Socialization of Medicine - II

Ensuring equitable access to healthcare and quality medicines to all sections of the society irrespective of their caste, creed, colour, religion or paying capacity is the hallmark of a just, humane and civilized society 

Socialization of medicines is sometimes perceived as the acquisition by the government of the complete output of medical services and redistribution of those services and commodities equally among all citizens. Provision of public goods is inevitably socialized in the sense that everyone’s consumption is constrained to be the same. Public goods, such as the services of mass transit, parliament, traffic lights, fire services department, law and order, defence and so on, are normally nationalized, that is, produced in the public sector. It is desired that the public sector must provide medical care for everyone because of the concern for those who cannot afford medical care and because of everyone’s concern that he may impoverished to provide care for himself at some future time. The principal motive for socialization is the income inequality. Under a regime of proportional or progressive income taxation, socialization can be beneficial to the poorer half of the community which pays less in tax than the per capita cost of the output of the socialized industry (Usher, 1977). Medicine is a social enterprise and so it is imperative to further realize the socialization of medicine in order to fully realize the great social function of medicine. 

Access is defined as having medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk from the homes of the population. Access to essential medicines has been viewed as an integral component of the right to health, which is a basic human right (Hogerzeil, 2003). Inequity in medicines access is widely perceived as symptomatic of weaknesses in the health-care system and represents a failure on the part of national governments to fulfil their obligations towards their citizens in terms of their right to health. Ensuring equitable access to quality pharmaceuticals is thus a key development challenge and an essential component of health system strengthening and primary health care reform programmes throughout the world (WHO, 2011). 

Entire world of a middle-class man gets shattered into shreds and pieces once he or his close kin is diagnosed of a serious affliction like some rare form of cancer, kidney failure or tuberculosis and he is left with no other choice but to pull out all his lifetime savings or sell some of his valuable assets like land or jewellery to bear spine-breaking expenses to the tune of several hundreds of thousands of rupees, on account of his dreadful disease. Even upper middle-class people find it catastrophic and devastating to pay the hefty medical bills after getting themselves treated at the corporate hospitals outside the valley.  Therefore, health is not just about diagnosing ailments, making hospital admissions and providing treatments, it is an issue of social justice, social solidarity and social security too. Getting good health care is not a privilege, it is considered to be a fundamental human right. A just, humane and civilized society must be able to provide basic health access to all its citizens irrespective of their social status or paying capacity. 

Universal health coverage (UHC) is the aspiration that all people obtain the health services they need without having to pay all costs out-of-pocket and without suffering any financial hardships paying for them. Universal Health Coverage implies that all people have access, without any discrimination, to the needed promotive, preventive, curative, palliative and rehabilitative basic health services and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardships, with a special emphasis on the poor, vulnerable and marginalized segments of the population (WHO, 2019). UHC ensures that out-of-pocket expenditures by patients on their healthcare are minimized and they are covered by adequate health insurance covers by the government for which citizens have to pay a very little amount on annual basis. It is a social security scheme in essence. 

Globally, about 150 million people suffer financial catastrophe annually while 100 million are pushed below the poverty line. Only one in five people in the world has broad-based social security protection that also includes cover for lost wages in the event of illness, and more than half the world’s population lacks any type of formal social protection, according to the International Labour Organization (WHO, 2010). Due to out-of-pocket spending of their income on medicines and healthcare services, about 3.2 percent of India’s population is pushed below the poverty line every year, as per published reports (Holloway, 2013). When poor households lack access to affordable medicines, they have to forego treatment, sell precious assets, or make difficult choices between paying for medicines and other basic necessities like food, clothing and children’s education. 

Promoting and protecting health is essential for human welfare as well as sustained economic and social development. This has been recognized almost 40 years ago by the Alma-Ata Declaration signatories, who noted that ‘Health for All’ would contribute both to a better quality of life as also to global peace and security. Recognizing this, member states of the World Health Organization (WHO) committed in 2005 to develop their health financing systems so that all people have access to services and do not suffer financial catastrophes paying for them. WHO celebrates December 12th every year as the International Universal Health Coverage Day and has published three annual world health reports in the years 2003, 2010 and 2013 on the theme of Universal Health Coverage. However, UHC cannot be achieved, except for a small minority of the population, without a well-functioning health financing system that determines whether people can afford to use health services whenever they need them. Government alone cannot bear all the expenditures on account of health insurance cover of its people. Households, employers, insurance companies, NGOs and individuals need to contribute their bit through minimal payroll taxes for this purpose. If all the affluent people make small contributions annually, that can pave way for social security of all particularly the poor. 

The path to universal coverage involves important policy choices and inevitable trade-offs. All funds for health and medical care need to be pooled at one place for this purpose. The way those pooled funds – which can come from a variety of sources, such as general government budgets, compulsory insurance contributions (payroll taxes), and household or employer prepayments for voluntary health insurance - are organized, used and allocated, influences greatly the direction and progress of reforms towards universal coverage (WHO, 2013). Pooled funds can be used to extend coverage to those individuals who previously were not covered, to services that previously were not covered or to reduce the out-of-pocket payments needed for each service. These dimensions of coverage reflect a set of policy choices about benefits and their rationing that are among the critical decisions facing countries in their reform of health financing systems towards UHC (WHR, 2010). 

The health sector in Jammu and Kashmir is beset by many challenges in spite of the considerable progress it has made of late in terms of extension, service coverage and augmentation of manpower. A combination of weak institutional capacity, limited access to modern equipment and infrastructure and shortage of healthcare personnel has limited the effectiveness of health service delivery in J&K. The healthcare system in J&K is primarily run by the local government while private sector plays only a minor role in health service delivery and the non-governmental sector is largely absent. Compared to the doctor-patient ratio of 1:2000 in India, as against WHO recommendation of 1:1000, J&K has one allopathic doctor for 3866 people, as per Central Board of Health Intelligence, New Delhi (GK, 2017). However, with the establishment of five new medical colleges and two AIIMS in J&K this scenario is likely to improve in future. Though J&K govt. has provided free health insurance cover to the tune of Rs. 5 lakhs to all its citizens during the current financial year out of central/foreign assistance, in order to make it sustainable for all times to come, a robust and comprehensive Universal Health Coverage Policy framework is direly needed. 

For J&K to achieve Universal Health Coverage for its 125 lakh population we need to cross three major milestones viz., raising sufficient resources for health; removing financial risks and barriers to access; promoting efficiency and eliminating waste. To get closer to universal coverage, the J&K govt. would need to extend coverage to more people, offer more services, and/or pay a greater part of the cost. In J&K allocations for healthcare and medicines are scattered and fragmented between two directorates of health services, two government medical colleges, two government dental colleges, directorate of ISM, two super-speciality hospitals. All these funds need to be pooled and utilized centrally for increasing efficiency and conserving the available resources. However contingency grants for meeting emergent needs need to be kept available at the hospital/medical college level too for seamless availability of medicines. 

In view of considerable gains made in the healthcare sector in the recent past this author is contemplating to undertake a study in J&K state in order to analyze the situation on ground vis-a-vis availability, financial accessibility, geographical accessibility, affordability and acceptability of healthcare services particularly essential medicines at public health facilities of Jammu and Kashmir with an aim to identify the gaps, barriers, prospects and challenges towards adopting and implementing universal health coverage. Subsequently a comprehensive policy framework covering all relevant aspects concerning UHC including health service delivery, health workforce, health information systems, access to essential medicines, health systems financing, leadership and governance shall be developed that shall lay a roadmap for future policy direction of the J&K government towards implementing Universal Health Coverage scheme here and will make UHC sustainable for all times to come. This study will provide the necessary impetus and direction for making UHC a reality in J&K in near future.