1. Making Healthcare a Public Good – Inverting the Political Economy
Ravi Duggal

2. Current Political Economy of Healthcare
Public healthcare services – Tax Financed
Private healthcare – OOPs/Insurance
Private Individual Health Insurance – public sector and private sector
Government/private employer purchased group health insurance
Social Insurance – CGHS, ESIS, welfare boards, Railways, Armed Forces, P&T…

3. Public Health Services
Primary Healthcare – preventive, promotive and curative
Secondary and tertiary healthcare
Tax based financing v/s insurance
Public spending Rs per capita or 1.02% of GDP

4. Top 5 and Bottom 5 States State Rs per capita 2017-18 Sikkim 5575
Mizoram
4304
Jammu & Kashmir
2797
Haryana
2667
Meghalaya
2567
India Average
1538
Maharashtra
975
Jharkhand
912
Bihar
898
Uttar Pradesh
892
West Bengal
806

5. Private Healthcare
Individual GP and consultant clinics – wide array of different systems and quacks
Nursing homes and maternity homes
Small to large to corporate hospitals
Diagnostic centres
Out-of pocket financing and private insurance
Rs 4000 per capita

6. Health Insurance
Total Premiums Rs crores covering crore persons (Rs 695 per person) – 33% of population
Govt sponsored Rs 3090 crores covering 33.5 crore persons (Rs 92 per person)
Private Group Insurance Rs crores covering 7.05 crore persons (Rs per person)
Individuals Rs crores covering 3.20 crore persons (Rs 3933 per person)

7. Social Health Insurance
Central Govt. Health Scheme covering 3.4 million Rs per beneficiary ( )
Employees State Insurance Scheme for organised sector employees drawing pay less than Rs per month covering 35.3 million insured person Rs per insured person ( )
Armed forces 12 million Rs 7500 per beneficiary ( )
Railways Rs 4155 per capita ( )
Welfare Funds – Rs. 120 crore Health spend (2015)

8. Deficits of the Public Health System
Deficit of Demand Based Planning (DPC, PIP..)
Deficit of investment and Expenditure (1.1% GDP, segmentation of healthcare)
Deficit of Governance and Implementation (top down decision making)
Deficit of Accountability & Legislative oversight (CBMP etc.)
Deficit of political will and executive commitment
Deficit of policy – market driven; need to reclaim healthcare as a public good

9. New Health Policy 2015 Draft
(i) That 2.5% of the gross domestic product (GDP) as public health spending should be reached by 2020, of which 70% should be on primary healthcare. (ii) That the per capita public spending on healthcare should be Rs.3,800 at 2015 prices. (iii) The Centre would contribute 40% of the resources instead of its present 20% share and for this would raise resources through health cess and cess on health degrading goods like tobacco, alcohol, etc.

10. New Health Policy 2015….
(iv) That the states would have to commit 8% of their total budget for health. (v) That free drugs and diagnostics in all public health facilities would be available. (vi) That all district hospitals would be converted into medical colleges. (vii) That all healthcare facilities—infrastructure and human resources—would be as per the Indian Public Health Standards (IPHS) norms. (viii) That financing all the above would be largely through a tax-based mechanism.

11. New Health Policy 2017 2015 Health Policy diluted by NITI Aayog
Privatisation, especially for secondary and tertiary care at its core
Ayushman Bharat Political Economy – NHPM and Health Wellness Centres
Emphasis on insurance based financing for above and dilution of tax based financing
Also privatisation of social insurance

12. Why Health Insurance Won’t Work?
It has not worked anywhere in the World
Requires life long premium payments that increase with age and declining income
Unregulated healthcare system -absence of ethics and use of standard protocols in medical practice
Does not solve the OOPs problem and would on contrary increase household burden and debt
Favours the rich and promotes inequity and elitism

13. Scope for Social Health Insurance
Expansion of Social Health Insurance models like ESIS and CGHS feasible
Universalize ESIS to cover the entire organized and unorganized sector – remove salary wage ceilings for coverage and keep a minimum threshold for contributions – this could raise up to 2% of GDP additionally for health sector
Above can cover 65-70% of workforce and the balance would be covered by state contributions

14. Challenges
Health system needs to be organized and brought under a single umbrella through a legal and regulatory framework
Healthcare provision prices have to be regulated
A national social health insurance legislation would be needed to create a single framework
Public spending needed to be upped to at least 3% of GDP or Rs 4000 per capita at today’s prices
Needs political will like Thailand, Brazil etc..

15. THANKS