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"India is moving towards a system of universal healthcare"

Jul 10, 2012

According to Dr Dileep Mavalankar, Director, Indian Institute of Public Health Gandhinagar, India cannot afford not to provide health care to all, because the consequences of lack of healthcare and lack of financial protection are too devastating for the poor.

Dileep Mavalankar

Social health insurance in Germany started about 150 years ago with the philosophy that no citizen should be denied health care just because of lack of funds.  This social philosophy is based on thinking that the government has the responsibility to protect the wealth of its citizens.

The rich people have physical wealth which needs to be protected from robbers through deployment of police and security force, but it was argued that what is the wealth of the poor people who have nothing?  One of the social philosophers of Germany argued that poor people’s wealth depended on their ability to produce labour and this depends on their health.  Hence, it is the duty of the Government or king to protect the health of the poor as it is the duty of the government or the king to protect the wealth of the rich.

It was this type of thinking and social philosophy which led to the development of social health insurance in Germany under the leadership of Bismark and Dr Virchow. In social health insurance, everybody contributes to a fund which is governed by the government regulations, and it pays for cost of sickness care to those who need it.  Social health insurance is a dominant model of health insurance in many countries of Europe.

Presently, the poor have very little health coverage and receive poor quality of care. India is thinking of moving towards a system of health care which will provide universal health care to everyone. Planning commission had also instituted a high level expert group on universal healthcare which submitted its report in November 2011. There will be substantial discussion on how the country can move towards universal healthcare, especially of the poor.

Over the last several years, India has developed rapidly expanding and vibrant self-help groups, and micro finance movements.  Self -help groups provide a support system for the poor and access to information and resource. The micro finance initiative to link self-help groups to structured systems of credit and savings, thus providing financial inclusion and financial protection encourages entrepreneurship and increase in income thus leading to poverty alleviation.
Indian data shows that sickness is an important reason for loss of income, high expenditure and indebtedness. One estimate is that every year four crore Indians fall below poverty line due to illness-related expenditures. Thus, it is imperative that the state and society stop this leakage of income and wealth from the hands of the poor which is happening because of ill health.
A simple simile could be that, one cannot fill a pot of water if the pot has holes in the bottom as all the water will leak out. Thus you cannot build wealth for the poor if the money is leaking out through sickness.   First the holes have to be plugged, then only the water to be filled.  Sickness can be prevented and sick people must receive treatment free of cost, so that wealth is not reduced because of treatment. 
The self-help groups and micro finance institutions provide readymade platform for developing health protection through various mechanisms. Already several microfinance organisations are adding health/sickness loans, health education to prevent illness and health care services to their members. This has also helped to improve the loan recovery as it reduces sickness.
This addition of health to micro-finance is a new effort and needs to be systematically encouraged and studied.  Unfortunately the health department has not paid much attention to this possibility while for micro finance organisations feel that health is not central to their work. Hence, there is a need for health activists and institutions to promote such integration of health into microfinance and SHG activities.
Fortunately, India is embarking on large scale programme of skill building through national livelihood missions.  This mission can provide the platform for building health activities through SHG and MFIs.  The poor badly need such a protection as they fall sick more frequently due to poor sanitary conditions under which they live.  Given the under-investment in public health in India most poor have to pay substantial indirect cost when they area sick.  Thus the poor end up spending the large proportion of their income in sickness care. Many non-poor are only “one sickness away from poverty”.  Thus, the social protection mechanism, which MFIs and SHGs provide should have much wider social impacts if they also provide health protection.
Fortunately, the Ministry of Labour of GOI has started Rashtriya Swasthya BimaYojana (RSBY) to provide indoor care coverage to the poor. This scheme is rapidly expanding and they cover one third of the population over next few years. RSBY is an excellent platform to setup and expand towards health protection in India.  Some state governments have already provided much more extensive coverage than RSBY.
For moving towards universal health care, we have to build success on SHG MFI initiatives as well as programmes like RSBY which provides direct health expenditure protection. Many people argue that a country like India cannot afford to provide health care.  But, I believe that India cannot afford not to provide health care to all because the consequences of lack of healthcare and lack of financial protection are too devastating for the poor.

Hence India must, as quickly as possible, move to a comprehensive universal health care guaranteed nationally, but delivered locally to its people.
The key to achieving universal health care is not getting lost in microlevel discussion on coverage package and cost, but to develop the social feeling of necessity of healthcare to everyone and the political courage to fund increasing amounts to ensure adequate coverage. If Andhra Pradesh can do it in terms of Rajiv

Arogya Shree Programme, the rest of India can also do the same or better.
Of course the health programmes have to be geared to cover common needs of the poor rather than more expensive and exotic health conditions, which means that primary health care and prevention has to be at centre of any universal health care system.  It also needs co-operation and constructive collaboration between the public and private health care systems.

If Germany could develop such a system more than 150 years ago, I am sure that India can develop if our political leaders and the society want such a system. India cannot be a developed nation without such health protection and promotion system with universal coverage.

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