A policy let-down

National Health Policy 2017 leaves the poor in the lurch as it passes on to the private sector the responsibility for providing quality, affordable health care, instead of putting the onus on the state.

The female fever ward at the District Headquarters Hospital in Khammam, Telangana, is so overcrowded that patients are treated on the floor. An October 2016 photograph.

IN February this year, the Union Finance Ministry asked a premier government medical institution in the national capital to review and revise the fees it charged for registration in the outpatients department, bed rentals, radiology tests, diagnostic tests, and so on. The Centre had expressed its inability to supplement the finances of the institution, and it was argued that the user charges were last reviewed 20 years ago and a fresh revision was due. There was also a proposal to have a VIP counter at the institution, which was subsequently abandoned following opposition by the faculty. The upward revision in user fees comes at a time when there is widespread awareness of the high out-of-pocket expenditure incurred on health in the country.

In an admittedly unconnected incident, a court in Chhattisgarh recently acquitted on technical grounds a doctor who was accused of botching up sterilisation procedures that led to the death of 21 women, most of them young tribal persons. Such incidents reflect the overall nature of the dystopia that is the country’s health care system, something that rarely finds adequate attention in policy documents.

National Health Policy (NHP) 2017, unveiled on March 16, was a much-awaited policy document and one long over due since the last one was released in 2002. The one before that had come in 1983 and had hoped to provide health for all by 2000. Curiously, the media were not given the policy document when the Union Minister for Health and Family Welfare held a press conference on NHP 2017 on March 16. It was uploaded on the Ministry’s site one and a half days later.

It was hoped that the new policy document, coming as it did after a gap of 14 years, would mark a distinct departure in approach. All it does, however, is reframe and reposition the issues that were flagged in the 2002 policy document. The commitment to raise the health expenditure to 2.5 per cent of the gross domestic product (GDP) comes at the fag end of the Twelfth Five Year Plan (2012-17), and that too only by 2025.

NHP 2017 also promises to increase state sector spending to 8 per cent of the budget by 2020. Interestingly, the 99th Department Related Parliamentary Standing Committee on Health and Family Welfare (demands for grants 2016-17) made a pertinent observation in the context of spending on health by States and the Centre’s plea that the States would gain from the new devolution formula. It noted that “despite the enhanced share in Central taxes divisible pool, all States and UTs [Union Territory] have not increased their budget in 2016-17”. While some State budgets registered a negative growth, others registered a marginal increase in their health budgets. “The assumption that the enhanced share of States and UTs in the Central divisible pool would compensate for the sharp reduction in the Central allocation of health has not been validated,” noted the committee. In fact, the Twelfth Plan document had recommended that core health expenditure was to be raised to 1.87 per cent of the GDP by 2017, but it was increased only up to 1.4 per cent in 2016-17, according to the Economic Survey. Interestingly, draft NHP 2015 stated that global evidence showed that “unless a country spent 5-6 per cent of its GDP on health and major part of it from government expenditure, basic health care needs could not be met”.

No underpinning of government role NHP 2017 does not underpin the government’s centrality in providing health care to all. It does acknowledge, however, that the “right to health cannot be perceived unless the basic health infrastructure like doctor-patient ratio, patient-bed ratio, nurses-patient ratio are near to threshold levels and uniformly spread across the geographical frontiers of the country”. This clarification comes in the context of a demand to make health a fundamental right.

A comparison between the 2002 policy and the latest one does not generate much optimism. The 2002 policy accepted at the outset that “if the decentralised public health services are to improve significantly, there is a need for the injection of substantial resources into the health sector from the Central government budget”. NHP 2017 makes a commitment to increase the health budget, yet there is little acknowledgement of the discrepancies in allocation vis-a-vis projected outlays in the annual health budgets. Its very first assumption that health priorities are changing is a matter for scrutiny, apart from its other assertion that maternal and child mortality has declined rapidly. Its broad optimism is not shared either by a Department Related Parliamentary Standing Committee report or by a document accompanying the policy titled “Backdrop to the National Health Policy”, 2017.

The Department Related Parliamentary Standing Committee on Health observed that India’s health care fell far below the benchmark and that the country was seriously lagging behind in health goals on maternal and infant mortality. It also observed that India’s level of public spending on health was one of the lowest in the world: at 1.15 per cent of the budget, it is much below the global average of 5.99 per cent. The squeeze on public finances has led to high out-of-pocket expenditure, which constitutes 64 per cent of the total health expenditure, pushing 7 per cent of the population into poverty, according to the 71st round of the National Sample Survey Office survey. India ranked 183 among 192 countries in terms of high out-of-pocket expenditure as a percentage of the total health expenditure and was better than only Bangladesh and Afghanistan among its neighbours. The Standing Committee noted that out-of-pocket expenditure was much lower in countries with economic indicators similar to India’s: Brazil (25 per cent), Russia (46 per cent), China (32 per cent), South Africa (1.6 per cent), Sri Lanka (42 per cent) and Thailand (0.8 per cent). According to the document on “Situation Analyses”, over 63 million people are pushed into poverty each year because of health care costs.

A close look at the policy reveals that it talks about preventive and promotive health care and universal access to good-quality health care without anyone having to face a financial hardship as a consequence. It also talks about increasing access to, improving the quality of, and lowering the cost of health care delivery. One of the key policy principles is equity, for which the policy says it would mean greater investment and financial protection. The Department Related Standing Committee had to say this on investment: The Twelfth Plan is concluding by 2016-17 but India is nowhere near the target of 2.5 per cent health allocation. Only 47 per cent of the funding envisaged for the National Health Mission (NHM, combining the National Rural Health Mission and the National Urban Health Mission) was allocated in the Twelfth Five Year Plan that ends in 2017. The committee observed that had the government allocated the entire amount for the NHM, the country would have seen much better health outcomes in terms of quality primary health care services and reduced out-of-pocket expenditure. Describing the budget estimate of Rs.26,690.70 crore for 2017-18 as grossly inadequate against the projected demand of Rs.34,315.66 crore, the Standing Committee on Demands for Grants recommended an increase of Rs.4,000 crore for the NHM. It observed that in comparison to the Revised Estimate allocation in 2016-17 of Rs.22,197.95 crore, the increase in the Budget Estimate of Rs.44,92.75 crore for 2017-18 was insufficient.

The policy document acknowledges that catastrophic health care expenditures, those that exceed 10 per cent of total monthly consumption expenditure, are unacceptable and yet does little by way of prescribing stringent regulation of drug pricing, maximum retail pricing, and hospitalisation charges, including for frivolous tests and investigations, which constitute the bulk of health care costs. It does speak about eliminating corruption in health care systems but falls short of suggesting a framework for the regulation of those systems in a highly privatised medical education as well as health care scenario.

Advocates dependence on private sector

Interestingly, while it talks about improving health status through concerted policy action through the public health sector, the part to do with the “public” aspect seems to have been whittled away in a gradual way. The gradual dismantling of the five pharmaceutical public sector units over the years and the Union Cabinet’s decision to close down the largest public sector pharmaceutical units, Indian Drugs & Pharmaceuticals Limited and the Rajasthan Drugs and Pharmaceuticals Limited, along with two others, do not speak of any honest government intention to strengthen the public component of health care. The emphasis on free comprehensive primary health care does not come close to addressing the high costs of secondary and tertiary health care. The commitment to universal coverage does not accompany a guaranteed increase in health care services at all levels. The policy document advocates optimum use of existing manpower and infrastructure and collaboration with the non-government sector on a pro bono basis for the delivery of health care services. The nature and the specifics of the pro bono service have not been fleshed out. Likewise, it states that improved access to and affordability of quality secondary and tertiary care services will be provided through a combination of public hospitals and “well measured strategic purchasing of services” in health care deficit areas from private care providers, especially not-for-profit providers.

Given the lax regulatory mechanism for the private health care system, the policy should have emphasised regulation in areas involving private partners. According to the policy, the private sector is to be enabled to meet public health goals and make health care systems more effective, rational, safe, affordable and ethical. But it is silent about tightening the regulatory framework relating to the private health care sector, in all its dimensions. The government’s inability to make mandatory a universal code for ethical marketing practices by pharmaceutical companies indicates the mismatch of intent between departments and Ministries of the government. The new slogan of “Health in All” as part of the policy thrust falls flat in the absence of inter-ministerial or inter-departmental synergy.

The document lists goals such as increasing life expectancy and reducing total fertility rate (TFR) to 2.1 by 2025. The goals for population stabilisation are laudatory, as is the plan to focus on male contraception and the moving away from the “camp approach” of family planning. Yet, by and large the actual government policy on population control is still tilted more towards female contraception, including the use of injectables and other options such as intra uterine devices.

Likewise, the reduction of under-five mortality to 23 by 2025, infant mortality rate to 28 by 2019, maternal mortality rate to 100 by 2020, the rate of still births to one digit by 2025, and neonatal mortality to 16 are all laudable objectives. But these are not accompanied by a robust publicly funded nutritional policy. There does not seem to be any section on the hunger and nutritional challenges, given that India ranks high on the global hunger index, other than a segment on malnutrition with a strong focus on micronutrient deficiency and food fortification. There is no mention of strengthening the public distribution system, which indicates a lack of understanding of all the crucial determinants of health affecting all ages of the population.

It is widely known and accepted that there is a serious shortfall as far as the coverage of health services is concerned. An average sub-centre caters to 5,000 people in the plains areas and 3,000 people in the hills. The policy sets out targets for greater antenatal care coverage and attendance by skilled birth attendants. Ironically, while the policy strives for universal health coverage, the approach appears to be targeted as far as the health outcomes are concerned. The United Progressive Alliance government had identified an Empowered Action Group of States (a euphemism for backward States) for target interventions. A further decentralised form of targeting has since been evolved, aiming at high-priority districts. Available evidence suggests that targeted interventions never achieve their objectives, for the “targets” do not benefit from such micro-focussed interventions. The policy purports to provide by 2020 health infrastructure and human resources such as paramedics, doctors and community health volunteers and establish primary and secondary care facilities, in accordance with the norms, in high-priority districts.

The policy envisages a greater role for the linchpin of the NHM, the nine lakh accredited social health activists (ASHAs) who will be expected to provide community or home-based palliative care and mental health services and work for primary prevention of non-communicable diseases. There is little in the policy about providing any long-term financial or economic security to ASHAs, with the government insistent on retaining the label of “activists” for such women.

The policy says that while ASHAs would be “mainly voluntary and remunerated for the time spent”, those who obtain qualifications “could be given” more regular terms of engagement. The approach towards these women workers who are the backbone of the health delivery system in rural India and are engaged in multifarious government duties and targets is indicative of the ad hoc approach that the government has to health outcomes.

The policy document does not offer guaranteed free and affordable health care. The emphasis on a gradual or progressively incremental assurance in the area of free drugs and diagnostics and making financing for additional infrastructure or human resources contingent on utilisation does not inspire confidence. The wider determinants of health listed in the policy do not include access to adequate nutrition. In fact, the recent decision of making Aadhar compulsory for mid day meal entitlements for students is an illustration of the strange policy contradictions within the government. There is a cursory mention of inadequate calorie intake and nutrition status in the context of reproductive and sexual health in the subsection on child and adolescent health. The focus on malnutrition is restricted to addressing micronutrient deficiencies through micronutrient interventions, ignoring overwhelming evidence of declining per capita calorie intake in the population, especially in the economically vulnerable sections.

There is a school of thought that advocates dietary diversification as a viable option to deal with malnutrition and micronutrient deficiencies. Unfortunately, much of what used to be consumed on a daily basis has gone out of the reach of the common individual for reasons of economic affordability and changing agricultural patterns. Yet many in the scientific community consider dietary diversification as the most rational approach to tackling malnutrition, both child and adult. But the policy’s focus is on micronutrient interventions as it justifies another evolving project of the government, that is, food fortification, and absolves the government from creating the conditions that allow for a diversified diet. The policy says: “While dietary diversification remains the most desirable way forward, supplementation and fortification require to be considered as short and medium term solutions to fill nutrient gaps.” Clearly the commitment to dealing with malnutrition is half-hearted in the policy, though the situation analyses report emphasises that “micronutrient malnutrition requires renewed focus on food fortification”.

The policy does not see overall morbidity and mortality as a function of either disparities in purchasing power or the declining ability of the majority of the population to have access to a diversified diet. The singular obsession with targets either in terms of reaching the millennium development goals or in terms of achieving the ideal fertility rates, at the cost of a declining child sex ratio, narrows the vision of the policy.

The draft NHP 2015 had observed that if countries like Thailand and Brazil were close to achieving Universal Health Coverage for the population, there was no reason why India could not accomplish the goal. The point is not just universal health coverage; it is about affordable, equitable, quality and accessible health coverage, the provision and ensuring of which should remain a government priority and not outsourced to non-profit or private health care providers. Health cannot be a matter of assurance alone; it should be guaranteed even without a legislative backing.