Ills of a draft policy

Draft National Health Policy mentions the ills that characterise the country's public health care system but fails to provide satisfactory solutions.

"The current annual per capita public health expenditure in the country is no more than Rs. 160."

- from Draft National Health Policy-2001.

THE Draft National Health Policy, which was released in August, has come under fire from several quarters. The first salvo came from the Jana Swasthya Abhiyan (JSA), an organisation dealing with public health issues. It has been close to 18 years since the last health policy was framed in 1983. Therefore the decision of the Union Ministry for Health and Family Welfare to frame a health policy document went largely unopposed though there were complaints of lack of consultation prior to the drafting stage.

Overall the draft policy, while emphasising federal principles and decentralisation in terms of public health and the role of State governments, is silent on how to remedy the ills of the public health care system. The blueprint for the system lacks the kind of vision that would ensure that marginalised populations have access to health care in the future. An assessment of the public health infrastructure has to be more than just platitudes and should take forward the objective of making equitable health for all a reality. The draft policy acknowledges some of the possible ills in the health care system. However, it fails in its basic function of including the fiscally starved State governments as well as people working in the area of community health in the task of addressing issues of public health.

The Ministry put the draft proposal on its Website and invited comments from the various forums concerned with health-related issues. The JSA, an umbrella organisation of 18 national networks dealing with community health and people's science, responded with a comprehensive critique of the draft policy. While welcoming the government's initiative, the JSA has drafted an alternative policy document which incorporates some valuable suggestions but excludes aspects that, in the JSA's opinion, misrepresent the situation. Members of the JSA met recently to review the policy document within the framework of the people's health charter evolved at a "national people's health assembly" held in Kolkata in December 2000. The health assembly was essentially a reiteration of the commitment of "Health for all - Now". The people's health charter included, among other things, a 'basic needs' approach and the need to confront the commercialisation of medical education and health care, issues that the people's health assembly expected the national health policy to address.

While the draft makes several candid admissions - for instance, it acknowledges the high levels of morbidity and mortality and the poor functioning and severe underfunding of health services - it is silent about a strategy to make comprehensive health care available to all. It expresses concern about the impact of Trade-Related aspects of Intellectual Property Rights (TRIPS) and globalisation policies on health and recommends a higher level of expenditure on primary health care; however, it lacks a comprehensive analysis of why National Health Policy-1983 failed. One of the primary premises of the 1983 policy was that India is committed to attaining the goal of "Health for All by the Year 2000 A.D." through the universal provision of comprehensive primary health care services. The words 'comprehensive' and 'universal' are missing in the Draft Health Policy of 2001.

The historic Alma Ata declaration, in which many governments have committed themselves to a "Health for All" strategy, is not even mentioned in the 2001 document. Government representatives from over 100 countries attended the World Health Assembly at Alma Ata, Kazakhstan, in 1978 and committed themselves to making comprehensive health care available to everybody, highlighted primary health care as a priority area, and acknowledged that in the matter of health care there were certain socio-economic determinants too that had to be dealt with. It was for the first time that health was not treated as a biomedical issue, said Amit Sen Gupta of the All India People's Science Network, one of the groups in the JSA. The 1983 policy had initiated a phased, time-bound programme to set up a well-dispersed network of comprehensive primary health care services, among other things.

Another area where the Union government has been criticised is its inability to involve the State governments in the drafting of the document. Even the Central Council of Health and Family Welfare, an apex body of representatives from all State Health Departments, was not consulted. Also, the one month that was given to elicit comments and suggestions on the draft was deemed inadequate, especially in view of the fact that the draft policy remained in the drafting stage for three years. Public and community health organisations like the JSA believe that the government acted in a hurry to secure approval for the draft, even without going through a consultative process with the State governments.

THE policy document brings to light several unpalatable features, such as the unacceptably high morbidity and mortality levels, the resurgence of malaria, especially of the deadly P-Falciparum type, and the dominant presence of tuberculosis and the growing of drug resistance in the types of infection prevalent in the country. In addition, water-borne diseases such as gastroenteritis, cholera and some forms of Hepatitis continue to contribute to the high levels of morbidity among the population. While the concern and facts are genuine enough, the remedies seem lopsided. For one, it blames the failure of the public health system for the unsatisfactory health indices. The draft policy admits that the investment in public health over the years has been comparatively low and has declined as a percentage of Gross Domestic Product to 0.9 per cent in 1999. The linkages between policy and ground realities are missing. The Central budgetary allocation as a percentage of the total Central Budget over a 10-year period has been stagnant at 1.3 per cent while in the States it declined from 7 to 5.5 per cent. Given these figures, the current annual per capita health expenditure works out to a paltry Rs.160.

The need for the universalisation of public health services has been substituted by a new concern - decentralisation of public health services. The intent, as is evident in the sub-section "Delivery of national public health programmes" in the draft policy, is a decentralised public health machinery. The obsession with vertically structured programmes is evident in the draft, which states categorically that the role of the Central government in designing broad-based public health initiatives will continue especially as the Central government will be responsible for funding additional public health services over a period of time. Interestingly, the policy arrogates to the Central government the areas of technical and managerial expertise for designing large-span public health programmes. The JSA has been especially critical of this overwhelming role of the government as it believes that designing programmes should be the primary responsibility of the State governments.

The Centre, if anything, should play a coordinating role and provide technical and financial support wherever necessary. The JSA, in its alternative draft policy, a copy of which has been submitted to Union Minister for Health and Family Welfare C.P. Thakur, suggests that in the long run it is a more sustainable option to integrate disease control strategies within the decentralised primary health care network, which should be linked to adequate secondary and tertiary support services.

On the section dealing with the public health infrastructure, JSA draft suggests that the primary health centres (PHCs) have been reduced to centres for family planning aid and immunisation. It is this situation, coupled with inadequate facilities, that has resulted in less than 20 per cent of the population seeking out-patient department services and less than 45 per cent availing itself of treatment as in-patients in public hospitals. The draft policy, while outlining the poor infrastructure facilities in public hospitals, including the shortage of medical and paramedical personnel, glosses over the relentless pursuit of "family planning and immunisation" goals by the PHCs. This aspect is mentioned in the alternative draft.

The draft policy suggests the need for specialists in "public health" and "family medicine" and agrees that the current curricula for graduate/post-graduate medical degrees are outdated and unrelated to contemporary community needs. "Contemporary needs" should be spelt out, given the ambiguity of the phrase. The JSA draft contends that the long-standing objective of the health movement has been to limit specialisation and re-orient undergraduate education to equip doctors to address the health needs of the common people. However, by suggesting the introduction of another course in family medicine and even specialisation in public health, the draft policy inadvertently encourages the craze for specialisation.

The draft policy is silent on the issue of private medical colleges and the need to regulate them. Similarly, on the question of medical research, it focusses more attention on frontier areas of research, calling them the thrust areas. This, the JSA draft observes, does not take into account the need to initiate and sustain research in public health. There is also no mention of the need to regulate medical research and develop ethical criteria.

The effect of TRIPS is discussed in the context of a possible impact on drug prices but there is no mention of any such impact on medical research. While lamenting that investment in public health has been comparatively low, the draft policy fails even to record that such investment as a percentage of health expenditure was perhaps the lowest in the world and that the country has the world's most privatised health system. The policy's prescription to raise the current health expenditure from 0.9 per cent of GDP to 2 per cent in 2010 fell drastically short of the health movement's demand that the expenditure should be nothing less than 5 per cent of GDP.

The JSA has objected to what it calls "prescriptions for further privatisation" of an already highly privatised health care system. The proposal in the draft policy to levy "user fees" at public hospitals, so that those who can afford to should be made to pay, would only serve to drive out the poorer sections. The government wants to shift the burden on the secondary and tertiary sectors while strengthening the primary health care sector by increased resource allocation.

The cursory mention of mental health given the tragic events at Erwadi in Tamil Nadu involving the death of 28 mental patients (Frontline, August 31, 2001), the casual treatment of women's health and the total absence of any mention of children's health have surprised activists in the health movement. The socio-cultural and economic factors that determine access to health care, particularly by women, are glossed over in the draft policy. The JSA's draft, however, contends that women's health issues go way beyond problems related to "child bearing" and the "reproductive tract" and that the entire gamut of problems faced in a patriarchal society has to be considered. Given the fact that more than half the children under five in India are malnourished, it is surprising that questions of their nutrition and subsequent well-being do not find even a fleeting mention in the draft. On the other hand, the policy draft does re-emphasise the connection between population stabilisation and improved health indices. It states: "The synchronised implementation of these two policies - National Population Policy-2000 and National Health Policy - 2001 - will be the very cornerstone of any national structural plan to improve the health standards in the country."

What is required is a paradigm shift, a shift away from the apparent panaceas of population stabilisation and private sector participation in the health sector. But the language continues to be the same. It is couched in platitudes with little or minimal emphasis on rejuvenating, strengthening and making effective the primary health care sector. This, according to the draft policy, is closely linked with the quality of public health services, which is in turn reflected in improved public health indices.