Prime Minister Narendra Modi’s Independence Day speech featured a prominent mention of India’s health system. Recognising the significance of healthcare and food in the lives of common people, Modi said that the poor person's food plate should not be allowed to become more expensive.
Despite this, Modi's government has actually been denying the public sector healthcare its due share of priority and funds. In the end, his speech revealed how distant his government is from the ground realities of the poor.
The first achievement of his government Modi listed was that the All India Institute of Medical Sciences and 40 other government hospital will no longer have long queues because "appointments can be taken online": patients turn up for their appointments without having to wait. This is clearly an arrangement that the middle class will avail of more than any other section, to the exclusion of those who cannot use digital technology. It ignores the reality of the substantive problems that ail the public system, as highlighted by reports of the woman under treatment at AIIMS who has been given a date in 2018 for a life-saving surgery.
No learnings on insurance schemes?
The prime minister also announced a grant of up to Rs 1 lakh towards the medical expenses of households below the poverty line. This government subsidy is for paid hospitalisation services and so based on the assumption that the poor will go to the private sector for healthcare. This is probably the reality in large parts of the country: medical expenditure is one of the causes of farmer’s suicides and for households falling below the poverty line. However, equally real is the well-documented distortion and misuse of such social insurance schemes, with unnecessary procedures, outdoor care required being converted into indoor admissions. A case in point are the mass hysterectomies in villages in Andhra Pradesh, Bihar and other states, being reported since 2010.
States with such social insurance schemes also show an increased rather than decreased out-of-pocket expenditure on treatment in areas where such schemes are availed of, demonstrating the flaws in the design of such programmes. Several insurance experiments from around the world show that social insurance in low-income and middle-income countries do not work unless they are matched with strong public service systems and the regulation of the private sector.
Falling health budgets
Despite implementation of the National Health Mission that is meant to strengthen public healthcare, government budgetary allocations on health have been decreasing in real terms since 2011-'12. The budget cut was so great in 2015-'16 that even routine activities could not be undertaken, necessitating a mid-year increase. That led to a marginal increase of the health budget for 2016-'17. However, even this increase becomes meaningless in strengthening health services for the poor because the money has been used for purchasing equipment like dialysis units without alleviating shortages of specialists, nurses and blood banking facilities.
The National Urban Health Mission and AYUSH Mission, both of which were initiated to help the under-served poor, have been starved of funds, thereby making the whole exercise mere tokenism. The opening of Jan Aushadhi low-cost medicine stores may work in some states, but they are not as effective for the poor as the free medicines that the government has promised both in its manifesto and under the National Health Mission.
The NITI Aayog’s statements make clear the government’s "niyat" (intentions) as much as "niti" (ethics), which is to encourage the private sector in healthcare and channelise funds from the public exchequer to the private sector. The government has refused to heed the admission even of the World Bank that there the forces of the market have failed to improve the healthcare sector and so public services are essential.
Farmers’ failing health
Agriculture and farmers’ issues are closely related to food and nutrition. Here too we see a disjunction. The bottom 40%-50% of India's people have high under-nutrition. The desire not to allow "any increase in price of the poor man’s plate" holds little substance when faced with the reality of inflation, nor is it enough to deal with this under-nutrition.
While the increase in cultivation of pulses is a welcome and long overdue measure, it needs to be bolstered by allowing benefits of minimum support prices to reach small farmers through the local procurement of millets and pulses for the public distribution system. The Right to Food campaign’s design of the public distribution system deserves close consideration in this regard. It would be in line with promotion of people’s capacities for their own development.
Planning for the urban middle class
Modi’s "ten commandments" to the NITI Aayog last month again tells of an orientation towards the urban middle class rather than the rural and the poor. While he asked the Aayog to map food requirements for the next 15 years, he is reported to have "told members of Niti Aayog to adjust food production targets based on public consumption trends as it would help to prioritise what would be required in the future". He also told the planning body to map long-term demands in terms of how much food people would eat at home and how much outside. Such planning for food availability can only add greater variety on the plate of the urban middle class.
Besides, availability alone does not translate into greater food intake and improved nutrition, as is evident by the continuing levels of malnutrition even after the Green Revolution. It is organisation of food production, distribution of support to farmers across regions and socio-economic sections, and employment, income and working conditions, that ensure small farmers and the landless eat better. Recognising the diversity of food patterns and providing for them is the cost-effective and ecologically sustainable way to ensure good nutritional status of Adivasi, Dalit, coastal, riverine and hill communities.
Efforts at food production and distribution fall short when the poor are forced to spend out of pocket for privatised education and health services. Data from the National Sample Survey Office shows how food expenditures are reduced due to rising education and health spending in poor households.
While allowing for the prime minister's niyat, one hopes that in the next year’s Independence Day speech, one will hear more about integrated systemic designs based on evidence of what can bring about improvements in the health and nutrition of the poor.
The writer is a professor at the Centre of Social Medicine and Community Health at Jawaharlal Nehru University, New Delhi.
