Flat no-1 B, Orient Manor
15, High Street, Cooke Town,
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The Honourable Prime Minister,
Government of India
Mr. Ghulam Nabi Azad, Minister of Health and Family Welfare, GoI
Mr. Montek Singh Ahluwalia, Deputy Chairman- Planning Commission, GoI
Dr. Syeda Hameed, Member- Planning Commission, GoI
Mr. P.K. Pradhan, Union Health Secretary, GoI
Subject: Regarding Universal Access to Health Care.
Dear Dr. Manmohan Singh,
Janaarogya Andolana Karnataka (JAAK) is the Karnataka state unit of the global People’s Health Movement (PHM) and the national level Jan Swasthya Abhiyaan (JSA) and comprised of public health professionals, activists, progressive people’s movements and representatives of community-based organizations.
JAAK had a one day state level convention on 30.05.2012 in Bangalore to debate and discuss the various processes underway to roll out Universal Access to Health Care (UAHC) in the country.
While we appreciate your efforts to place health as an important agenda on the 12th five year plan, we would also like to express certain apprehensions following the publication of the PC-SCH report which we feel is not in the right spirit of a truly Universal Health care system.
We support the recommendations of the High Level Expert group with regard to strengthening the public health; primary funding through tax-based funding, abolition of user fees of all forms for accessing health care facilities and provision of free essential medicines for all. One more specific recommendation which we support is the advice against any forms of commercial insurance for organizing the healthcare in this country.
The subsequent PC-SCH report of February 2012 shows significant deviation from the vision of Universal Access to Health Care. Some of our concerns are as follows:
Essential Health Package (EHP) – The PC-SCH restricts the EHP to only Reproductive Child Health and the vertical programs. This would lead to exclusion of several medical conditions which contribute to significant mortality and morbidity in the country. Since one of the principles of UAHC is that healthcare services are arranged according to the needs of the community, curtailing these needs would defeat the spirit of universality. In addition to this, the PC-SCH proposes that the services additional to EHP should be purchased by the families from open market with “top-ups”. This is tantamount to encouraging user fees and we strongly denounce such a move to introduce user fees through other means. Given that one of the objectives of Universal access to Health Care is to reduce out of pocket expenditure (OOPE), ‘top-ups’ as proposed by PC-SCH will only aggravate OOPE leading to further impoverishment of vulnerable families. The UAHC model should involve comprehensive primary, secondary and tertiary care with the government as the provider of choice.
Financing of UAHC – The HLEG, while giving prominence to the public health systems
strengthening, had suggested that the public expenditure should be increased from the
present 1.2% of GDP to 2.5% of GDP by the end of 12th plan and to 3% of GDP by 2022 for the UHC system. We are now given to understand, even though not explicitly mentioned in the PC-SCH report, that there is a move to reduce this to 2.1% by the end of the plan and the Union contributing only 30% and the rest 70% expected from the states. Going by the financial situation that the states are in and also due to the fact that some of the revenue generating avenues for the states have got transferred to the Union, it would be unreasonable to expect the states to contribute to the UAHC system. This would also run counter to your own Independence Day 2011 pronouncement that funds would not be a constraint to the important areas of health and education.
Health insurance – We also strongly condemn the present Rashtriya Swasthya Bima Yojana (RSBY) model of financing the private and public providers on a fee-for-service basis. This would result in not only huge cost spiral and waste of precious public resources but only focus on some tertiary care further consolidating the dominance of private providers and weakening of the public provision. JAAK believes that private providers should never substitute public provision of health care services.
Additional Central Assistance (ACA) – We have noted with apprehension the proposed model by the Planning Commission to provide ACA directly to the District societies which has the potential of bypassing the Ministries of health and family welfare at both the union and the state levels (p24). We strongly oppose any such move as we strongly feel the leadership for UHC should come from the respective Health ministries.
Contracting in private services – The PC-SCH report points to making public health facilities compete with private providers while allowing for financial and operational autonomy. JAAK opposes the corporatization and privatization in health and other social services, whether at the planning, policy making, financing and provisioning of health care services and in all its forms including user fees, contracting-in, and public private partnerships.
Autonomy of district units – JAAK is deeply concerned with the drive towards making primary, secondary and tertiary health units autonomous and functioning as Societies. While operational autonomy (planning and day to day functioning) is desirable, these hospitals/ health centers should not have to raise their own funds or provided only conditional performance-based grants. Further, they should be accountable to district or local health authorities.
Regulation of the private sector – The PC-SCH report repeatedly mentions regulating the health sector including the private sector. We welcome this, but the report lacks the details for bringing about concrete and effective regulatory mechanisms. If this important piece of reform is left vague without giving sufficient attention and detail, we feel that it would be subjected to regulatory capture by vested interests. A strong regulatory structure must be set up for the private sector. This would cover hospitals, medical colleges, private practitioners, diagnostics labs and all other health providers. The private sector must be made more transparent and accountable.
Piloting in a single district – The PC-SCH proposes that to be eligible for the ACA, the states have to prepare a UHC plan along with a District Health plan; Frame standard treatment guidelines and to ensure its compliance; strengthen the program units both at the state and district levels; empanelment of private providers by means of a transparent selection system put in place; enhancement of community involvement in planning and management and development of a strong monitoring and evaluation mechanism. While these are all laudable objectives, it must be noted that most of these processes that have to happen at the state level at both systemic and legal levels. The states would have very little incentive to bring in all these reforms just for piloting in a single district. In the absence of these state level enabling reforms just piloting at the district level is bound to fail. Hence we urge that the piloting of these reforms must happen at the state level rather than a piecemeal approach of doing it at district level.
We also note with some concern that the states, which are largely responsible for healthcare services, are kept largely out of discussion. JAAK advocates for a central role for the government in stewardship, governance, financing, regulating and provisioning of health care services, with community participation in planning, implementing and monitoring of health care at all levels.
Keeping the above concerns in mind, we urge you to use your high offices to organize further consultations with all the stakeholders giving the Union Ministry of Health and Family Welfare the lead role in the larger interest of the health of the people of this country and to make your Independence Day pronouncement reach its logical conclusion.
K B Obalesha, State convenor, JAAK, 9742586468, [email protected]
Dr Gopal Dabade, MBBS, DLO, Chairperson JAAK 9448862270, [email protected]
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