HEALTH FINANCING ISSUES

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Public expenditure levels

Fair financing of the costs of health care is an issue in equity and it has two aspects how much is spent by Government on publicly funded health care and on what aspects? And secondly how huge does the burden of treatment fall on the poor seeking health care? Health spending in India at 6% of GDP is among the highest levels estimated for developing countries. In per capita terms it is higher than in China Indonesia and most African countries but lower than in Thailand. Even on PPP $ terms India has been a relatively high spender information sheets based on reporting from a network associating private doctors also as has been done successfully at CMC Vellore in their rural health projects or by the Khoj projects of the Voluntary Health Association of India. It is only through such community based approach that revitalization of indigenous medicines can be done and people trained in self care and accept responsibility for their own health.

PHC approach was also intended to test the extent to which non-doctor based healthcare was feasible through effective down staging of the delivery of simpler aspects of a care as is done in several countries through nurse practitioners and physician assistants, ANMs; physician assistants etc can each get trained and recognized to work in allotted areas under referral/supervision of doctors.   This may indeed be more acceptable to the medical profession than the draft NHP proposal to restart licentiates in medicine as in the thirties and give them shorter periods of training to serve rural areas. Such a licentiate system cannot now be recalled against the profession's opposition nor would people accept two level services.

Finally it is important 10 noie some dangers inherem m arrangemenis itiai promote delivery systems substantially outside government channel either through NGOs or through registered societies at State and district levels. Clearly this may by a better approach than leaving it to the market and welcome as path breaking of innovative efforts as a precursor to launching a public program. But as a long run delivery mechanism it is neither practical nor sustainable as such arrangements tend to bypass government under our constitutional scheme of parliamentary responsibility and would also cut into the potential of panchayatraj institutions. Each major disease control program has now got a separate society at state and district levels often as part of access to foreign aid. What is lost is the principle of parliamentary accountability over the flow of funds that arise out of voted budgets and international agreements to which Government is a party and answerable to parliament. Like campaign modes and vertical interventions, the registered society approach would weaken the long-term commitment and integrity of public health care systems.