[Answered] Examine the assertion that the shift from MGNREGA to RAM G transforms an employment guarantee into labour control. Critically analyze its implications for landless labourers and agricultural wages.

Introduction

India’s out-of-pocket health expenditure remains around 47% of total health spending (NHA 2021), exposing limits of insurance-led UHC and underscoring the need for universal, publicly financed healthcare.

Conceptual Distinction: Universal Healthcare vs Universal Health Coverage

1. Universal Healthcare (UHCare): Goes beyond financial risk protection to ensure equitable access to preventive, promotive, curative, rehabilitative and palliative care.
2. Universal Health Coverage (UHC): Focuses primarily on insurance-based financial protection, often hospital-centric and disease-package driven.

Normative Foundation: Health as a Right

1. Health is a human right, reaffirmed by World Health Organization through the Alma-Ata Declaration.
2. Later global shifts, especially WHO (2010), prioritised risk pooling and insurance, diluting the primary healthcare vision.

Limitations of Insurance-Centric Approach in India

1. Hospital Bias: Schemes like Ayushman Bharat-PMJAY emphasise tertiary care, neglecting primary and secondary levels.
2. Persistent Out-of-Pocket Expenditure: NSS data show costs for diagnostics, medicines, and follow-ups remain uncovered.
3. Supplier-Induced Demand: Evidence of unnecessary procedures and inflated billing in private hospitals.
4. Equity Concerns: Informal workers, migrants and women face exclusion due to documentation and awareness gaps.

Importance of Primary and Secondary Care

1. Gatekeeping Function: Strong primary care reduces avoidable hospitalisation and costs.
2. Cost-Effectiveness: WHO estimates every $1 invested in primary care yields up to $9 in health and economic benefits.
3. Epidemiological Transition: Rising NCDs require continuous, community-based care, not episodic hospital treatment.

Asian Models: Insurance Embedded in Strong Public Systems

1. China: After near-universal insurance, high fiscal stress led to renewed investment in township hospitals and family doctors.
2. South Korea: Single-payer insurance supported by robust public provisioning and regulated private sector.
3. Thailand: Tax-funded Universal Coverage Scheme with strong district health systems drastically reduced catastrophic health spending.
4. Key Lesson: Insurance works best within a publicly funded service-delivery backbone.

Role of Public Spending

1. India spends about 2.1% of GDP on health, below WHO’s recommended 3–4%.
2. Higher public spending enables: Human resource expansion (doctors, nurses, ASHAs), Infrastructure at Health and Wellness Centres and Free drugs and diagnostics, reducing OOPE.
3. Strong public sector acts as a price and quality regulator for private healthcare.

Indian Context: Legacy and Missed Opportunity

1. Bhore Committee: Advocated comprehensive, state-funded healthcare before insurance.
2. Chronic Underfinancing: Weakened public provisioning pushed poor households towards costly private care.
3. COVID-19 Lessons: Highlighted limits of insurance when public hospitals and primary care are weak.

Way Forward: From Coverage to Care

1. Increase public health expenditure to at least 3% of GDP.
2. Strengthen Health and Wellness Centres as first point of care.
3. Integrate insurance schemes with referral-linked public systems.
4. Invest in social determinants: nutrition, sanitation, housing.

Conclusion

As argued in Amartya Sen’s Development as Freedom and WHO’s Primary Health Care approach, health systems anchored in public provision are essential for equity, efficiency and genuine universal healthcare.