By Daisy Ni (PO ’21)
India ranked 154th on the Healthcare Access and Quality Index in 2015, making it among the biggest underachievers in Asia. Their public health situation is notorious, with increasing levels of water and air pollution as well as other issues such as malnutrition and poor sanitation. The Indian government has announced a new healthcare system—the National Health Protection Scheme (NHPS), or what they have termed the “world’s largest government-funded healthcare programme.” Details remain unclear for now, but the pronouncement has already raised questions regarding its potential for implementation and efficacy.
Health has been established as a fundamental right in India. Article 21 of the Indian Constitution states that “no person shall be deprived of his life or personal liberty.” The Supreme Court has clarified and expanded the scope of the article to include health under its provisions. In Bandhua Mukti Morcha v. Union of India, the court concluded that the previous determination of the “right to live with human dignity” enshrined in Article 21 includes the “protection of the health and strength of workers, men and women.” In particular, the Directive Principles of State Policy declare that “the State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.”
These constitutional provisions have failed to manifest in Indian society—healthcare formed 1.4 percent of India’s GDP in 2014. Although in principle all medical services at government facilities are free, severe shortages of staff and supplies can limit access to care. The wealth disparities between states lead to a discrepancy in both quality and coverage of treatment across the nation. Quality of care often involves long wait times and corruption. Many Indians consequently turn to the private sector; however, the high burdens of the out-of-pocket expenditures make healthcare costs catastrophic and unaffordable.
NHPS represents one of the biggest healthcare initiatives in India so far, indicating the country’s recognition of the importance and necessity of health. Under the NHPS, the government would allot 100 million families up to 500,00 rupees (about $7,860) to be used for healthcare costs. The Finance Ministry has allocated $314 million to the project. However, the government has announced no concrete method of funding. As part of the budget proposal, finance minister Arun Jaitley has stated that a new surtax would raise around $1.7 billion a year specifically for the healthcare program.
There are obstacles and problems that the government will need to address in the upcoming months while policymakers engage in negotiations and detailed planning. Critics of the proposal point to the government’s substandard history of addressing healthcare concerns. The Rashitriya Swasthya Bima Yojana (RSBY) program which the NHSP replaces represents an example of poor mismanagement. Although it similarly aimed to insure poor families for health service, a study found that the RSBY, due to “low enrollment, inadequate cover and lack of coverage for outpatient costs,” failed to bring down out-of-pocket expenditures for its targeted audience. Additionally, the NHPS is not India’s first experiment with cash-transfer programs. The Health Protection Scheme was also announced in 2016 to provide health overage of up to 100,000 rupees per family, but was ultimately never funded. These failings all represent concerns that the Indian government will need to consider and account for, and raise doubts regarding the success and implementation of the new program.
Additionally, health experts question the comprehensiveness of the program. For example, they note that NHPS does little for preventative care, and neither addresses nor solves any of the root causes of poor health conditions. NHPS also covers only secondary and tertiary services, for patients on referrals or consultative care. The lack of initiatives regarding primary care, the first and most generalized stop for medical treatment, raises concerns—weak primary services leave open the possibility of overloading the NHPS and disproportionately draining resources from the health budget, ultimately weakening primary care services. In essence, the NHPS seems to address only part of the healthcare concerns rather than take a multifaceted approach to fully to deal with all the problems of the current public health situation.
NHPS depends substantially upon state cooperation, with states themselves responsible for the deliverance of service for those within the program. States with preexisting health programs are expected to integrate their system with the central government’s proposal. For a pan-Indian initiative such as the NHPS, cooperative federalism is a necessity for making the project viable through ensuring conditions such as the transferability of coverage between states. A national healthcare program which does not incorporate and resolve state differences would fail to address one of the core issues with Indian healthcare: the variance of quality between states. The heavy burden on states, however—they are expected to make up 40 percent of the program funding—may disincentive wealthier states to participate and exacerbate the variance in coverage quality. West Bengal, for example, has opted out entirely, setting a dangerous precedent. The Chief Minister Mamata Banerjee referenced Bengal’s current free hospitalization and medical treatment policies, stating that there was no need in spending more funds on a separate program with the same aim.
The NHPS is a step toward a universal healthcare system in a country that desperately needs one. Government conversations are taking place for the next few months trying to determine exact eligibility standards and details, and half a billion Indians wait with bated breaths to see how the policy system will manifest to address concerns and expectations.