At the stroke of midnight on 12th December, the global community will rise to the Day of International Universal Health Coverage themed: ‘Health For All: Keep the Promise’. Countries will share about interventions by the government and the private sectors that have contributed towards Sustainable Development Goals, mapping their progress towards universal health. What will India have for sharing? A divisive, anti-constitutional Citizenship Amendment Bill passed by the upholder of democracy, the Parliament. And quite paradoxically, both these historic days have an uncanny relationship with one another.
India, in recent years, has undertaken substantive measures aligning with this promise. The National Health Policy 2017 laid the roadmap to comprehensive health and well-being for all, and Ayushman Bharat, the flagship programme was launched on these lines in 2018. However, much lies at stake in achieving universal coverage with the realities grappling the country at present.
Global evidence demonstrates that higher per capita public health investment contributes to strong primary healthcare and improved health outcomes. India’s public health spending currently is only 1% of the GDP that has stagnated across years (National Health Profile, 2019). Low public investments in health have implications on the availability and access to quality healthcare. For instance, in terms of human resources, 27% of the sanctioned posts of Primary Health Centre (PHC) Physicians were found vacant, while rural areas had a shortage of 22% of Primary Health Center facilities (Rural Health Statistics, 2014-15) in the country.
The country contributes to one-fourth share of the burden of Tuberculosis with maternal mortalities in states that cross over 200 (highest in the South-east Asian region). The utilisation of healthcare is much higher in private care than public, and consequently, 18 % of the population incurring catastrophic costs, results in indebtedness due to healthcare. Clearly, in terms of health outcomes, India is way behind its similar contemporaries such as Bangladesh, Sri Lanka, Thailand, let alone rest.
On the occasion of 73rd Independence Day, Prime Minister Narendra Modi had urged the country to think of the consequences of uncontrolled population growth on the health and economy of the country. Five months henceforth, the BJP-led Government introduced and passed the divisive Citizenship Amendment Bill(CAB) that would provide Indian citizenship rights to all non-Muslim residents in Pakistan, Afghanistan, Bangladesh. This clearly implies an influx of immigrants from these countries and accessing resources and citizenship in the second-most populous country in the world. Quite ironically, induced population growth is what the country will witness.
The CAB has clear implications on states like Assam, reeling under a past and present of illegal immigration, ethnic tensions, and violence. Assam with a Multidimensional Poverty Index of 0.16 (the equivalent of Cambodia and other EAG states), is one of the slowest and disrupted economies in the country. Only 43% of the state’s population accesses public health facilities for care (NSSO, 75th round), and it stands highest in terms of Maternal Mortality Rate and the incidence of cancer (as well as Infant Mortality Rate higher than all-India levels).
Poor health infrastructure, access to medicines, tensions and poor access are predominant socio-economic factors for the high load of disease burden and mortalities. With the implementation of the CAB, this state is bound to bear the biggest burden of influx with an estimation of lakhs of immigrants (especially from Bangladesh) to move into Assam henceforth. Moreover, with a slow economy and poor health infrastructure, it is bound to slip further behind in terms of overall growth and health outcomes.
The goal of Universal Health Coverage as underlined by the World Health Organisation includes the utilization of health care services as per need of the communities, services that are comprehensive and are of good quality, and financial protection of individuals and families. The National Health Protection Scheme under Ayushman Bharat aims to cover over 10 crores of the lower quartile groups. The second part of the programme is creating 1.5 lakh Health and Wellness centres for a population of 1.3 billion.
Clearly, the programme itself does not have adequacy in terms of universal coverage. With CAB coming into effect, the per capita public health expenditure at ₹1657 (at present) will further dwindle with the population influx, while the overall public health spending sees no possibility of rising in the times to come.
Health as an indicator cannot be seen separate from politics that affect it both at macro and micro levels. The CAB is not just cross-cutting anti-secular, divisive lines but also bringing into serious critique the question: how do we envision Universal Health Coverage when the country’s politics induce divisive population influx? This needs to be argued, from the standpoint of its draconian nature and the threat to limited resources, dwindling investments, rising population, recession, and the high triple disease burden that the country is plagued with.