wife and three children) that is for 32-35 crore beneficiaries, providing annual cover up to Rs. 30,000 per family. The premium is Rs. 750/- per year per family. Calculates to be 5250 crore annually. RSBY was modified to NHPS,  with the premium cost of Rs. 6000 per annum , for protection to 10 crore families with a health cover up to Rs 1 lakh per family and an additional Rs 30,000 for senior citizens.

Estimated cost Rs 6,000 crore annually, NHPS had been approved by the Expenditure Finance Committee in 2016-17. Beneficiaries were to be listed not only BPL families  but also on the basis of  "deprivations”  listed in the socio-economic caste census, in order to provide cover to more families than that in BPL category alone. The same was reiterated during 2017-18. It has also been argued that even if the premium is 1% of the sum assured the amount needed is 50,000 crore, likewise for 2% or 3% the same shall be one lakh crore and 1.5 lakh crore.
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Presently announced National Health Protection Scheme mandates payment of 40% of the premium by the State Governments. In view of the poor economic status of the state governments, they shall either not agree to the scheme or shall curtail the budgetary provisions from other health care delivery items and thus push the already poor state health services to still a low level.
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DISEASE BURDEN REQUIRING SECONDARY AND TERTIARY CARE 

Cancer 55,00,000  with 17.6 lakh new cases per year by 2020. Among women 2000 new cases of cancer are diagnosed daily ,1200 being in advanced stage. Even at an average per capita expenditure of Rs. one lakh annually, total annual expenses calculate to be Rs.55,000 crore, 3.5 crore pregnancies, 2.5 crore births including cesareans, average per capita cost Rs. 5000 total 12,500 crore, for miscarriage at average per capita of 2000 total annual 2000 crore,  voluntary abortions were 3,59,148 during 2017, average per capita expenses Rs. 2000-3000, cost of 8,50,000 infant deaths, 40 lakh new patients of heart attack and total 2 crore, expenditure  at Rs. 10,000 per case , comes to be Rs. 20,000 crore, Diabetes 6.91 crore patients, Rs. 100 per patient 6910 crore, Accidents  6,45,409 with Rs. 20,000 per case 1200 crore, Dialysis 2,20,000, new patients annually. As per estimates in para 64 of the budget speech 2016-17 "every dialysis session costs about Rs. 2,000 – an annual expenditure of more than Rs. 3 lakh.”  As such total annual expenses of dialysis to new patients alone comes to Rs. 6600 crore per annum .

Liver cirrhosis 10,00,000 annual, total expenses 25,000 crore, chronic obstructive Pulmonary disease 3,00,00,000 and deaths 8,00,000. Preventable blindness 2 lakh annually, HIV/AIDS 21,00,000 and 80,000 new annually, birth defects 5 lakh annually, dengue in 2016 alone 1,29,166 patients , swine flu 50,000, depression, intoxicants, osteoarthritis knee and so on. For Secondary and Tertiary care of 50 crore beneficiaries, even at the average cost of Rs. 5000/- per person per year, the total cost comes out to be Rs. 2.5 lakh crore.
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It is obvious that the National Health Protection Scheme shall become a vehicle for pushing Government funds through insurance companies, and the poor patients under bait of insurance cover, towards private sector.
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PAST EXPERIENCE:

Finance Minister while announcing NPHS  in the budget 2016-17, in para 52 of the budget speech spoke thus, "Catastrophic health events are the single most important cause of unforeseen out-of-pocket expenditure which pushes lakhs of households below the poverty line every year. Serious illness of family members cause severe stress on the financial circumstances of poor and economically weak families, shaking the foundation of their economic security. In order tohelp such families, the Government will launch a new health protection scheme which will provide health cover up to Rs. One lakh per family. For senior citizens of age 60 years and above belonging to this category, an additional top-up package up to`30,000 will be provided.”
 
Rashtriya Swasthya Bima Yojana (RSBY) was to be converted into the new avtar called NHPS and as such RBYS stood modified to NHPS in 2016-17. However despite certain approvals the NHPS 2016 could not move further. Thereafter the same NHPS was reiterated during 2017-18. But during the current financial year too RSBY had to continue because the National Health Protection Scheme, which was to have taken its place, failed to get the cabinet’s nod for 11 months. RSBY beneficiaries during 2017 have been 3,63,32,475 only. The scheme has miserably failed to provide coverage in rural areas. 
 
Apart from RSBY some other health insurance schemes have also been implemented in India. In the year 2000 Janashree Bima Yojana (JBY) was launched for  around 45 categories of unorganised workers but stood merged in Aam Aadmi Bima Yojana (AABY) in 2013. Universal Health Insurance Scheme (UHIS) has also not been so successful. An impact study on health insurance in India, published in Public Library of Science (PLOS) 2017, depicted that the utilization of healthcare improved by insurance but there is no palpable evidence to show if out of pocket expenditure has come down. Another study by PGIMER, Chandigarh and IIPH concluded that in order to achieve the benefits of insurance schemes, the infrastructure for primary health services is the pre-requisite besides giving specialist services.

Presently announced National Health Protection Scheme mandates payment of 40% of the premium by the State Governments. In view of the poor economic status of the state governments, they shall either not agree to the scheme or shall curtail the budgetary provisions from other health care delivery items and thus push the already poor state health services to still a low level.

It is obvious that the National Health Protection Scheme shall become a vehicle for pushing Government funds through insurance companies, and the poor patients under bait of insurance cover, towards private sector. The insurance limit likely to be getting exhausted in one or two episodes and thereafter the family shall have to sell their assets or raise loans for footing the bill imposed at the sky rocketing costs of the private sector. The stories of unnecessary operations like uterus removal, gall bladder removal, knee replacements, stents, keeping in ICU, unnecessary tests and charging high rates at total print price for drugs and other appliances supplied by the hospital from in-house stores mandatorily,  is a common knowledge and belief. 
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Another scheme is 1.5 lakh health and wellness centres, with a provision of a small amount of Rs. 80,000 per centre only. This meagre amount is insufficient to meet even the minimum wages of an employee for four months.
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1.5 LAKH HEALTH AND WELLNESS CENTRES:

Another scheme is 1.5 lakh health and wellness centres, with a provision of a small amount of Rs. 80,000 per centre only. This meagre amount is insufficient to meet even the minimum wages of an employee for four months. Only nurse and no doctor to provide primary level curative services. The said 1.5 lakh health and wellness centres had also been announced in para 64 of the budget speech 2017-18, the extract is as under :

"Poverty is usually associated with poor health. It is the poor who suffer the maximum from various chronic diseases. Government has therefore prepared an action plan to eliminate Kala-Azar and Filariasis by 2017, Leprosy by 2018 and Measles by 2020. Elimination of tuberculosis by 2025 is also targeted. Similarly, action plan has been prepared to reduce IMR from 39 in 2014 to 28 by 2019 and MMR from 167 in 2011-13 to 100 by 2018-2020. 1.5 lakh Health Sub Centres will be transformed into Health and Wellness Centres.

For making 24 Government Medical College by upgradation of District Hospitals  the time required is at least 5 years, going by the earlier records of All India Institute of Medical Sciences, Bathinda.
 
For TB, Rs. 500 per month for the 6 months duration of  treatment. Rs. 600 crore have been provided for 19,38,158 patients identified and being treated out of  a total of 27,90,000 patients. As such in eyes of WHO, India has failed to identify 8,50,000 patients and has left them without starting the treatment .

Malcolm Grant, Chairman, National Health Services of UK, a seven-decade-old free health service for not just UK’s population but even its non-residents remarked on NHPS, ‘Wise to invest in primary healthcare, not more shiny hospitals’. Grant while commenting upon health care in US said, "In America major cause of bankruptcy is healthcare costs,” and on NPHS he said , "Firstly, it will take a long time to achieve this. Secondly, it would be wise to ensure that a significant amount of investment goes into primary care and not into more shiny hospitals. Some of the healthcare problems are at a much earlier stage in the life-course of individuals and the NHSof U has been founded on primary care. There is a system of triage, where specialists are referred to by general physicians who treat most of the illnesses in society. It is very tempting when looking at healthcare to see it through the lens of smart new hospitals but what we need to do is roll out simple diagnostics across the country, specially rural areas.”
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Malcolm Grant, Chairman, National Health Services of UK, a seven-decade-old free health service for not just UK’s population but even its non-residents remarked on NHPS, ‘Wise to invest in primary healthcare, not more shiny hospitals’.
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In order to ensure the universal health care without consideration of capacity to pay, we have to tred an alternative path, may be as under:
instead of banking on Private and five star hotel like corporate hospitals, 
instead of resorting to health insurance schemes , 
we need to strengthen our health services infrastructure and expand the same too, 
we have to train quality manpower at low cost and provide the requisite human resource to each institution,
we have to reduce the prices of drugs and appliances used in the treatment, by controlling the same  by way of fixing sale price based on the formula of production cost. Drug Price Control order 1972 and 1978 can guide us.

By reduction of cost of drugs and appliances, making treatment available at all places, we can reduce the man days lost on account of illness and thus can, not only improve the economic condition of the victim family, but also can raise the GDP, that shall become real support to the economy of the country, which in turn shall be a mile stone in maintenance of our sovereignty.
 

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