The National Health Protection Scheme (NHPS) which aims to provide healthcare access through insurance to 50 crore families is seen as a milestone towards Universal Healthcare (UHC). However, to arrive at a conclusion whether such announcements are progressive steps towards the wellbeing of the people requires a comprehensive scrutiny.
Recently, several issues surfaced such as not enough dosages of medicines available to treat Tuberculosis (TB) patients, the Delhi High Court judgement against “genetic discrimination” and cases with regard to sheer exploitation by the private hospital industry. These three issues represent multiple hardships that pose challenges to the healthcare system in India.
The TB Case: India bears the highest burden of TB disease across the world and has incidences of all the three types of TB — TB, TB with HIV, multidrug-resistant (MDR) TB. The World Health Organisation (WHO) approved the use of Bedaquiline and Delaminid drugs in adults respectively in 2013 and 2014 to treat MDR TB and recognised them as a part of essential medicines in the WHO Model List of Essential Medicines.
India has fewer than 1,000 patients on it and just 81 patients have access to Delaminid. One of the primary reasons associated with the low availability of these drugs is the patent protection accorded to the molecules (Active Pharmaceutical Ingredients) used in these drugs. The World Trade Organisation’s (WTO), Trade-Related Intellectual Property Rights (TRIPS) agreement signed in 1995 and implemented in 2005 led to an exorbitant rise in drug prices, escalating the healthcare costs in India.
In the case of Bedaquiline and Delaminid, the manufactures Janssen (US), Otsuka Pharmaceuticals (Japan) hold patents and only if they allow for voluntary licensing can the domestic companies in India manufacture them. In case, they deny voluntary licensing, then the Indian government can go for compulsory licensing (CL), a provision under WTO TRIPS agreement provided to member countries to override patent rules under life-threatening conditions.
Till now, only once in 2012, the provision of CL has been put to use in the case of Bayer’s anti-cancer drug Nexvar, which has reduced the price of the drug by 97%. It is such dichotomous relationship between the public health prospects and Intellectual Property Rights that the country, in general, is facing and specifically more so in the context of infectious diseases like TB which are in most cases life-threatening.
The case of genetic discrimination: In the developed countries, the advancement in genomics knowledge is put to use by insurance companies to discriminate its buyers on the basis of their genetic profile.
For insurance, companies that work on the principle of risk pooling, such discrimination will reduce the number of cases that have to be covered, thereby, earning them more profits. Particularly, in the context of epidemiological transition taking place in India, where there is a steep rise in the number of cases of NCDs, genetic tests are going to increase and it is important that the state proactively tackles such profit motive practices.
The recent judgement by the Delhi High Court is just an interim relief to the patients. The ruling was based on the argument that appropriate genetic testing has not been done in India. However, with the rampant spread of genomic centres that sell genomic tests, the insurance companies are only going to obligate their customers to provide their genetic information. Given such a scenario, a comprehensive law to prohibit such discrimination is essential in India, where currently none exists. Countries such as the US, the UK, and Canada already have stringent mechanisms in place to put an end to the practice of genetic discrimination.
The private hospital industry: While the political regimes, both at the Centre and states, have done very little in improving the conditions of the public hospitals, they actively encouraged the establishment of private hospitals as part of their perusal of neo-liberal agenda.
According to a high-level expert committee in 2012, the private sector accounts for 82% of all outpatient visits and 52% of hospitalisation. While the world average of out of pocket spending on health expenditure is 18.2%, in India it is 62.4%. An estimate by the National Health Policy 2015 suggests that nearly 6.3 crore people face poverty due to catastrophic health expenditure.
The recent move of the government in transferring Bhupendra Singh from the post of chairman of National Pharmaceutical Pricing Authority for exposing how private hospitals were making excessively high profits, indicates the extent of power the private hospital industry lobby yields.
The report is a result of an investigation after the death of seven-year-old Adya Singh, who was admitted for dengue in a private hospital in Gurugram. The private hospital industry was mostly self-regulated until the passing of Clinical Establishments (Registration and Regulation) Act, 2010.
This regulatory Act was passed by the central government which has initially come into force in Arunachal Pradesh, Sikkim, Mizoram, Himachal Pradesh, and all Union Territories except Delhi from March 2012. Health, being a state subject, the Act becomes applicable to a state, only if the respective state legislature passes a resolution adopting it in accordance with Article 252 of the Constitution.
How far are we from UHC?
The WHO constitution of 1948, which declares health as a fundamental right, and the health for all agenda by Alma-Ata declaration in 1978 envisages universal health coverage (UHC) as, “that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”
The three cases mentioned above are in deep contrast with the objectives under the UHC. The NHPS which aims to provide health insurance up to Rs 5 lakh to 50 crore families, though is a welcome initiative by the state, is not enough and a lot needs to be done in terms of enacting laws to curb issues as mentioned above. Only such measures can truly ensure a sustainable path towards UHC.
(The writer is a research scholar with ISEC, Bengaluru)