Talk better health, talk politics

What does Nitish Kumar’s Bihar and a Swiss town best known for its jazz festival and a statue of rock legend Freddie Mercury have in common?
On the face of it, precious little. But Montreux, Switzerland, which hosted the First Global Symposium on Health Systems Research last month showcased a simple and powerful idea that is at the heart of Mr Kumar’s recent landslide victory. The Bihar chief minister is the new rock star of development. He has shown that even in a fractious, deeply divisive society, the politics of development works.
Roads, schools, jobs for women, bicycles for students, better-functioning primary health centres and, of course, law and order — all these were changes that affected the lives of millions across the state that had not known “development” in decades of misrule. All these garnered votes.
One of the most fascinating takeaways from Montreux: health research is necessary but not sufficient for health reforms. You need that much-maligned species — politicians — to use that research as evidence to push through policies.
Thailand is a telling example of a not so rich country where politics pushed through universal health coverage. In 2001, Thailand extended government-financed coverage to all uninsured people with little or no cost sharing, becoming one of only a handful of lower-middle income countries to do so. Interestingly, the man responsible for this move was Thaksin Shinawatra, the controversial Thai billionaire politician and businessman who was the prime minister of his country from 2001 to 2006. Means-tested healthcare for low-income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. Was Mr Thaksin criticised when he did this? Of course, he was. But despite the critical comments, the reforms were a a big hit with poor Thais, especially in rural areas, and survived the change of government after the 2006 military coup.
What is the essence of the Thai experience with healthcare reforms? The operative principle here is “good for the most as against best for the few” says Dr Viroj Tangcharoensathien, director of International Health Policy Programme in Thailand’s ministry of public health, and one of the experts who attended the Montreux meet. In Thailand, it was national politics that set the universal health coverage agenda. Then, technocrats and research communities pitched in during policy formulations. What really worked was the close relations between political reformists, policy and research networks. It was pragmatism rather than idealism that helped achieve the UHC goal, points out Dr Tangcharoensathien.
Mr Thaksin was ousted in a coup four years ago. But guess what? His 30-baht ($1 co-payment) insurance system, which gives almost every poor Thai access to decent medical care, has remained. The number of uninsured Thais has declined from 16.5 million in 2001 to 2.9 million in 2005 and even the poorest of the poor in the shanties in Thailand can access the medical system without much hassle. No political force dare take this away from them.
The efforts of Ghana, another developing country, to provide universal healthcare coverage for its nearly 24 million people also won the hearts of experts gathered at Montreux. At the turn of the decade, African leaders promised to substantially increase their health budgets to combat killer diseases such as malaria, tuberculosis, HIV/AIDS in a landmark agreement known as the Abuja Declaration.
However, apart from Ghana and a few other African countries, progress in meeting those targets have been slow. Ghana has taken the lead by mobilising $115 million in the past few years. This has come mainly from consumer taxes and the value added tax (VAT), popular in most African nations, to improve the provision of health services and fund health insurance.
In Ghana, as in Thailand, it was politics which centrestaged affordable healthcare. High political premium was put on the successful implementation of National Health Insurance Scheme and its success was seen as important in proving the competence of the government and subsequent re-election.
Less than 15 per cent of India’s population has any kind of healthcare cover. Out-of-pocket medical expenses plunges millions into debt. Why then is affordable healthcare not a burning political issue in this country? I tossed this question to many health experts. But I did not get a satisfactory answer. A partial explanation is that the most vocal sections of the population — the middle class and the rich — do not depend on public hospitals; in many parts of the country, the public health system is so bad that no one has any expectations from it at all; most people are resigned to paying for medical care themselves; many are more comfortable going to a private practitioner, sometimes a quack, than a government health centre. The flagship National Rural Health Mission has brought some changes on the ground. The new National Health Insurance Scheme offers support to many BPL (below poverty line) households. But health for all is a distant dream.
To come back to Bihar. Mr Kumar has done wonders for the roads, law and order and education in his state. But there is one key area where the Nitish-effect is less visible. This is healthcare. As Prof Alakh Sharma, director of the Delhi-based Institute for Human Development puts it, “When Nitish Kumar came in power in 2005, the public health system in Bihar had collapsed completely. Primary health centres had no doctors nor medicines. They are functioning far better today. Institutional deliveries are also increasing. But during his first term, education rather than health was among his top priorities in the social sector. The reason: education links directly to aspiration. It is seen as the passport to mobility. In his second term, health may well move up the policy agenda”.
There are positive signals from the Centre too. The Congress-led United Progressive Alliance government realises the political benefits of universalising a set of basic rights in the run-up to the next general elections. Right to Education is already a reality. Universal health coverage could well become a mega vote-catcher if delivered well. In October this year, the Planning Commission set up a high level expert group under the stewardship of Dr K. Srinath Reddy, president of the Public Health Foundation of India, to work out a comprehensive strategy to ensure quality, universal reach and access to healthcare services, particularly in underserved areas.
The committee, which is expected to submit its report within eight months, will also look into the role of private and public service providers in meeting the human resource requirements to achieve “health for all” by 2020. The report of this expert committee will hopefully generate enough evidence to prod the political leadership in the direction of universal health coverage. If Thailand and Ghana can do it, there is no good reason why India can’t.

Patralekha Chatterjee writes on development issues in India and emerging economies and can be reached at patralekha.chatterjee@gmail.com [2]