By Dr. Arun Mitra
There were high expectations from the Prime Minister on healthcare issues while addressing the nation from Red Fort on 15th August. His announcements of building toilets, Ayushman Bharat, and opening up of more AIIMS do not fulfill the requirements for universal comprehensive health care to our citizens. The social determinants of health, like supply of clean drinking water, adequate sanitation system, proper housing, nutrition and sufficient wages to meet the day to day needs and health education are the primary factors related to healthcare. However, these determinants are not integrated into the government’s policy making in practice.
The government has come up with the National Health Protection Scheme (NHPS), the Ayushman Bharat. This is claimed to be the biggest ever health insurance scheme in the world. It will cover 10 crore families, that is 50 crore people with a coverage of rupees five lakh for secondary and tertiary hospitalisation care. This means about 75 crore people will be kept out of any coverage benefit. Very little number of these left out population fall in the category of affluent population. Moreover, NHPS will not cover outpatient care or preventive healthcare. Therefore, NHPS does nowhere meet the criteria of comprehensive universal health care.
It is well known that the insurance companies’ primary motive is to earn profit. It is presumed that since the number of insured in the NHPS will be very large and at any given time very few people are hospitalised, this will give enough scope for the companies to reap profits. But if at any stage the companies find it to be unviable, they would not hesitate to pull out on one excuse or the other. If the premium is low then many of them may not join the scheme at all.
As the scheme does not cover OPD care, the majority of patients will remain devoid of real benefit. Eighty per cent of the time, the out-of-pocket expenditure of patients is a heavy burden on outpatient care, which is not covered under NHPS. It is also not clear whether post hospitalisation expenses will be met by the insurance companies or by the patient. In many diseases post hospitalisation care is very expensive and lifelong. In any such scheme based on insurance, the common experience is that patients have to struggle hard to get their dues from the companies.
Making of toilet sounds good but it has to be monitored. Since in most of the cases the toilets are not connected to the sewer lines in the rural areas, holes have to be dug to collect the excreta. This needs proper maintenance in a scientific manner. Just putting one time seat may not serve the purpose. Many such toilets are not being put to the desired use; some are being used as store houses. The government gives Rs. 4,000 for construction of such toilet. In fact, this amount is too low. The minimum cost to build a toilet of the size of 5X5 feet will not be less than Rs. 12,000. To construct this size of toilet a minimum of 800 bricks are needed @ Rs.5 per brick. If Rs. 8,000 has to be contributed by the person himself then it is unlikely that each and every family will build toilets.
Similarly, there is need to put water supply lines in both rural and urban areas and their functioning must be fool-proof. There should be no leakage in these pipes. Ironically in urban areas many of these lines have outlived their life and need replacement, which is not in the agenda and budgetary allocation. Very few villages have centralised water supply system. The samples from the municipal water supply system invariably do not clear the required standards.
Nutrition plays the most important part in health. That a well-nourished person is less likely to be taken ill compared to the one with poor nourishment needs no explanation. For proper nourishment we need a balanced intake of proteins, carbohydrates, fats, vitamins and minerals etc. All this comes from daily intake of staple food like wheat/rice, vegetables, meat, eggs, milk, fruits etc. As per calculation for a daily intake of 2100 calories through balanced diet for an adult, the cost comes to around Rs.90 per day at the present rate of prices. For a family of 5 persons it requires Rs. 13,500 per day for food only. With falling wages, insecure jobs, and contractualisation of employment, all this is a pipe dream for the vast majority. Thus most of our population remains undernourished. Over and above, with dilution of trade union rights, more number of people will get into this category.
Housing is another issue which is a major determinant of health of a person. One’s longevity much depends on the environmental conditions one lives in. With large number of our population living in shanty houses, it would be naïve to expect them to be healthy.
Much more needs to be done to ensure healthcare for all. The social determinants have to be taken care of while talking of health care. For this public spending on health, which is a meager 1.04 percent of the GDP at present, has to be increased at least to 5 percent. Sufficient funds have to be released towards the schemes to meet the requirements for nutrition, housing, water supply, sanitation and health education. (IPA Service)
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