Healthcare socialism: Can India achieve it and if yes, how?

Healthcare is a very sensitive issue. It shows a nation’s prestige, quality of life and economic power. The health of a nation is reflected in the health of its citizens. The markers of a healthy nation are determined by certain indices like Infant Mortality Rates, Maternal Mortality Rates, Life Expectancy, etc. How powerful a country is, is determined by a few social markers such as the level of education of the society, the strength of its defence forces, the healthcare indices and general economic status and growth.

A welfare state’s goal is to provide free or affordable education and healthcare to all its citizens. There is a huge divide in healthcare delivery systems between developed and developing countries. However, private enterprises in India had been catching on to medical tourism attracting patients from its neighbouring countries like Bangladesh, Bhutan and Pakistan for advanced tertiary care services in like Cardiac, Neurosurgery and Oncology. Patients from the Middle East and even uninsured citizens from developed countries are seen occasionally undergoing bypass surgery or brain tumour removals in India. But these glossy corporate hospitals similar to any good private hospitals in developed countries do not reflect the health of a nation.

These centres are far and few in number and usually confined to bigger cities and metros. An important but sometimes overlooked data in welfare societies is individual freedom. Fraser Institute, Canada assesses human freedom and economic freedom of countries. Countries like China and a small country like Cuba try to achieve uniform healthcare at the cost of individual freedom. Whereas in a democracy like India, welfarism needs to be tightly balanced with individual and economic liberty and also sustainable healthcare systems with ample resources. An affordable and robust healthcare need not necessarily mean a better system.

Table 1 shows a comparative analysis on health indices and individual freedom between different governmental systems.

TABLE 1

In India, health is a state list subject in the constitution, meaning the onus is on each state to look after the health of its subjects. Article 21 of the Indian Constitution, advocates Right to Protection of Life and Personal Liberty. The government has the responsibility for the safekeeping of its citizens. The 15th Finance Commission, 2017, suggested Health be shifted to the Concurrent list, thus bringing greater control of the health systems in the country and to bring in uniformity of care. Although the National Health Mission launched in 2005 and Prime Minister Modi’s flagship programme, Ayushman Bharat, PMJAY (Prime Minister’s Jan Arogya Yojana), launched in 2018, envisage to bring in uniformity to the system, still it is a far cry to achieve the best of goals. Correlation between the centre and state had been an issue due to different political ideologies of different elected governments.

Conflicts arise when political dispensation varies between state and centre. Cooperative Federalism is a dynamic process. With one-seventh of humanity clubbed under a single nation like India, the task is gargantuan. Can a centric control system work better, or will decentralisation of power and implementation achieve the goal of Universal Healthcare? Numerous national programmes for the prevention or eradication of diseases and vaccinations come under national programmes, but are implemented through the states. In developed countries like the United Kingdom, the National Health Service covers primary health care effectively. In the US, insurance-based systems take care of the majority of the population. We also see the Cuban Health System as being egalitarian and completely state sponsored. Can similar models offer an egalitarian society at the cost of individual liberty and enforced state control? In India, PMJAY is catering to a 500 million population (out of approximately 1.4 billion Indians) which allots Rs 5 lakh per family, which is the largest health insurance system in the world. Wherein the top echelons of society are covered by numerous private insurance companies, there is a large ‘missing middle’ class which does not fall under the PMJAY and those who cannot afford or are unaware of health insurance, either governmental or commercial. 

The challenges of the states as well as the centre are manifold. Budget allocation, implementation of uniform health care, a structured countrywide medical, nursing, paramedical and technical personnel under a singular Health Services System is the need of the hour. Corporate and Private Health care delivery systems run a parallel system, very rarely under the uniform health code. The Centre overall devolves 41% of tax collection to the states. However, there is always a conflict between the states and the centre to prove which model of governance is better. On one hand, political one-upmanship plays a part and on the other hand, offering freebies creates vote banks which are obviously perceived as such. This is a part of the appeasement politics which numerous political parties play to achieve electoral benefits. But at what cost? Is Free Health Care possible or sustainable in a country like India. We need to analyse this in terms of finance and delivery systems. In 2020-21, only 8 million Indians paid taxes, which is about 4%. The Economic Survey of 2015-16 and the various models show 23% Indians ‘should’ pay taxes. This low taxation is a result of faulty policies and lack of political will for economic reforms. We should also analyse how much budget allocation has been for healthcare since independence. This will put things into perspective and what changes need to be done. Resources for healthcare delivery are related to finance and human resources. But without proper financing, no human resource can be nurtured. 

India’s minuscule increase in healthcare expenditure from 1.8% in 2020-21 to 2.1% in 2021-22 is not enough, though the National Health Policy of 2017 is planning to increase this to 2.5% by 2025. India ranks 179 amongst 189 countries in health prioritisation accorded to healthcare in budgets. The reasons for lack of prioritisation are manifold. Since 1947, health was growing in India at a Hindu rate of growth, there had never been an attempt to create a pan-India healthcare system, neither a uniform health service envisioned, nor health insurance given its due importance. The socialistic fervour, with which Nehruvian policies were constructed, failed to achieve the desired rate growth in infrastructure and delivery systems. Our defence allocations comparatively are huge. Errant neighbours who are into war-mongering and sponsor terrorism as state policy necessitates diversion of funds to secure the nation. In 2022-23, the allocation for defence was 2.21%, which is 70.6 billion US dollars. India is the third-largest spender in defence after USA and China, UK and Russia follows next. A robust health care of a country needs to look at analysing these data, comparing GDP, budget allocation to health and collection of taxes. Table 2 shows prioritisation of health by different countries, and here too we can see healthcare allocation in India is grossly low, more worrying is the percentage of  population under health insurance. The introduction of Ayushman Bharat PM-JAY scheme has done a wonderful start but the ‘missing middle’ class needs to be put under the ambit of insurance to achieve generous results. Financing healthcare through state sponsored schemes requires tax collection and India fares poorly in that aspect. 

Although National Health Mission launched in 2005 and Prime minister Modi’s flagship programme, Ayushman Bharat, PMJAY (Prime Minister’s Jan Arogya Yojana), launched in 2018, envisage to bring in uniformity to the system, still its a far cry to achieve the best of goals. Correlation between Centre and State had been an issue due to different political ideologies of different elected governments. Conflicts arise when political dispensation vary between state and centre. Cooperative Federalism is a dynamic process. With a one seventh of humanity clubbed under a single nation like India, the task is gargantuan.

Can a centric control system work better or decentralisation of power and implementation will let achieve the goal of Universal Healthcare? However numerous National Programmes for prevention or eradication of diseases and vaccinations come under National Programmes but implemented through the states. In developed countries like United Kingdom, National Health Service covers primary health care effectively. In US, insurance based systems take care of majority of population. We also see Cuban Health System as being egalitarian and completely state sponsored.

Can similar models offer an egalitarian society at the cost of individual liberty and enforced state control? In India, PMJAY is catering to 500 million population (out of approximately 1.4 billion Indians) which allots 5 lakhs rupees per family, which is the largest health insurance system in the world. Wherein the top echelons of society are covered by numerous private insurance companies, there is a large ‘missing middle’ class which does not fall under PMJAY and those who cannot afford or are unaware of health insurance, either governmental or commercial. 

The challenges of the States as well as the Centre are many folds. Budget allocation, implementation of uniform health care, a structured countrywide Medical, Nursing, Paramedical and Technical personnel under a singular Health Services System is the need of the hour. Corporate and Private Health care delivery systems run a parallel system, very rarely under the uniform health code. The Centre overall devolves 41% of tax collection to the states. However, there is always a conflict between the states and the centre to prove which model of governance is better. On one hand political one up-manship plays a part and on the other hand offering freebies creates vote banks which is obviously perceived as such.

This is a part of the appeasement politics which numerous political parties play to achieve electoral benefits. But at what cost? Is Free Health Care possible or sustainable in a country like India. We need to analyse this in terms of finance and delivery systems. In Financial year 2020-21 only 8 million Indians paid taxes, which is about 4%. The Economic Survey of 2015-16 and the various models show 23% Indians ‘should’ pay taxes. This low taxation is a result of faulty policies and lack of political will for economic reforms. We should also analyse how much budget allocation had been for healthcare since independence, to understand and this will put things into perspective and what changes need to be done. Resources for healthcare delivery is related to finance and human resource. But without proper financing no human resource can be nurtured. 

India’s minuscule increase in healthcare expenditure from 1.8% in 2020-21 to 2.1% in 2021-22 is not enough, though the National Health Policy of 2017 is planning to increase to 2.5% by 2025. India ranks 179 amongst 189 countries in health prioritisation accorded to healthcare in budgets. The reasons for lack of prioritisation are manifold. Since 1947, Health was growing in India at a Hindu rate of growth, there had never been an attempt to create a Pan India Healthcare System, neither a uniform Health Service envisioned, nor health insurance given its due importance. The socialistic fervour with which Nehruvian policies were constructed failed to achieve the desired rate growth in infrastructure and delivery systems.

Our defence allocations comparatively are huge, errant neighbours who create war mongering  and sponsors terrorism as state policy necessitates diversion of funds to secure the nation. Financial Year 2022-23 allocation for defence has been 2.21% which is 70.6 billion US dollars. India is the third largest spender in defence after USA and China, UK and Russia follows next. A robust healthcare of a country needs to look at analysing these data, comparing GDP, Budget allocation to health and collection of taxes.

Table 2 shows prioritisation of health by different countries, and here too we can see healthcare allocation in India is grossly low, more worrying is the percentage of  population under health insurance. The introduction of Ayushman Bharat PM-JAY scheme has done a wonderful start but the ‘missing middle’ class needs to be put under the ambit of insurance to achieve generous results. Financing healthcare through state sponsored schemes require tax collection and India fares poorly in that aspect. 

Alternatives to Income Tax should be sought and reforms needed in this aspect. 

TABLE 2

A country’s economy is also directly related to improved healthcare services as can be comprehended from Table 3.

Since 2010, India’s economy has been on an upswing, though confronted with the recent Covid pandemic. A growing economy like India, can and should put more stress towards healthcare infrastructure and human resource development.

TABLE 3

Healthcare infrastructure needs ample resources and a nation has to harness plenty to invest. In this market driven economy, one sided traffic of providing freebies where the taxable population is minimum cannot sustain a standard health care system. Means to generate self sustainable healthcare projects need to be realised. Apart from that, a uniform health system delivery system monitored through big data collection is of utmost importance and finally comes long term sustainability through continuing skill development and increasing the pool of skilled human resources. Different states and cities have different standards of healthcare. Tertiary care is usually confined to metros and bigger cities, increasing super speciality health care to  all Tier II cities is being increasingly required due to the looming epidemic of cardiovascular illnesses. A uniform system with equal financial valuation of services, universal health insurance through public and commercial private enterprises, and human resources to utilise the infrastructure to the optimum should go hand in hand. With the coming of faster internet services, an efficient networking service, and use of Artificial Intelligence a country wide system is feasible. Many times, budget allocation in massive infrastructure projects are under-utilised due to deficiency in technical, paramedical and specialist doctors. The bottom line is, a greater allocation in healthcare in India’s annual budgets, placing Health in the concurrent list, increasing cover of health insurance to all citizens, introducing a National Health Service system for all 3 wings namely, Nursing, Paramedical and Doctors and establishing a uniform code of service is of paramount importance. 

Tertiary care is usually confined to metros and bigger cities, increasing super speciality health care to  all Tier II cities is being increasingly required due to the looming epidemic of cardiovascular illnesses. A uniform system with equal financial valuation of services, universal health insurance through public and commercial private enterprises, human resources to utilise the infrastructure to the optimum should go hand in hand. With the coming of faster internet services, an efficient networking service, and use of Artificial Intelligence a country wide system is feasible.

Many a times, budget allocation in massive infrastructure projects are under-utilised due to deficiency in technical, paramedical and specialist doctors. The bottom line is, a greater allocation in healthcare in India’s annual budgets, placing Health in the concurrent list, increasing cover of health insurance to all citizens, introducing a National Health Service system for all 3 wings namely, Nursing, Paramedical and Doctors and establishing a uniform code of service is of paramount importance. 

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Dr. Rajnish Duara Reporter, EastMojo

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