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Nursing Pockets Back to H(W)ealth

Praying might miraculously save the patient, because paying will chew away their minuscule pocket making them indebted forever. Skyrocketing medical expenses that cost a fortune and prevent timely aid from reaching the needy have made existence the most expensive luxury. Pivotal to all forms of human progress are eradication of poverty and disease, affordable healthcare and provision of basic health facilities for all. Sadly, our nation, one of the medical tourism destinations of the world, with state of the art hospitals, qualified professionals and sophisticated equipment lags behind in providing primary health care to a majority of its citizens. Rising healthcare costs are not a new phenomenon but have acquired a new dimension in the aftermath of the Covid-19 pandemic. In public health, the sum of fee paid by the consumer of health services directly to the provider at the time of delivery of the services is Out of Pocket Expenditure (OOPE).

Medical debts refer to the debts incurred due to healthcare expenditure. The exponential Out Of Pocket Expenditure figures wedded with alarmingly high medical debts not only encapsulate Indian health woes, but also offer an explanation for the calamitous impact of the 2nd wave of the pandemic on the nation. Penny-pinching allocations for health Rajkumari Amrit Kaur, our first health minister, the Princess who envisioned AIIMS would be disheartened by 21st century India’s high incidence of catastrophic health expenditures and scanty health budgets. According to the National Health Account (NHA), 2016-17, out of pocket expenditure incurred by people was nearly 2.2 per cent of GDP. This is higher than the Government of India’s total expenditure on health which amounts to 1.6 per cent of GDP for 2020.[1] These figures embarrassingly outline the dilapidated shape of healthcare infrastructure which is a far cry from the ‘Health for All’ commitment for a welfare state like India.

The given chart shows government spending on healthcare, which is roughly 1.13% of GDP. The share of states is significantly higher and is supplemented by transfers from the centre for CSS (Centrally Sponsored Schemes) but is still grossly inadequate. The stunted earmarking for health highlights the lack of a citizen-centric approach resulting in retardation of the progress of primary health systems. An increase in public spending from 1% to 2.5-3% of GDP – as envisaged in the National Health Policy 2017 – can decrease the OOPE from 65% to 30% of overall healthcare expenditure.[2] Meanwhile, the health budget allocations for 2021 offer a ray of hope amidst the usual ‘a drop in the ocean’ allotments. Pandemics and Pockets

Studies have shown that health care emergencies hamper the supply chain management of medicines and increase the OOPE, especially for poor families.[3] The unforeseen and explosive spread of coronavirus in the 2nd wave tormented the already fragile health infrastructure of the nation. Political bickering instead of resource mobilization and swift response in this heart-rending situation put patients’ lives at risk and fractured the ill-prepared supply chains. Logistical mismanagement coupled with disturbed distribution timelines may have contributed to the dire condition of patients in choking hospitals, the scarcity of life-saving drugs and acute oxygen shortage. Remdesivir, a drug authorized for emergency use and hyped as ‘The Sanjeevni’ was prescribed to even those who were unlikely to benefit,causing its price to leap by 10-12 times. The unprecedented rise in demand offered the ideal ecosystem for service providers to charge exploitative rates for essentials and indulge in black marketing and hoarding. One of the main goals of any public health system is to ensure financial protection against health care costs, and this was most necessary during the pandemic when lockdowns undermined or destroyed the livelihoods of millions and transformed a healthcare crisis into a social and economic crisis. The lack of an affordable, equitable and accountable health system translated into a multi- faceted humanitarian crisis- impoverishment of households and the inability to meet survival needs.

Pooling of healthcare expenditure via health insurance can help to reduce healthcare risk at the macroeconomic level. The central government’s ambitious Pradhan Mantri Jan Arogya Yojana (PM-JAY) enhanced health insurance coverage as the proportion of households with health insurance increased by 54 per cent for the states that implemented PM-JAY.[4] If the poor, with no assets or medical insurance, fall sick, they are forced to borrow money at exploitative rates of interest pushing them into debt traps and in the long term, below the poverty line.

A potential pathway to reform involves mainstreaming block level health facilities. Here is a take on Mohalla Clinics, an innovative step towards universalisation of healthcare and are the national capital’s ‘Florence Nightingale’.

New Delhi’s Florence Nightingale

The Delhi Government has been a pioneer in localizing primary health services to the otherwise impoverished sections by establishing user-friendly Mohalla Clinics which has reduced OOPE and paved the way for holistic advancement in healthcare. These clinics provide the inadequately serviced sections with a basic package of essential health services including medicines and diagnostics. They are a game-changer in terms of reducing the patient load in bigger hospitals and streamlining health services delivery mechanisms to the poorest of the poor.[5] Mohalla clinics capture the essence of decentralization of health services in eradicating economic and social backwardness. It is a trailblazing initiative for providing an immediate, proximal and cost-effective solution to the health woes of those to whom tertiary care hospitals hold little relevance when they can’t access treatment for common illnesses. Remoteness is not a hesitation for women, diseases aren’t undiagnosed due to distance and health records are digitized making Mohalla clinics an internationally acclaimed action plan. As we embark on our way to become an economic superpower, it is imperative to undertake structural reforms for health care systems to give health the attention it deserves. Particularly the government is responsible for eliminating any financial risk associated with health uncertainty by strengthening Primary Health Care (PHC), thereby ensuring Universal Health Care (UHC) and thus reducing out-of-pocket health expenditure. Increased prioritization of primary healthcare in the central and state budgets is important as it critically impacts how much protection citizens get against economic hardships due to out-of-pocket payments. The gains made so far concerning improvement in health outcomes must be accelerated via robust mechanisms for health services delivery and better response to future disasters.[6]
Prayer, when prescribed with a dose of hope blended with early, prompt treatment, can mend maladies, can work miracles.

Aarna GalhotraWriting Mentorship, 2021


1. 3.;year=2020;volume=9;issue=12;spage=5872;epage=5880;aulast=Lahariya6.‘Nursing-Pockets-Back-To-HWealth’)
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