The government needs to increase spending on healthcare to improve infrastructure at health facilities and enhance skilled human resource to ensure quality healthcare for all thereby helping it achieve universal health coverage, said Prof T Sundararaman, Dean, School of Health System Studies, TISS,
In India 70 per cent of the healthcare expenses is met by out-of- pocket pushing scores of people into financial hardship.
The Draft National Health Policy, 2015 commits at least 2.5 per cent of Gross Domestic Product (GDP) as public health expenditure on health sector. The existing expenditure by the Government is at one per cent after the commitment. Globally, most nations showing progress towards universal coverage spend about 5 per cent of countries' GDP with 75-80 per cent of public sector expenditure.
In Sri Lanka, 95 per cent of secondary and tertiary care is provided by public hospitals. In Thailand, 95 per cent of primary care is funded and provided by government- and most of secondary and tertiary care as well . Cuba is almost completely funded and provided by public sector. In Brazil, 80 per cent provisioning of healthcare is utilised in public hospitals and 50 per cent of total health expenditure is public expenditure that support this.
Hardly, 2-3 per cent people pay direct taxes in India and indirect taxes are major source of revenue. Poor are already paying major part of taxes and need to get return on it. Social health insurance and Employees State Insurance Corporation (ESIC) insurance don't work in a situation where 50 per cent of the population is in precarious terms of employment as they fall under unorganised sector, said Prof Sundararaman.
Hence, tax based financing system is necessary to improve access to healthcare. Experts often suggest considering insurance as a medium to ensure healthcare access to all but it has some limitations, as it is less likely to cater to healthcare needs of people across the board.
As per the study done by my department in TISS, there are lacunae in empanelment of hospitals for insurance coverage. There is a cap. In certain places, there is informal system existing. For instance, 100 hospitals apply for empanelment, while only 20-25 are empanelled which translates to no financial protection for most hospitalisations. Even in these empanelled hospitals poor cannot enforce the hospitals to treat them on a cashless basis. Thus, the public funded health insurance has some limitation and cashless health service seems a distant goal. On the other hand, private healthcare insurance is limited to a small size of population.
Public provisioning in free and subsidised primary healthcare facilities and public hospitals are the main forms of financial protection and ensuring access. However even in these there are different proportion of payments out of pocket for cost-recovery. A reduction of user fees in public hospitals must be considered to improve access to healthcare. Considering the limited capacity of public hospitals, large private hospitals would also need to be contracted in – but as supplementary. There must also be a push to ensure that all public hospitals are empanelled in the publicly funded health insurance programmes and this would contribute to increase revenue and quality of public hospitals, he said.
Another concept that is being pushed by the government is that the public and private hospitals must compete for government funds with insurance acting as a medium, he added. This is not as a good idea, as what we need is an expansion of hospital and healthcare capacity- not a substitution of one by the other.
In the discourse on how to achieve financial protection from impoverishment due to health costs, the provision of free and subsidized service provided by public hospitals is not included and the discourse is limited to insurance mechanism. The argument is that costs cannot be compared between public and private hospitals as public hospitals are highly subsidized. As per the study of state health accounts done by a consortium of research agencies led by PHFI, government spending on supply side to public sector is far less than the costs involved in purchasing from the private sector. Hence government needs to play central role in achieving financial protection through both acting as a provider and as its financer, he opined.
In India, 70 per cent healthcare expenditure is on ambulatory care. There is discussion on public financing to purchase primary care but what we need is a universal comprehensive primary healthcare system which is provided by the network of public health care facilities- supplemented especially in urban areas by contracting in some private capacity. Today primary care is limited to very selective interventions which undermines their effectiveness and credibility.
Prof Sundararaman suggested that government should revitalize and strengthen the National Health Mission rather than considering an alternative model to improve access to healthcare in the country.