THE DRAFT NATIONAL HEALTH POLICY (NHP)-2015 document, bereft of vision and loaded with administrative and operational guidelines at the cost of broad policy principles, calls for scrutiny—especially since it is the first health policy of a new political establishment. The NHP-2015 is reinforced by the current annual Budget for 2014-15, which introduced serious and unjustified cuts in the allocation for the health sector and a general rollback from social sector investment. This trend was pursued in the past as well and it kept health services out of reach for a large number of people. If the state is serious about universal health care, then the policy needs to be revised and rewritten, keeping the following in mind.
Context and Vision The state must ensure that the economic growth of the country does not remain jobless and that the gains of the growth reach the poor. It must ensure that a wide range of minimum social welfare services, such as food security, drinking water, education, transport, housing, sanitation, roads and electricity, are available for all so that the existing exclusion of a large number of people is addressed. This is critical for health, which is an outcome of not just medical care services but a combination of all these inputs.
We need to learn from history that leaving the health sector to market forces will have catastrophic consequences, as in Britain’s National Health Service. South Africa, Brazil, China and Mexico, despite structural adjustments, protected or realised early the need to protect their public sector infrastructure in health.
Despite the lower growth rates over the 1970s and the early 1980s, India’s achievements in human development were better, reflecting greater distributive justice. Instead of using this potential energy, born out of well-being, into revitalising productive forces, India opted for structural adjustment. The subsequent two and a half decades of near jobless growth and privatisation of services excluded people from welfare as well as productive processes. The rates of improvement in health indicators also slowed down.
A health policy at this stage, therefore, needs to be based on a total review of the past, especially the 12th Plan, the 12th Plan expert committee reports, and the High Level Expert Group (HLEG) reports, to take the best ideas forward. It must be grounded in an epidemiological assessment of its priorities and a review of what went wrong in the past. It cannot ignore the conscious undermining of the country’s preventive and promotive strategies, where organised medical care in the public sector was to play a key role in controlling major diseases that continue to persist, such as tuberculosis, malaria, diarrhoea and leprosy.
The Draft Policy document reflects no such understanding. It lacks the vision to address the issues of the larger majority and succumbs to the pressures that push forward the pre-existing policies of dependence on markets, big business and the corporate sector. It ends up with the highly medicalised approach to the issues of public health which calls for a systemic review of both private and public sector services, convergence of welfare programmes, and a vision for strengthening the public sector by addressing its weaknesses and its failure over time to bring about internal reforms with adequate financial inputs. Without this, the talk of “catastrophic expenditure” is simply leading to subsidy shifts from the state to the private sector as past policies have completely destroyed the public sector and left it in no position to compete with the private sector as far as medical services are concerned.
The public sector is still the mainstay of public health services as it is single-handedly responsible for the provision of basic minimum care, national programmes, health information systems and medical, nursing and paramedical education and research. The document recognises the value of the public sector but does little to address its rebuilding on a war footing over the next 10 years. It is only when this sector rebuilds itself and provides free/low-cost primary health care that we will have the mechanism to regulate the private sector and not otherwise. Creating regulatory institutions alone will not help, as is clear from the Clinical Establishments (Registration and Regulation) Act, 2010.
The policy document needs to revise its views on the contributions of the medical industry and medical tourism. This industry may have made some contributions to general economic growth, but who are the beneficiaries? The medical industry flourishes owing to the Indian elite and the expanded middle class, and their international counterparts seeking cheap and hi-tech clinical interventions. It is out of reach for the rest of the Indians. The corporate hospital beds meant for the poor are inevitably used by the privileged. Policy, we believe, should reflect the idea of free and compulsory primary health care services as a right for all, and not just medical treatment, to address the issue of “catastrophic expenditure”, wherein people end up paying such huge amounts in relation to income that it results in a financial catastrophe and forces them to cut down on necessities or children’s education. Research has shown that the insurance experiments have failed in any case to redress this problem. Assurance for such coverage cannot be the answer to India’s health care needs.
The draft policy document claims that in the changing contemporary context, priorities too are changing. Unfulfilled expectations are rising, a robust health care industry has consolidated itself, catastrophic expenditure is growing and also the fiscal capacity of the state has increased; this is only a half-truth that does not confront the fact that the medical industry is the driving force behind the rising or unfulfilled expectations not only among the aspiring middle class but also among those who do not have basic facilities. In the quest for revenue, this dangerous and distorted development is underplayed. The fact that increasing fiscal capacity with economic growth has been accompanied by declines in quality of and coverage by the public health sector is ignored and passed on as the “changing context”. These very tendencies that account for the failure of the system to control diseases and attain in time the limited (Millennium Development Goals (MDGs) are not taken seriously, as the document claims that we are almost there!
Health needs to be visualised as an integral part of the developmental process where inclusive economic growth with job creation, livelihoods and minimum wages, and welfare services and food security are core elements. Convergence of social sectors with the health sector needs to be envisioned adequately by highlighting the specific linkages of health with nutrition, drinking water, housing, environmental sanitation, etc. The lack of food lowers immunity and makes people vulnerable to diseases. Basic education goes a long way towards spreading health education, making people capable of helping themselves and accessing information. Along with these, investment in housing, sanitation, drinking water and environmental safety is also protective. A scientific assessment of necessary minimum requirements of each of these, for promoting health, is necessary rather than simply fuelling the medical industry. Leaving these to their respective departments as the policy does will not work.
Even setting up bodies to bring out this convergence is inadequate as shown by the past experiences of committees set up by the Planning Commission; they were ineffective outcomes. Hence, a new policy needs to spell out the methodology of convergence and the responsibility of the public health sector to lay out the minimum requirement from each of these sectors on a rational epidemiological basis.
Rebuilding public sector health care The NHP-2015 document uses “Comprehensive Primary Health Care” (CPHC) loosely without defining it or stating that it accepts the Alma Ata Declaration (1978) definition. (The Declaration was a major milestone of the last century in the area of public health and it identified primary healthcare as the key to the attainment of the goal of “Health for All”.) Hence, nothing deters it from adopting a reductionist approach that fragments the health system and reduces comprehensive primary health care to primary-level care. Almost apologetic about strengthening the infrastructure and its referral links first and foremost within the public sector, it jumps to public-private partnerships (PPPs) and limited insurances, which, as mentioned earlier, are not the answers to India’s health crisis.
To address the current crisis in health, the first and the foremost priority should be to rebuild the public sector in health through a tax- or national insurance-based financing system. This alone can provide stability to the sector, give priority to strengthening and regulating the balance between curative and preventive components, and help it grow. It can simultaneously be used as a regulatory mechanism for the private sector as it begins to offer cheap and effective services over the next 10 years.
Although the document recognises the money value of public sector institutions, it does not recognise the urgency of the need for their time-bound strengthening. Priorities of programmes and their integrated conceptualisation and operationalisation need to be based on epidemiological and systems analysis and research. This interdisciplinary approach alone can avoid the present policy’s fragmented handling of health services.
The Draft Policy talks of broadening the scope of services provided through the primary health care network, but in a clinical sense. Integration of vertical programmes is also mentioned but without broad methodologies and time schedules. Integration demands visualising reorganisation of personnel, competencies and planning processes. Even the National Rural Health Mission (NRHM) needs to be a part of this integration process, with the district system linked with public tertiary care institutions to complement secondary- and primary-level services.
Formal regulatory mechanisms are required for the public as well as the private sector. To talk of investments in medical institutions for “operational purposes” and “strengthening of infrastructure” is not enough; investments in the entire gamut of preventive, curative and rehabilitative levels need assessment. Inability to pay should not come in the way of people having access to health services. All essential drugs should be provided free of cost by state institutions and the state must, over time, take full responsibility of provisioning services, not just assuring coverage.
Public hospitals are getting dysfunctional and losing the culture of service because of their commercialisation, internal competition and increasing corruption. Private investments and providing spaces to private providers within public institutional premises must stop.
Human resource requirements of the entire system need to be re-evaluated and training of resources needs to be strengthened. The sharp deterioration in medical education needs to be addressed if there are to be adequate numbers of physicians (managerial and clinical). What is called for is not only a revision of curriculum or making it more in tune with the public health needs of the country but also a stop to the mushrooming of private medical schools.
The huge capitation fee (Rs.30-50 lakh for MBBS seats and Rs.80 lakh-Rs.3 crore for postgraduate specialisations) leads to either the trained persons leaving the country or their engaging in profiteering and malpractice to earn back the investments. This unhealthy trend in no way strengthens the public health infrastructure.
Research institutions and organisations need to emphasise and undertake social epidemiology research and recognise the importance of social sciences that not only help implementation of technology but also recognise the reasons for the failure to implement.
These institutions also need to systematically add to their list operational research (OR) and systems analysis (SA) to optimise functioning of health services systems.
The continued pressure for population stabilisation, despite the inability of services to meet the demands, has led to the dangerous outcomes of entering into PPPs at the primary health centre (PHC)/community health centre (CHC) level. Unless the entire infrastructure at the primary level is strengthened, tragedies that led to a large number of deaths among seekers of family planning services, as in Bilaspur this November, will continue. Both these—the push and the approach—need to be transformed.
The two much-needed policy recommendations are regarding administrative reforms. The first calls for the formulation of a cadre structure to attract competent public health personnel in the services by creating possibilities of promotion for those who run district and State health services to reach the higher echelons of the Health Ministry.
We need a cadre of managerial physicians with proper training for public health services within each State from where they could be drawn for the Central service. Secondly, as delivery of health service is constitutionally a State subject, the resources to perform should be handed to them. This will ensure State autonomy.
The States can develop appropriate institutions for education and training of various categories of personnel, health system planning and research to give shape to their health services according to their epidemiological, ecological, sociocultural, political and economic conditions and be answerable.
The Central Health Council, too, ought to play a decisive role in restoring power to the States to run their own health services according to their specific challenges and conditions.
Role of private sector The private sector is not new to India; it has had some of the country’s most eminent physicians. Its limitation is its very nature, which is attracted to clinical practice alone. It is a fragmented sector where at best one has institutional chains, delinked from each other, unorganised and hence unable to rise to the challenge of disease control or prevention that needs collaboration, cooperation, integration of services and epidemiological monitoring.
The policy document recognises different categories but its treatment of them is heavily biased. It provides maximum support to the corporate and minimum to the small private providers. This imbalance is highly undesirable. As in Sri Lanka, the state could have used the small private providers to strengthen its primary care base and restrict the tertiary-level partnerships.
Corporate hospitals have come of age, with state support, and must not be pampered or allowed to clamour for higher incentives. If they are efficient and more effective, then they should be able to hold their own and not depend on state resources. Heavy state subsidies to the corporate medical industry camouflage the flouting of the very principles they claim to operate upon—efficiency, effectiveness, quality and competition. It began with subsidies such as services of public sector-trained personnel, heavy import subsidies and inclusion in the government list of empanelled hospitals for visas and Union Public Service Commission and other such certifications.
Since the 1990s, free land allocations, PPPs and the Rashtriya Swasthya Bima Yojana have only made this sector more demanding and heavily dependent upon the state for maximising its profits and yet, it remains uncaring about the state of comprehensive primary health care in India as defined by the Alma Ata Declaration.
The present dependence on the private sector for tertiary and secondary services is not only costly but also biased in favour of tertiary care.
Countries like China have managed to provide 70-80 per cent of services via the public sector, while in India it is just the opposite. This ratio needs to be reversed over time along with the pattern of taxation and rise in service tax, as in India it favours the corporates at the cost of public sector services for all. This uninhibited fragmentation of an integrated health service into neat packages to be accommodated in the medical market by the Draft Policy—hiding behind “70 per cent private expenditures”, when firms and employers actually invest 6 per cent at best, with the rest of the private expenditure borne by the harassed public (compelled by a degraded public sector)—and the conscious refusal to rebuild the public sector only push people into medical markets but do not “assure health”.
Imrana Qadeer is a distinguished Fellow at the Council for Social Development, New Delhi. Arathi P.M. is a postdoctoral Fellow at the Berlin Social Science Centre.
Endnotes
1 http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf
2 See: Reddy, S., Selvaraj, S., Rao, K.D., Chokshi, M., Kumar, P., Arora, V., …&Ganguly, I. (2011). A critical assessment of the existing health insurance models in India, A report submitted to the Planning Commission of India, January, New Delhi. ; Selvaraj, S., & Karan, A.K. (2012). Why publicly-financed health insurance schemes are ineffective in providing financial risk protection. Economic & Political Weekly, 47(11), 61-68.
3 Das, A., & Contractor, S. (2014). “India’s latest sterilisation camp massacre”. BMJ, 349, g7282.; Jha, M.K., Majumdar, B.C., &Gorea, A. (2015). “Responsibility for Deaths of Mothers in Sterilization Camps”. International Journal of Ethics, Trauma &Victimology, l(1), 44-47.
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