Interview: Why is India investing in insurance schemes instead of primary healthcare?

The health sector has great expectations from the Union Budget to be announced on February 1. The government is expected to expand its flagship health insurance scheme, the Rashtriya Swasthya Bima Yojna, into a universal health insurance system. It now only covers families below the poverty line. But K Sujata Rao, former Union health secretary and author of the new book Do We Care, says the little money that is available for the health budget would be better spent in improving primary healthcare and containing infectious diseases rather than on insurance schemes that only benefit corporate hospitals.

Rao retired as union secretary with the the Ministry of Health and Family Welfare in 2010. Between the years 2006 to 2009, she served as director-general of National Aids Control Organisation, which cut down HIV rates in the country by 57% with the annual HIV infections among adults reduced from 2.74 lakhs in 2000 to 1.16 lakhs in 2011. She was part of the design process of the National Rural Health Mission Programme.

In an interview with Scroll.in, she talks about why we need major reform in public health sector and how the so-called development story of India will not count for anything if people are not healthy.

Your book talks about how India has always invested very little in health, even during Nehru’s time as the Prime Minister. What have the consequences of this policy been?
We are spending 1.1% of our Gross Domestic Product on health. Five years ago also we were spending 1.1%. My argument is that whether it is a 3% rate of growth or a 9% rate of growth, there is no change in the health sector. Where is that extra money going? Why is it not being invested in health?

The government has to realise that [tackling] poverty is just not about giving some doles and some income-generating initiatives. Poverty has a multi-dimensional impact, as you have read in book’s preface. It is related to housing, nutrition, sanitation, access to water. These are the basic public goods, which you have to give to a person for him or her to be able to take advantage of development. But if you are constantly going to have diarrhoea, and you are malnourished, your economic productivity is low, when your youngsters are skinny and unproductive, what wealth will you produce?

These have to be core to your development, which is why all countries, like China, the US and almost all countries invested on health and education in their early years of development.

Countries such as Thailand, Brazil, Turkey, Sri Lanka were equally poor like us and were colonies. When they can achieve these goals, why are we not able to? It is only because we are spending the wrong way. Health is the basic foundation for development not malls, airports and roads.

Our priorities in India – not just this government but all governments of the left, right or centre – are guilty of neglecting these aspects.

We do not bother to take care of our own people. We have to first put them on the priority list. Just mainly pushing revenue is not enough.

What would you like addressed in the budget for health?
India has lot of competing demands and one cannot set aside that reality. If money is scarce, then at least we should invest sequentially and intelligently in a way that we can make maximum bang for the buck. What really is value for money? That is primary healthcare which prevents people from getting sick, helps early diagnosis and early treatment.

Primary care has to be the foundation of India’s health system. You cannot give a voucher to someone living in Bastar and tell him to go to Raipur if he has a heart attack. He will be dead by the time he reaches Raipur. If there is no primary care to stabilise him in Bastar, what is the point of giving him that voucher?

Last year, the finance minister introduced dialysis [units in all district hospitals]. Seventy five percent of dialysis is due to hypertension and diabetes, which can be handled at the primary care level. Unless we attack the causal factors which are contributing to the disease burden, just going on investing money on the [later] stage, is not really value for money.

If there is not much money, don’t waste it on health insurance programme, which only corporate hospitals benefit from. Let’s not spend for stents for every patient. India is too poor to go the specialist surgery or robotic surgery kind of route.

I hope finance minister can announce and increased budget from 1.16% to 1.5% and use that for just constructing the infrastructure in rural and urban areas in primary care. Thailand spent its entire budget on building health infrastructure in rural areas for five years. They didn’t spend a penny in the urban and semi urban areas. And that is what enabled them, after a couple of years, to announce universal health coverage.

My second priority would be to focus on infectious diseases. They do not respect boundaries or class. Anyone from Prime Minister downwards can get an infectious disease. We need to have to have good surveillance systems and have to invest in public health.

You write about the tedious processes of releasing money to states. Apart from increasing investment in health and setting priorities right, how else can we work on finance systems so that it works better?
You need to bring in deep reform in the finance sector. Right now we are carrying on with British systems. Their approach to finance was accounting and not an outcome-based. Some amount of accounting is necessary but the focus is so much on giving vouchers and getting signatures of people. But has this achieved the health goal?

Also, if there is an economic downturn, do not slash health budgets suddenly. In a field like health, it could affect patient who need drugs to live. If you cut access to drugs without thought, you can develop drug resistance. Budget cuts should be thoughtful in health. There is a human being at the end of it all. It is not like a building under construction where if the fourth floor construction stops, nothing happens.

What is the role of foreign funders in our public health system?
Health is extremely culture specific. You cannot simply let a foreigner who is here for two days come tell you what to do. This dependence is a colonial hangover. We still continue to be very struck by what a white man tells us. We won’t look at Thailand, Sri Lanka or even Bangladesh. This colonial mindset has to go.

For instance, the World Bank was not in favour of comprehensive primary healthcare. They said it needs too much money and that we should just look at progarmmes for TB, malaria, etc. So when a pregnant woman suffered from malaria, the auxillary nurse midwife said she did not know what to do.

For the National Rural Health Mission programme, which was completely in-house, the World Bank was not willing to support ASHA workers. We removed all the donors and went ahead with the programme. Now institutional deliveries have gone up and immunisation rates have gone up.

Donor assistance is hardly 2% but their intellectual domination is significant. That means we can only take our view if we invest in research, then we have our own data, and our own pride and self respect intact. But in such a big country, we do not have a single health institution that is doing good work.

Your work as the director of NACO is fascinating, particularly on how the programme brought out people who are stigmatised to the forefront of the movement.
A sex worker is reviled in society. She is not allowed to get a ration card. She is denied fundamental freedoms. In 1992, when I spoke to a sex worker in Bombay, she asked me “Why should I change my behavior? I do not care if I live or die.” From there, it was such a huge jump over 10-15 years, be it Sonagachi in Kolkata or Mysore. Sex workers formed communities and self-actualised. The same thing with the Men Having Sex with Men community. It was one of the most humbling and exciting jobs I ever did.

Even as a retired officer I cannot get an appointment with joint secretary today. But as when I was a senior officer, I would have MSM or drug addict or a sex worker next to me and tell me if the guideline I developed was good enough or not. Unless and until we do not democratise policy making, we cannot get anywhere in public health issues. That’s what NACO taught me.

It is really the poorest people who took the programme forward because it was a life and death matter. From asking why they should be bothered to save society from HIV they found the will to want to live, to be healthy for their children’s sake, to be able to say that they also have personalities and to bring aspiration back in a very hopeless kind of life. This is the big contribution of all the civil society workers who actually did all that work by educating them.