POLITICS

If The BJP Is Clear The Government Can't Provide Public Goods, Why Collect Taxes?

Several Gorakhpurs happen every day in many parts of India.

15/08/2017 12:30 PM IST | Updated 15/08/2017 12:31 PM IST
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After last week's tragedy in Gorakhpur in which 72 children died allegedly due to non-availability of oxygen at a government hospital, BJP leaders have been desperate to find excuses to defend the Uttar Pradesh government and the party itself.

In its bid to whitewash the tragedy, or even cover up and deflect the blame from itself, the party has tried all kinds of unreasonable answers, but the worst came from senior BJP leader and surface transport and shipping minister Nitin Gadkari.

According to him, its not "possible to provide professional healthcare to patients at government health facilities."

Although, he didn't specifically mention Gorakhpur, the context was too obvious. While the UP chief minister Yogi Adityanath blamed the hospital authorities and even found unlikely reasons for the sudden death of a large number of children at a single location, Gadkari tried to absolve the State of its fundamental responsibility to provide healthcare to its people.

Universal Health Care (UHC), in which the State guarantees and delivers free, cashless health services to its people, is the ideal that the world is moving towards.

Speaking at the inauguration of the first phase of a National Cancer Institute in Nagpur, Gadkari said that the government was incapable of providing healthcare because of "various factors such as non-availability of expert doctors, skilled manpower, lack of funds and ticklish rules and regulations," adding that "as such, inviting social institutions and entrepreneurs to run such facilities on government lands provided at nominal cost would help provide professional healthcare service to poor and middle class patients."

Showing helplessness at a tragic time when the nation needed stronger assurance from the party -- that rules the centre and 18 states, and trying to expand in the rest of India -- that it's incapable in providing welfare to its people is a shocking let down. His statement, and the ground reality in Uttar Pradesh that led to the disaster, call into question the credibility of the BJP to govern.

Gadkari is either completely uninformed about the role of the State in public health in a democracy, or he doesn't care. Probably he doesn't know that healthcare was Barrack Obama's single most important political agenda during the two terms of his presidency, that even Donald Trump tried to dismantle; or that a neoliberal Margaret Thatcher couldn't touch the free National Health Services (NHS) while she was privatising everything in England.

India is a country with very high tax rates -- with the imposition of the the GST, the tax burden of one with a relatively higher income could be as high as 58%. And to say that the government was unable to care for its people's health after taking away a sizeable part of their earnings as taxes is not just irresponsible, but callous. If a government cannot provide basic services such as health, water, public infrastructure and education that are inevitable for the survival of its people, why should it levy taxes at all? What does it use the money for?

As in India, there are many countries where direct and indirect taxes together can take away 50% or more of people's earnings, but most of them guarantee high-quality, free healthcare and other public utilities. Either through a directly operated public system such the NHS in England, or those in countries such as France and Canada, where the private sector does play an important part without an undue burden on the people. These countries provide Universal Health Care (UHC), a system that is cashless and available to everyone, rich or poor. Only in despotic and lawless countries, people get nothing in return for their high taxes.

By Gorakhpur standards, India is certainly one of them.

It doesn't matter if the government wants to involve the private sector, as the BJP appears keen, the key to universality is cashless services and not insurance.

Universal Health Care (UHC), in which the State guarantees and delivers free, cashless health services to its people, is the ideal that the world is moving towards. The UN, WHO and even institutions such as World Bank, that had once been sceptical of the feasibility of this idea, now champion this cause. It's also one of the Sustainable Development Goals (SDG), which is the new global benchmark in human development. Had there been a semblance of UHC in India, incidents such as Gorakhpur wouldn't have happened.

Is it shortage of money that prevents India from moving towards UHC or lack of governance?

It's a combination of both because the government, as Gadkari's statement itself reveals, doesn't know how to prioritise and how to govern. The country certainly needs to spend more on health, probably a little more, not as much as 11.5% of the GDP that France does, because in our neighbourhood, Thailand has successfully demonstrated that a country doesn't need to be rich to achieve UHC. Thailand's UHC, today covers 98% of the population and it even supports people living with HIV and those with chronic kidney disease that require prolonged and expensive treatment including periodic diagnostics and regular dialysis. The total expenditure is just over 4% of the GDP; Indians pay about half of it (as a share of the GDP) from their own pockets and get practically very little.

It was not money that made Thailand a sparkling example among the upper middle income countries, but political commitment, efficient governance and civil society participation. Through concerted efforts since the 1970s that intensified in the 1990s, the country had been able to achieve universal coverage 15 years ago. Even during the political instability between 2001 and 2011, the universal coverage thrived. Through legislation, appropriate national institutions and a decentralised network that allow people access the services in their neighbourhood, the government has made healthcare a constitutional guarantee. People in Thailand don't need to worry about catastrophic health expenses any more, or the disasters that await them in hospitals, and paying for health is not going to bankrupt them or push them into irreversible poverty. They pay nothing, the State takes care of it.

Several Gorakhpurs happen every day, not just in UP, but in many parts of India.

UHC had been the ideal that India also pushed during the 12th plan period, but the UPA government wasn't serious despite some initial commitments by prime minister Man Mohan Singh himself. The BJP government too made some similar noises and used a different terminology - health assurance right from the day it came to power. In its national health policy that was unveiled in the Parliament in March, it promised to strengthen the infrastructure, capacity, financing and human resources, and envisaged a complete overhaul of primary care in a way that will expand its scope and scale to ensure continuity with higher levels of care. It also promised to raise government expenditure on health to 2.5 per cent of the GDP.

It doesn't matter if the government wants to involve the private sector, as the BJP appears keen, the key to universality is cashless services and not insurance. Both the centre and many state governments have erroneously taken insurance, wherein only a limited part of the healthcare needs of the beneficiaries are assured, for universal care. What's needed instead is a system in which the government becomes the provider, no matter where it purchases the services from.

In Thailand, it's mostly the public sector, whereas in France and Canada, it's the private sector. For a resource-poor country such as India, the Thailand model looks more suitable. It's in fact astonishing to note that Thailand could achieve universality at an average cost of US $80 per person, mostly because of its reliance on the public sector. In fact, this model is suitable for India because it also strengthens the infrastructure, capacity and governance of public institutions. India can try various innovative ways to find the financing needs. Can't India find Rs 5000 per person, that Thailand roughly spends, to keep its population healthy?

Evidence all over the world has shown that universal health ensures better equity in healthcare (the poor and the rich will have equal access) and greater financial protection (because one doesn't suffer catastrophic expenses). It's not an utopian idea, but the standard practice in the civilised parts of the world where kids don't die like they did in Gorakhpur.

Standard-setting punishment for the guilty might help Uttar Pradesh chief minister Yogi Adityanath save his face, but not prevent such incidents from happening again. Gorakhpur is just a flash in the pan that people noticed because of the scale - in Uttar Pradesh, out of every 1000 newborns, 64 die before they turn one (In most parts of the civilised world, it's less than 10).

Several Gorakhpurs happen every day, not just in UP, but in many parts of India. If the country wants to really prevent it or rather reduce its incidence, it needs a systemic change that is not to run away from its responsibility or allow the private sector to take over as the likes of Gadkari might advocate for, but to move towards universal health.

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