The debate over Obamacare seems to have fuelled the creative juices of India’s National Advisory Council (NAC), as it was announced in February 2012 that the body would consider universal healthcare for India. As the Indian Express reported, the idea was to provide equitable access to all to quality healthcare, including promotive, preventive, curative and rehabilitative. Furthermore, every citizen would be entitled to a national health package whose contours would be decided by an expert group. While the government would play the role of guarantor of such services, it would not be the only provider of these services. Citizens would have the option of purchasing additional coverage on their own.

I don’t know if this is a case of “First the West, then the Rest” or it is mere coincidence that India is talking about UHC at this juncture of its development. Perhaps it is the United Progressive Alliance’s (UPA) way of impressing India watchers abroad to distract them from the endless corruption scandals and the failure to implement a second round of reforms. Nonetheless, the issue certainly deserves a vigorous public debate, one which has been lacking so far. At the outset, I should point out that though this issue is being discussed in the shadow of Obamacare, healthcare is fairly country-specific – what ails the US does not necessary trouble India and vice versa.

UHC and Public Spending on Health in India

First, what is the purpose of UHC? The belief is that the pooling of risk allows for better and universal access to facilities at lower costs. A simple illustration is if, for example, my wife gets Saturdays and Sundays off but my job allows me the flexibility to take Mondays and Tuesdays off, at least one of us would be with the kids at home four days of the week and we’d both have to put up with in-laws for only three rather than five days of the week! Second, what defines a good UHC system (according to its advocates)? Four criteria come to my mind – 1. universal access to an adequate level without excessive burden; 2. fair distribution of financial costs and burden in rationing care; 3. competence, professionalism, empathy, and accountability on the part of providers; and 4. special attention to vulnerable groups such a children, women, disabled and the aged. Third, why does India need a UHC? Well, according to the medical journal, Lancet, 78% of expenditure on health in India is private, compared to 14% in the Maldives, 29% in Bhutan, 53% in Sri Lanka, 31% in Thailand and 61% in China. Only Pakistan is worse off at 82.5%. Approximately 30% of illnesses in rural areas and 20% in urban areas went untreated because of financial reasons, and 47% of hospital admissions in rural India and 31% in urban India were financed by loans and the sale of assets. Public spending on health is barely 0.94% of the GDP, among the lowest in the world, meaning that India spends $19 per person while Thailand spends $207, China $122, Sri Lanka $88, Maldives $751, and Bhutan $60. This is judged to be inadequate. Finally, fourth, what are the factors that constitute rising medical costs? 1. inflation (never forget that!); 2. drugs and medical devices; 3. rising provide expenses; 4. government regulations; 5. consumer demand; and 6. litigation.

First Principles

Before we get to numbers, it is a sound practice to see if the underlying philosophy of the proposal, UHC, has any intrinsic merit. I do not think so. The aim of ensuring that everyone in India has easy access to doctors and medicine when they are at their most vulnerable is certainly laudable, but it is based on emotion and not reason. It is often stated that pooling risk is cheaper than individual risk. However, a key fact that is overlooked in this assumption is that the final price is lowered only by hiding a part elsewhere. In the example I gave above, it is certainly true that my family will save on the emotional cost of having to deal with the in-laws (or the financial cost of a babysitter). Nonetheless, because my wife and I have shifted our schedules in the way suggested above, we’d probably have less time with each other. Thus, while we have pooled the child rearing and saved on some costs, we are paying in other ways. Now, we might decide that it is a cost we are willing to pay (the in-laws might be exceedingly boring or overbearing!), but it is worth our while to make sure we understand all the costs before leaping to action.

In the case of UHC, depending upon coverage, the premium for the average person may indeed be lowered, but what is the hidden cost? As the term ‘pooled risk’ should imply to you, it means that the cost is hidden by distributing it among people not sick. To illustrate, imagine a sample set of 1,000 people. it is statistically improbable that all will be sick at the same time. It is possible that some people will be sick more and some people hardly ever. When person 139 falls sick, he can rely on a distributive system that lowers his cost by sharing it with his fellow set members, and the same for person 847. The financial burden on the pooled money will not be heavy in either case. As we all fall sick at one time or another, over time, the costs will be even. But what if person 139 is a smoker? And what if person 847 is obese? The chances that these people are sick more often is higher than, say, person 665 who leads a healthy lifestyle. This means that ultimately, people like person 665 will carry a greater share of the burden that persons 139 or 847. The concept of greater burden-sharing is not problematic in and of itself, as we have accepted progressive taxation (something even Adam Smith endorsed). Rather, the point is that, in this case, the activity that makes persons 139 and 665 a greater burden on the system than person 665 is voluntary.

Unlike the US, it cannot be argued that risky living is a consequence of economics (which, recent studies have shown, is not entirely accurate). Obesity in the United States, for example, affects the economically lower classes more than it does rich people. However, in India, it is the educated middle and upper classes that have the largest share of obese people (and the numbers are growing, no pun intended). By implication, obesity, which can in turn cause a myriad of other complications, is a health problem brought on by a voluntary bad habit rather than happenstance – we all know how hard it is to reject that malai kofta for a ragi roti when we are hungry. Similarly, the negative effects of smoking on health has been widely popularised, and it smoking-related illness should not be an excuse for younger people (we must make some allowance for older people as the smoking scare kicked in only in the late 1980s/early 1990s).

There is another category of voluntary illness – some diseases, such as gout, are thought to be genetic. If not taken attended to properly, it can cause severe complications and pain (ask Henry VIII). The argument could be made that in a just society, we should take care of the less fortunate. Gout is not curable, and the best care for it is through a regulated diet low in purines and high in consumption of water. It is possible to go through life without even knowing that one has gout if the diet is appropriate (low consumption of meat and alcohol, as is not uncommon India). However, if a person diagnosed with gout did not take adequate measures to prevent its outbreak due to voluntary bad habits, is society still required to support him/her?

It is said that UHC is a right, but with rights come responsibilities; how are the latter factored into the UHC schemes being considered?

By Other Means

It cannot be disputed that the health of a polis is a good; but is UHC the only way of obtaining that good? In any business proposal, one of the first questions asked is about why funding is needed to the extent planned, and how to acquire it in the most effective manner. Passing the UHC off as a tax (even if the Government of India does not levy a special UHC cess, all GoI money belongs to the taxpayer) is one way of achieving the goal – but it is a band-aid approach, a lazy, unimaginative, and ineffective way which will cost much more in the long run. To understand how to minimise cost, we must look at what is sought to be accomplished and what the inputs to such a venture are.

Despite the obstreperous defence of a UHC for India, it may shock one to know that there is no clear definition of what health actually entails. As a philosophy, it comprises of not just medicine but also diet, sanitation, cleanliness, exercise, and psychological balance. Interestingly, no scheme in the world addresses all these issues (in fact, these are also the criticisms against the Global Health Initiative, Global Alliance for Vaccines and Immunisation, and other such grand schemes), and yet, they are the bedrock of a healthy society. What makes this particularly pertinent is that this wholesome approach shifts much of the costs from the health budget to the infrastructure budget, something the Ministry of Health and Family Welfare (MHFW) will be quite unhappy about. Unless these questions are resolved, UHC will be like trying to fill a bucket with water when it has a hole at the bottom. So what are these issues?

Cleanliness: India is not known for its cleanliness. In fact, the British called it a land of death, dirt, and disease. The situation has no doubt improved, but not nearly by as much as some would think or hope. Standing water is a frequent sight across India, particularly during the rains. These become the breeding ground for a host of waterborne diseases, including malaria. The Yamuna, according to Newsweek, has 10,000 times higher amount of fecal bacteria than is safe for bathing despite a 15-year programme to build 17 sewage plants. It is estimated that around 37.7 million Indians are affected by waterborne diseases annually, 1.5 million children are estimated to die of diarrhoea alone and 73 million working days are lost due to waterborne disease each year. The resulting economic burden is estimated at $600 million a year.

Sanitation: Shockingly, most Indians still do not have access to good sanitation, with rural penetration as low as 21% in 2008. A few centuries ago, when armies laid siege to cities, they were more often than not devastated by diseases such as cholera and typhoid spreading their ranks due to poor sanitation. Today, less than 600 million Indians, barely 45%, have access to a proper toilet. Only 55% of the 15 million Delhi residents are connected to the city’s sewage system. More Indians have access to mobile phones than to clean running water or sanitation.

Malnutrition: Inadequate quantity and quality of food has serious long-term effects on health. For one, malnutrition during childhood or pregnancy can result in developmental issues and is known as a leading cause of immune deficiency diseases. There are at least 50 neurotransmitters that are affected by the intake of food and micronutrients by the child in his/her first 1,000 days, the deficiency of which is lasting. Yet about a third of India is malnourished and 40% don’t receive enough food.

Pollution: India has the worst air pollution in the world according to a survey by the World Economic Forum. Emissions from vehicles, thermal power plants, industries, and refineries, not particularly noticed by most, have a significant impact on health – Bangalore is the nation’s asthma capital, and 6 out of 10 causes of death in Madras are respiratory illnesses according to Dr. D. Ranganathan, director of the Institute of Thoracic Medicine. Pollution from coal-burning power plants alone cause 70,000 premature deaths per year in India. According to Dr. B. Shyam Sunder Raj, around 70% of Hyderabad has some form of respiratory illness or the other, and 45% of Calcutta has reduced lung function.

Food: Unlike the United States, Indians are not exposed to High Fructose Corn Syrup nearly as much. However, between bad dietary habits, unhygienic restaurants, and pesticides, the quality of food most people consume are a direct cause of illness. This is clearly not an issue on the government’s radar – in Bangalore, for example, there are over 25,000 registered outlets that sell food (restaurants + carts) and there are only three food inspectors (a fourth is available only for VVIP duty) to ensure that the city’s outlets serve food fit for human consumption. This means that each inspector has to certify over 8,330 points of sale, meaning an outlet every 14 minutes. In terms of danger from pesticides, India remains the only country in the world to still manufacture DDT, and in Kerala, the pesticide endosulfan killed several people last year before the government finally closed the factory manufacturing it. The lack of an efficient and muscular regulatory authority such as the European Food Safey Authority (EFSA) or the European Medicines Agency (EMA) continues to erode India’s health every day.

Costs

We have discussed the philosophy of pooling health risk and how risky habits create an unfair burden on the system. We have also seen how the failure of the state to provide basic infrastructure has far more serious effects on hundreds of millions of people than merely economic growth. A third aspect we should look at before deciding on whether or not a UHC suits India is the composition of a medical bill. Six factors were listed above, which we should look at more closely:

Inflation: This is beyond the control of the MHFW or the medical profession, and is far larger in scope than the context of a discussion on UHC.

Consumer demand: As we have seen above, the GoI’s failure to provide basic services combined with risky health habits inundates India’s health infrastructure with hundreds of millions of patients. Naturally, market forces dictate that with greater consumer demand and limited resources (doctors and other medical professionals), prices would be driven upwards. Steps must be taken to educate and train more staff; strictly speaking, a job for the Ministry of Education and the Ministry of Human Resource Development, more colleges are required with better credentialing. This is a larger developmental goal that will have no short-term impact on medical costs, but is essential to pursue in the long-run.

Drugs and medical devices: India is the world’s largest manufacturer of generic drugs and has the third-largest pharmaceuticals industry in terms of sheer volume of manufacture. While this can keep costs low, India suffers from insufficient indigenous R&D. Foreign drugs are criminally expensive and patented, so they are not affordable and cannot be duplicated. Furthermore, there is pressure on India from foreign interests to raise prices on certain drugs. Nonetheless, India recently ordered Bayer to license a patented drug, Nexavar, bringing the cost down from Rs. 280,000 per month to Rs. 8,800 per month. This may not be the best thing for the free market or for foreign confidence in Indian courts, but it will bring relief to millions of patients all around the world. The cost of medication being what it is, this is one area in which some sort of insurance (not necessarily UHC) makes sense.

Rising provider expenses: This is related to the rise in consumer demand. Ever greater numbers of patients puts strains on India’s already inadequate hospital infrastructure, resulting in the market driving up prices. There is a desperate need to increase facilities available, which is connected to increasing trained professionals. Even if foreign players were to enter the market, it would not solve the shortage of staff due as they would also have to hire staff with Indian credentials (global recognition of medical credentials is another issue).

Government regulations: While in most countries, regulations drive prices up, in India, the lack of regulations affects prices and quality. Studies indicate that inadequate regulation and the failure to implement existing regulations has left healthcare largely in the hands of private interests. In itself, private sector domination is not a bad thing, but the government’s failure to even ensure quality has lowered quality while prices keep rising. Presently, a National Health Regulation and Development Authority (NHRDA) is being planned along with a couple of sister bodies to monitor accreditation, operations, and administrative protocols.

Litigation: Thanks to the country’s overloaded judicial system, this is not nearly as big a problem as in the United States. If the judiciary ever got its act together, it remains to be seen how Indian torts will treat doctors found guilty of malpractice. Nonetheless, this is still somewhat of an issue, and malpractice insurance premiums add a chunk to the patient’s final bill. Part of this is a direct addition of the doctor’s cost of doing business (premium), and another part is the (sometimes additional) tests mandated by insurance companies to protect themselves from malpractice suits. Thus, even if a doctor feels comfortable in diagnosing the patient from two tests, s/he may be required to perform two more. The doctor has inadvertently lost some autonomy to actuaries and administrators, and this is reflected in the bill. One insurance analyst also noted that often (45% of malpractice lawsuits), doctors over-recommend services for a small cut from the service providers.

A UHC System

The authors of the Lancet series on India’s precarious healthcare position admit that “multisectoral actions need to be initiated to favourably change the distal determinants to promote health and prevent disease,” but “hope that these will receive detailed deliberation in subsequent reports and action.” However, I am not sure how any sensible doctor or medical administrator can spend thousands of crores of rupees on symptoms while waiting on “subsequent reports” for an analysis of the root causes. Certainly, the argument is not that India should fix its infrastructure before creating a UHC, but rather that a UHC may not be required if costs can be brought down significantly; perhaps government-assisted healthcare may need to be extended only to the poorest of the poor, and the rest may avail of private insurance.

It is frustrating to read report after report that compares India’s expenditure on healthcare to what other countries spend, because the aim is not to spend more money but actually keep people healthy. Reports about the dire state of health services in India also need to stop sensationalising meaningless numbers and realise that the numbers could be much lower if even the most basic amenities are made available to citizens. Thus, the debate needs to be reoriented – it s not that India does not need to spend thousands of crores of rupees on health – it does. The debate is on the scope of the term, ‘health.’ If UHC is merely a welfare scheme to cover cost of medical services, it would be an unmitigated economic disaster. However, if the GoI defined health more broadly – and more sensibly – to address the issues that send millions to the doctor in the first place, there would be merit to the idea…but it would not be UHC anymore.

This is not an ideological issue (for me) but a strategic and logistical one. Infrastructural problems need to be addressed with priority, and if we feel that India still needs UHC, the option can be explored again with the latest significant data. We hear a lot of talk about sustainable growth – health is the prime example of it. The idea is to not to cure a person once of an illness, but ensure that the need is obviated, or at least lessened. For now, the question is, do we want to actually improve the health of India’s teeming millions, or do we want to only appear as if we are trying to help, soothe our consciences, and go to bed smugly?

Attached: CRI Chief Editor Prasanna Viswanathan was kind enough to send me the official report on UHC that was submitted to the Planning Commission. Needless to say, its focus is almost entirely on medical issues rather than health issues. This is the problem with thinking on UHC that I have underlined above.