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Democratizing Debate on Development
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Section-4 Health and Family Welfare
When the United Progressive Alliance (UPA) came to power in 2004, several announcements in different forms were made before the masses for the improvement of conditions in our shattered public health system. Among all these announcements, the promises made by the UPA government in its National Common Minimum Programme (NCMP) are noteworthy. The UPA government promised that;(a) In order to get out of the stagnation in the public health system in the country, the government would increase public expenditure on health services from around 1 percent of GDP to around 2-3 percent of GDP. (b) While focusing on primary health care in a substantial manner, all efforts shall be made to provide health insurance to all rural families. (c) In order to tackle all communicable diseases, the government would increase investment in health services. (d) The government would make all life saving drugs affordable to all. (e) The government would be careful that all sections of population can afford and avail health services. If one compares these promises to what the government has done over its five years of rule, one would get disappointed. The UPA government had promised to spend 3 percent of GDP on health but during the five years of UPA total spending was around 0.86 percent of GDP on an average. Table -18 shows that the Union Government’s allocations for health services, in absolute terms, more than doubled from around 8191 crores in 2004-05 to Rs. 16787 croe in 2008-09. However, both as percentage of GDP as well as total government expenditure, it is in no way significant compared to the promise of the government to increase the overall expenditure upto 2-3 percent of GDP. Of course, when we assess the promise of the government in the NCMP, we refer to the earlier UPA government, but the promise of its previous reign is yet to be fulfilled. Table-19 provides head wise allocation in the Department of Health and Family welfare.
Table-18 Budgetary Allocations on Health Services in India (in Rs Crore)
Note: Total Union Budget Expenditure is a net of total central Assistance to State and UT Plans, Non Plan Exp in Uts without Legislature, Loans to Foreign Govt, Loans and advances to state govts, other loans, grants to states and Uts and Grants to foreign Governments Source: Union Budget Documents Table-19 Trends in Budgetary Allocation
Table-20 Public Sector Expenditure as % of Total Health Expenditure: A Comparison across Selected Countries
Source: Jan Swasthya Abhiyan, (2006), “Globalisation and Health: Towards the National Health Assembly-II”, Booklet-I, National Coordination Committee, JSA
It is often said that the Indian health care sector is the most privatized health care system in the world. Public sector expenditure in India as proportion of total health expenditure (16 percent) is even less than countries like Ethiopia (36 percent), Burkina Faso (31 percent), Nigeria (28 percent) and Pakistan (23 percent) (See Table-20). Table-21 presents a very important aspect of health infrastructure in India. It is estimated that in 1974, around 80 percent of hospital units and 80 percent of the hospital beds were under the management of the public sector. Till 1984-85, in terms of number the hospitals, the government sector still dominated the scene with around 56 percent hospitals under its control. However, after that, the trend reversed and by the year 1996, only around 32 percent hospitals were under the government and 68 percent were under the private sector. However, in terms of number of beds, the government sector still dominates with more than 63 percent beds[1]. Table-21 Growth of Private Hospitals without any Corresponding Growth in Hospital Beds
Source: India: Raising the Sights - Better Health Systems for India's Poor, World Bank, 2001 as cited in Planning Commission, Report of the Steering Committee of Health, 2002
Most of the private hospitals are tiny in size and with less than 25 beds per hospital. Again, they are largely concentrated in urban and developed areas where there is a ready market for them[2]. This is something that has critical significance. The disproportionate growth of private sector in healthcare services have not only failed to provide necessary infrastructure for a comprehensive health care system both for rural and urban areas, but also, the exorbitant rate at which the private sector charges their fees from the patients, is also making the system inaccessible to the poor people in India. In Table-22, we have provided a brief comparison between the private and the public sector in health care in India. The table suggests that the cost of availing private health care in India is around 8 times higher than the cost at government health care facilities[3]. Figure-6 shows an indicative share of burden a common Indian bears to finance his/her health expenses. The purpose of giving this figure here is to highlight the amount of expenses a common person bears for availing health services in a highly privatized health system like ours and the amount of government support for the purpose. On an average an Indian spends around Rs. 5.80 per day out of pocket for availing health services. As per the estimates of NSSO, the average daily per capita expenditure in rural areas was Rs. 24 in 2006-07. This clearly shows how intimidating this cost of health is for the poor masses in India. As per NFHS-3, even the poorest section of population has to depend on private health care system in India (See Table-23). Figure-6 Per Capita Private out of Pocket expenditure on Health in India per Day[1] During 2009-10
Figure-7 Share of public Subsidy for Curative Care Benefiting Different Income Groups
Source: Rajiv Mishra, (2003) “Pro Poor Health Reforms- Why, What and How”, WHO < http://www.who.int/macrohealth/events/en/rajeev_misra.pdf >
The government sector is not only marred by lack of allocation, there also is an issue of equity involved with it. The available information suggests that the largest proportion of public subsidy does not reach the poorer sections of the population (See figure-7). Around 10.10 percent of total government subsidy goes towards the benefit of the poorest 20 percent population in India whereas, the richest 20 percent avail around 33 percent of government subsidies for the curative care[2]. To add to it, the increase in prices of drugs and medicines has made it more difficult for the common masses to avail health care in the country (See figure-8). While there has been a rapid increase in the prices of every thing in recent years (as measured by the Whole Sale Price Index for all Commodities) from 100 in 1993-94 (base of the index) to 187 in 2004-05, the prices of drugs and medicines have grown at a disproportionately higher rate, from 100 to 267 during the same period[3]. The situation further worsened during UPA rule. The gap between WPI all commodities and WPI –Drugs and Medicines widened further, indicating a proportionately higher prices for medicine prices compared to other prices during the UPA rule. In nut shell, a squeezing government sector, growth of privatization and increasing drug prices have led to an increase in the out of pocket expenditure and an increase in the inequalities in availing health services in India.
Figure-8 Increase in the prices of drugs and Medicines in India
Unfortunately, basic services like health and education have emerged in India as major potential markets for the private sector. It is estimated that the total expenditure on health[4] (both by the government and the private entities including the out of pocket expenditure) as proportion of GDP has increased from around 4 percent in 1996 to 5 percent in 2005. However, the government expenditure during this phase has declined from around 1 percent of GDP to 0.9 percent. To our understanding, due to such a decline or stagnation in the government expenditure on making health services available for the masses, the private out of pocket expenditure for using these services as proportion of GDP has increased from 2.7 percent in 1996 to 3.8 percent in 2005 and private out of pocket expenditure on health as proportion of total private final consumption expenditure has increased from 4.2 percent to 6.2 percent[5] (See Table-24). During the decade of 1996-2005, while the total expenditure on health increased by 223 percent, the government expenditure has increased by only 131 percent and private out of pocket expenditure has increased by 263 percent[6] (See Table-25). Table-22 Private and Government Health Care in India: A Comparison
Note: Year for different items is not presented as the table is compiled from several sources with information pertaining to different years. It provides an indicative picture of the situation. Sources: Report of the National Commission on Macroeconomics and Health (2005), Planning Commission, Report of the Steering Committee of Health, 2002, Rajiv Mishra, (2003) “Pro Poor Health Reforms- Why, What and How”, WHO < http://www.who.int/macrohealth/events/en/rajeev_misra.pdf > Table-23 Sources of Health care in India
Source: People’s Health Manifesto-2009, Jan Swasthya Abhiyan
It is unfortunate that services like education and health have become a business for the capitalist class under the present UPA regime. The neglect by the Union Government accompanied by apathy of the state governments has led to a deterioration of the public health system in our country.
Table-24 Expenditure on Health in India Some Selected Indicators
Source: Compiled from WHO Table-25 Growth in the different Indicators of Expenditure on Health between 1996 and 2005 (Growth in %)
Source: Compiled from WHO
As per an estimate, the number of PHCs working in our country have declined from 22875 in 2002 to 22370 in 2007[7]. The number of doctors working in these PHCs have declined from 25724 to 22608 during the same period. At one hand, the Government is making announcements for National Health Missions and on the other hand the basic elements of health service delivery has deteriorated. In this situation, instead of being careful about the issue of access of the masses, the government is clamoring for Public-Private-Partnership (PPP). Of course the global demand for Indian health services have increased in the era of liberalizations. Many rich people from other countries are coming to India for heart and kidney transplantation, cancer treatment and so on. But the poorer masses of our country are dying in large numbers in very common ailments like malaria, cholera, diarrhea and snake bite. Around 52 percent child birth in our country take place in the absence of any qualified health worker. More than 70 percent children in our country are anemic and around 36 percent women have a Body Mass Index below normal. 2.2 crore population in our country are physically challenged and are living in a situation of utter neglect without any proper health care and social security. Under such a scenario, there was a lot of hope from UPA when it came to power. However, the Union government have not only done nothing about it, but also persuaded the state governments to go for surplus budgets owing to the Fiscal Responsibility and Budget Management Act (FRBMA). The result of such a run for producing surplus budgets by the state governments got reflected in massive fund cut in several social and economic sectors including the health services. As shown in table -18, the health related expenditure by the state governments have declined from around 4.5 percent to 3.6 percent of their overall expenditure between 1999-2000 and 2008-09. To sum up, the UPA period has made a lot of promises in the health sector but has shown little financial commitments to back those promises. [1] The information on year wise expenditure on health is extrapolated on the basis of information compiled from WHO database. Population figure for the year 2009-10 is calculated through five year moving average method on the basis of population estimates provided by the Registrar general of India. [2] Rajiv Mishra, (2003) “Pro Poor Health Reforms- Why, What and How”, WHO < http://www.who.int/macrohealth/events/en/rajeev_misra.pdf > [3] Reserve Bank of India [4] It should be remembered that the total expenditure on health (THE) comprises of (a) government expenditure (GGE), (b) private investment in health (PIH) and (c) private out of pocket expenditure on health for availing health services and medicines (PCH). While GGE and PIH are demand side factors determining the availability of health care facilities in India, PCH is something in the demand side determining the use of those services. It is therefore, methodologically erroneous to club both the types of expenditures in order to assess the market size as government expenditure can potentially reduce the expenditure by the private for using the services. [5] WHO Estimates for country NHA Data (1996-2005) < http://www.who.int/nha/country/IND.xls > [6] Ibid. [7] Rural Health Statistics of India 2007 [1] Planning Commission, Report of the Steering Committee of Health, 2002 [2] For more details, please see, Report of the National Commission on Macroeconomics and Health (2005), Planning Commission, Report of the Steering Committee of Health, 2002, Rajiv Mishra, (2003) “Pro Poor Health Reforms- Why, What and How”, WHO < http://www.who.int/macrohealth/events/en/rajeev_misra.pdf > and Ismail Radwan (2005), “Policy Note: India- Private Health Services for the Poor” Health Nutrition and Population, the World Bank available at < http://info.worldbank.org/etools/docs/library/240322/India%20%20private%20health%20services%20for%20the%20poor.pdf > [3] Ajay Mahal, Janmejay Singh, Vikram Lamba, Anil Gumber & V. Selvaraju, (2002) Who Benefits from Public Health Spending in India, NCAER as reported in Planning Commission (2002)
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