National Health Policy 2017

Public policy, private care

Print edition : April 14, 2017

The electronic urban primary heath centre set up under PPP model in Hyderabad with eVaidya. Photo: K.V.S. GIRI

Patients waiting to collect free medicine from the goverment's pharmacy at the Calcutta Medical College. Photo: PTI

A careful reading of the National Health Policy 2017 reveals that its stated goals are just window dressing for the continuation of the state’s role as the steward of the private sector.

A SUBSTANTIVE policy document is that which clearly states the directions of an organisation’s future and its perspective. It is not required to elaborate on procedures as an advisory document but it is incumbent on its authors to state unambiguously the priorities and provide timelines for its objectives and its financial requirements. When we reviewed the 2015 Draft National Health Policy (NHP), our primary concern was that while the document accepted that only the public sector health services gave value for money, its emphasis was on promoting the private sector. We had argued that only a strengthened public sector could act as a regulator for comprehensive primary health care if the national policy was serious about reaching out to the underserved. We had also pointed out that a policy needs to be located in the given epidemiological and socio-economic context. A quick reading of the subheadings of NHP 2017 gives the impression that these have been addressed. A careful reading, however, reveals that the generosity of its goals, the commitment to building public sector infrastructure, the principles of equity, affordability, universality, professionalism, ethics and integrity, quality, accountability, and so on, are more of window dressing for the continuation of its role as the steward of the private sector.

NHP 2017 emphasises the contextual changes since 2008 and proposes that this led to changes in health priorities and major shifts. It states: “Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases. The second important change is the emergence of a robust health care industry estimated to be growing at double digit. The third change is the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty. Fourth, a rising economic growth enables enhanced fiscal capacity” (page 1).

The so-called “rapid” declines of maternal and child mortality are certainly not as rapid as the policy suggests if we go by the fact sheet of the National Family Health Survey (NFHS) 2015-16. A reduction in the infant mortality rate (IMR) from 57 to 41 per 1,000 live births between 2004-05 and 2015-16, and a reduction in the under-five mortality rate (U5MR) from 70 to 50 for the same period still keep these rates far behind the achievements in other parts of South Asia, especially Sri Lanka, Bangladesh and Nepal 1. On the other hand, the growing burden of infectious diseases is underplayed despite our failures to contain old as well as new infections such as tuberculosis, sepsis, malaria, dengue, and chikungunya.

The medical industry is mischievously labelled as “health care industry” even though it is a part of the medical-industrial complex that thrives on the tertiary medical care needs of the middle class and the elite, as indicated by the relatively higher rise in the out-of-pocket expenditures (OOPE) of the richer population quintiles between 2004-05 and 2011-12 2. NHP 2017 also considers the medical industry “robust” as the revenue it generates adds to the gross domestic product (GDP), but the shift of state subsidies and the negative impact on public sector infrastructure and distributive justice in health care is not considered as a contextual shift.

Rising catastrophic expenditure was actually the rationale behind accelerating the pace of private penetration of public institutions, in the name of supporting and strengthening them, and setting up public-private partnerships. This link between the medical industry and rising expenditures is ignored even while recognising that the latter pushes people living on the margins into poverty, impeding faster pace of improvements in health indicators. The truth is that despite this rising expenditure, catastrophic or otherwise, the policy document continues to pursue “inclusive partnerships” with the private sector as a “public goal”, when experience has clearly shown that this strategy is not only futile but also expensive, both for the state as well as the people. Yet another aspect of the contextual change postulated is the increased fiscal capability of the Indian state, which now enables it to build its health sector infrastructure. The transformation of health services into a commodity and a means of capital accumulation in the process of building this fiscal capability is ignored.

It is evident then that the selection and contextualisation of the thrust of NHP 2017 is in favour of the medical-industrial complex and not ordinary Indian citizens. Its fragmented and one-sided view of a conflicting set of contextual shifts reflects its underlying perspective as reflected in its goals. The quantitative goals of the policy are mostly for 2025 (U5MR of 23, neonatal mortality of 16, and life expectancy of 70), with the exceptions of IMR (28 by 2019) and maternal mortality (100 by 2020). The goal for the total fertility rate (children per woman) is 2.1 by 2025; the figure is already 2.2, according to NFHS 2015-16. The largest democracy has thus deliberately chosen to go slow and stay behind its neighbours, each of whom has been experiencing its own set of socio-political problems. This is clearly linked to the pragmatic excitement of policymakers with the “robust health industry” and its double-digit growth rates as being more critical for economic growth (even if jobless) than the health and increased access to services for the less privileged—below, on, and just above the poverty line. The unmentioned contextual shift of state subsidies towards the private sector and the restricted financing of public sector are bound to further the bias against the marginalised and slow the pace of improvements in overall health indicators. This pragmatism has no doubt contributed to improved fiscal capability but will that now transform into a vision that assures “availability of free, comprehensive primary health care services, for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable, non-communicable and occupational diseases in the population”? Not really, as would appear from the substance of the policy document.

The current policy proposes a financial investment of 2.5 per cent of the GDP—not now but in 2025. In contrast, the High Level Expert Group of the Planning Commission (2012) had made a financial estimate of at least 2.5 per cent of the GDP by the end of the 12th Plan and 3 per cent by 2022. The Draft NHP 2015, to achieve the core principles of equity, universality and affordability, had set three major objectives for the public sector: (a) expanding preventive, promotive, curative, palliative and rehabilitative services to improve population health status; (b) assuring universal availability of free, comprehensive primary health care services; and (c) significantly reducing out-of-pocket expenditure by ensuring affordable secondary and tertiary care services. Unlike the present document, “taking into account the financial capacity of the country”, it set minimalist fiscal targets of public health expenditure of 2.5 per cent of the GDP: 40 per cent of this, or 1 per cent of the GDP, would come from the “Central expenditures”. However, the Centre’s annual budgets over the last three years have not managed to reach even one-third of this target. They have increased investments in insurance, clinical and tertiary care, but have neglected the National Rural Health Mission (NRHM), the Integrated Child Development Scheme (ICDS) and food subsidies. The Budget for 2017-18, while restrained in its deductions of NRHM funds, invests heavily in tertiary care at the cost of primary health care 3. The robust health care industry feeds on the wealth of the growing middle class and the elite, 1 per cent of whom control 53 per cent of the wealth in the country 4, while the Socio-Economic and Caste Census (2011) shows that 73 per cent of all households live in rural areas, of which 74 per cent earn less than Rs.5,000 a month, 56 per cent are landless, and 51 per cent work as casual manual labourers. And when urban poverty is further entrenched with smart cities focussing on the most developed areas of the chosen cities, how are we to understand the materialisation of an undefined free “comprehensive primary health care”?

Primary health care

A look at the policy perspective on organisation of primary health care throws light on this question. Firstly, state-led primary health care or universal health coverage as defined by the World Health Organisation (WHO) is not the framework for NHP 2017. For most democratic states these have been the guiding spirit. Secondly, the role of the government is visualised as one that shapes, finances, assures, strengthens and regulates, rather than as the prime provider. Thirdly, an unrealistic divide is created between universal health coverage and the public health care system. The former is confined to tertiary and secondary health care provisioning, and the latter to state-run facilities, which, in any case, are advised to make generous use of private providers. Though “reinforcing trust in the public health care system” is a stated objective, the required resources and timelines to achieve it remain unstated; priority of service is given to tertiary and secondary care under both universal health coverage and the public health care system.

Fourthly, “strategic purchase” from non-governmental institutions, which logically should be based on an assessment of gaps, weaknesses or absence of public facilities in the timelines laid out for strengthening them, is simply seen as “where the government acts as a single payer”. In other words, there is nothing strategic about it except for being a general remedy for any shortfall in service. The policy hopes that it “would create a demand for private health care sector” which would align with public health goals. Simultaneously, it is envisaged that strategic purchase of non-governmental secondary and tertiary care services is “a short-term measure” and would be replaced by public institutions over time. The two assumptions are no doubt contradictory and wasteful.

The primary health centres (PHCs) that move from selective to comprehensive services will be called “wellness centres” but the comprehensive package adds only screening for non-communicable diseases (NCDs) and palliative, rehabilitative and geriatric care. What happens to its curative, promotive and preventive functions, the national programmes and their integration into the working of PHCs and the improvements required at this level remains unstated.

Until now, the entire complexity of primary health care consisted of PHCs fully supported by secondary-level clinical and public health facilities and tertiary institutions and it was conceived as a basic pyramid of district health services. The current policy leaves primary health care centres in the lurch but uses the old frame of zonal, regional and apex institutions only for tertiary care. This surgical separation of clinical and public health services is nothing short of tragic. The overemphasis on private partnerships and collaboration at all levels and in all areas of training, education and services provisioning and procurement, in fact, leads the policy to even hand out primary care to private and voluntary institutions through incentivising the sector in every way possible. The hope of a state-led integrated health system is thus put to rest.

Inadequate diets

The national programmes remain independent entities and, in the name of promoting health through tackling the social determinants of health, programmes such as Swachh Bharat Abhiyan address healthy diets and regular exercises; tobacco, alcohol and substance abuse; traffic accidents, gender violence, safety in the workplace, and indoor and outdoor air pollution. However, access to adequate food, wages, work, public transport and education are not considered relevant.

Malnutrition, especially micronutrient deficiencies and not under-nutrition, is seen as the central issue when the reality is that, divided into five monthly per capita expenditure quintiles, 90 per cent in the poorest quintile to 38 per cent in the richest do not get the prescribed minimum calories 5 and the quality of diets of the lower three quintiles has deteriorated over time. This lapse in policy is critical given that the importance of adequate diets in the control of tuberculosis (and other infections and MCH) has been underlined by many concerned experts 6. This aggressive promotion of the private sector leaves little space to lay guidelines for incentivising and creating timelines for filling gaps in the state-led district primary care system, the backbone of primary health services, or reinforcing its human resources.

Even the paramedical workers are seen primarily as the technical support staff for tertiary and secondary care but little attention is paid to auxiliary nurse midwives and multipurpose workers. The need for more medical colleges is emphasised and its critical areas such as admission process, pedagogic styles and seats available for post-graduation are considered, but there is total silence on the quality of education in private medical colleges. Integration of district hospitals with the new colleges is rationalised by a need for realistic training but the limits it imposes on the quality of education and the two kinds of medical schools it might create is not considered a problem.

There are guidelines that have waited in the queue for years, such as making free drugs available at public hospitals, attention to occupational health, disease surveillance, male sterilisation and regular services in the place of camps, and plurality of services.

However, the closure of the National Nutrition Monitoring Bureau by the government, the past experiences in each of these areas, the paucity of finances and the present priorities infuse little confidence in their materialisation. This is especially so as the policy, out of fear of legal implications, rejects making health services a justiciable right, using the logic that health is a state subject, or that given the multiple determinants of health and types and levels of health care the country is not ready for such a law. Behind this smokescreen, even emergency care is not seen as a fundamental right although it is closely linked to Article 21 of the Constitution that grants right to life as fundamental.

The apex court in India has interpreted the right to health as part of Article 21 by limiting it to emergency medical care ( Paschim Baga Khet Mazoor Samiti vs State of West Bengal) and primary health care ( Mahendra Pratap Singh vs State of Orissa). The document ignores this and leaves us wondering about the nature of democracy in its largest abode.

Imrana Qadeer is Distinguished Professor, Council for Social Development, New Delhi.

Arathi PM is Assistant Professor, Council for Social Development, New Delhi.

Footnotes:

1. Mahbub ul Haq Centre, Human Development in South Asia 2015, http://mhhdc.org/wp-content/themes/mhdc/reports/changed_report_2015.pdf accessed on 21.3.2017

2. Sakthivel Selvaraj, Anup K Karan and Indranil Mukhopadhyay 2014: Publicly-Financed Health Insurance Schemes in India: How effective are they in providing Financial Risk Protection? Social Development Report, Council for Social Development, editor I .Qadeer, OUP, New Delhi.

3. Qadeer.I, Ghosh SM, 2017: An Inadequate and Misdirected Health Budget, https://thewire.in/106575/health-budget-2017-18/

4. http://www.livemint.com/Money/VL5yuBxydKzZHMetfC97HL/Richest-1-own-53-of-Indias-wealth.html accessed on 23.3.2017

5. Qadeer. I, Ghosh SM, Arathi PM, 2016: India’s Declining Calories: Development or Distress? Social Change, 46 (1) , pp 1-26.

6. Bhargava A. 2016: Undernutrition, nutritionally acquired immunodeficiency and tuberculosis Editorial, BMJ;355:i5407 doi: 10.1136/bmj.i5407 (Published 12 October 2016) page 1 of 2

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