Tag: National Health Policy

Budget Decrease or Near-Stagnation in Some Health Sector Domains Surprises Experts

‘COVID-19 was a stark reminder that research needed more push. What we have done is otherwise,”

This article was originally published on The Wire Science, our website dedicated to science, health and environment reportage and analysis. Follow, read and share.

New Delhi: The health sector has been allocated only Rs 200 crore more this year as compared to the revised estimate of last year’s budget. This year the outlay for the Union Ministry of Health and Family Welfare stands at Rs 86,200 crore.

Indranil Mukhopadhyay, a health economist who teaches at O.P. Jindal University, estimated that including inflation the allocation to health this year actually declined by 7% compared to what had been allocated in last year’s budget (revised estimate).

Experts told The Wire Science that this was a clear indication that the Union government is no longer focusing on the health sector as such and is shifting its attention towards others.

K. Srinath Reddy, president of the Public Health Foundation of India, said, “The budget this year clearly seems to suggest that the country is now in post-COVID phase. And the government wants to divert resources to economic development”.

According to him, the health sector did get as much allocation as was expected – but what has experts surprised is either the decrease or the near-stagnation in some key domains of the health sector.

Indian Council of Medical Research (ICMR), the government’s central decision-making body on COVID-19 and the agency steering the research response to the pandemic, didn’t get any hike this year. It was allocated Rs 2,133.07 crore, as per the revised estimate for 2021-22. This year, its outlay stands at Rs 2,198 crore. In fact, ICMR’s allocation this year is Rs 150 crore lower than last year’s budget estimate.

“COVID-19 was a stark reminder that research needed more push. What we have done is otherwise,” Mukhopadhyay said.

Also read: Broken Promise: PM Cares Fund Hasn’t Given Rs 100 Crore To Develop COVID Vaccines

However, the budget for health research has been increased under a new scheme called ‘Prime Minister’s Ayushman Bharat Health Infrastructure Mission’, or PM-ABHIM, launched last year. The research domain of this scheme has an outlay of Rs 690 crore, compared to Rs 140 crore spent last year (revised estimate).

The finance ministry has also only marginally increased the outlay of the National Health Mission (NHM). The NHM is an umbrella programme for the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM), and caters to the health needs of the majority of the Indian population. The NHM received Rs 37,000 crore this year versus Rs 34,447.14 crore last year (revised estimate).

“I expected a bigger increase, especially because NUHM has hardly been able to expand to tier-2 and tier-3 cities,” Reddy said. He added that even NRHM deserved more because the country is perennially short of human resources vis-à-vis healthcare and medicine in rural areas.

The Union government was also supposed to build 1.5 lakh health and wellness care centres by 2022. Though neither this year’s Economic Survey nor the Union budget have said how many of these centres have been built, Reddy said that even if the buildings are there, they will serve no purpose given the scarcity of mid-level healthcare workers. This, the demand for more money for NRHM.

There were two domains that did receive sharp increases. One was the National Digital Health Mission. Prime Minister Narendra Modi announced it in 2020 with the aim to provide a system for digital healthcare. According to this scheme, a health ID is to be issued to every citizen, linked to a health account containing details of tests, disease profiles, doctors visited, medicines taken and the history of diagnoses.

This year, the government has allocated NDHM Rs 15,163.22 crore – which is about Rs 1,000 crore more than last year’s revised estimate. “When the main programmes, which provide quality healthcare, are sinking, the government wants to shift focus on digital,” Mukhopadhyay said.

The other domain that received a big hike was the government’s flagship ‘Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana’ (PMJAY) scheme. The budget estimate for 2021-22 for the scheme was Rs 6,400 crore. However, the allocation was revised through the year to just Rs 3,199 crore, or half. PMJAY’s actual spending in 2019-20 was also Rs 3,200 crore. These are signs that the scheme has been underperforming.

Yet the government has again allocated PMJAY Rs 6,412 crore.

Why would the allocation be increased for a scheme that has not been able to utilise the money originally allocated previously? “Maybe post-COVID, the government thinks that the scheme will perform better,” Reddy said.

Also read: Under Ayushman Bharat, Poor Patients Are Not Going Cashless but With Less Cash

The government also allocated Rs 5,000 crore for the COVID-19 vaccination programme in this year’s budget. Last year, it had allocated Rs 39,000 crore, according to the revised estimate. The allocation this year, the experts said, was by and large sufficient since a large chunk of the population (including 75% of eligible adults) has already been vaccinated.

The government last year announced the ‘PM Atma Nirbhar Swasth Bharat Yojana’ with an outlay of Rs 64,180 crore to be spent over six years. The plan was to improve primary, secondary and tertiary health centres and create an ecosystem to detect and cure new and emerging diseases. The scheme has received another Rs 4,000 crore in the current budget.

“On the face of it, the allocation does not look bad,” Reddy said. “But when you consider that more than Rs 64,000 has to be spent in the six years, the amount allocated this year does not look enough.”

According to this year’s Economic Survey, India has achieved the goal of spending 2.1% of its GDP on health – but experts called this claim a “farce” because this included the budget not just for the health ministry but also the water and sanitation ministries.

The milestone is important because the National Health Policy 2017 envisages spending 2.5% of GDP on health. Does this year’s budget push India towards achieving this goal? Both experts, Reddy and Mukhopadhyay, replied in the negative. Going by the prevailing trends, they said, India might not even be close.

The Good, the Bad and the Impossible of the 2020 Union Health Budget

The total allocations increased modestly from Rs 62,659 crore in last year’s budget to Rs 65,012 crore in the current year.

The 2020 Union budget, presented by finance minister Nirmala Sitharaman, did not cut India’s health budget. The total allocations increased modestly from Rs 62,659 crore in last year’s budget to Rs 65,012 crore in the current year. However, in real terms and accounting for purchasing power parity, the allocations remain more or less the same.

This scenario has three implications for India’s public healthcare programmes, classifiable as the impossible, the bad and the good (if only to end on a positive note).

The Impossible – The National Health Policy had targeted increasing the health budget to 2.5% of GDP by 2025. The current health budget (Union and state together) languishes at about 1% of GDP. Increasing it by 2.5x in the next five years would require, very simply speaking, at least a 25% increase in allocations on a year-on-year basis. But with no real increase in allocations this year, it seems the 2.5% goal will be impossible.

The Bad – 2020 is being celebrated as the year of nurses and midwives around the world, thanks to a call by the World Health Organisation. However, the 2020 budget has decreased the allocations for the heads related to the development and improvement of nursing care. Specifically – from Rs 50 crore to Rs 16 crore for ‘Development of Nursing Services’; from Rs 41 crore to Rs 35 crore for ‘Regional Institute of Nursing and Paramedical Science’ (in Aizawl); and from Rs 32 crore to zero for ‘Upgradation of Nursing Services’. Together, these cuts will be detrimental to the development of India’s nursing facilities and human resources, and is bound to affect the access to and quality of healthcare in the country.

A budget head called ‘Prime Minister Development Plan for Jammu and Kashmir’ (PMDP-J&K) had received Rs 273 crore in 2018-2019, and which was slashed to Rs 63 crore in 2019-2020. For 2020-2021, however, there appears to be no allocations under this head – or indeed under any other health-related heads for J&K. Since the Centre read down Article 370 of the Constitution in August 2019, the special allocations within health and other sectors were bound to be removed. However, it isn’t clear what these funds have been replaced with, and it seems unlikely that state-level allocations under the National Health Mission (NHM) will be increased for J&K to compensate. A sudden drop in health funding can have significant implications for a region still recovering from significant financial losses due to the protracted internet shutdown.

Ayushman Bharat, the flagship programme of the Union health ministry under Bharatiya Janata Party rule, has two components: health and wellness centres (HWCs) to provide primary health care and the Pradhan Mantri Jan Arogya Yojana (PMJAY) for insurance for secondary and tertiary care. The allocation for rural HWCs hasn’t been increased. According to the NHM, 29,000 HWCs were set up in 2019. To achieve the goal of 1.5 lakh HWCs, some 40,000 more HWCs will need to be set up every year hence. But stagnating funding means it will be impossible to set these up as well as run the existing HWCs. Ergo, the future of primary healthcare in India is in trouble. Rural HWCs are included under the budget head called ‘National Rural Health Mission’, which includes funding for strengthening other components of public health systems in rural areas. This budget head hasn’t had a hike since last year either.

The other – and more celebrated – component of Ayushman Bharat is PMJAY. Of about 12 crore people who have received cards till date, 81 lakh have sought hospitalisation benefits under the scheme. This year, the government has allotted Rs 6,400 crore for PMJAY, the same as last year – obvious insufficient since the number of people seeking coverage is bound to increase. Sitharaman also announced that the PMJAY scheme will be expanded by setting up more hospitals in India’s tier II and III cities through a public-private-partnership. Proceeds from taxes on medical devices are to be used to develop hospitals, as a viability gap funding.

The last piece of bad news: Autonomous institutes such as the All India Institute of Medical Sciences (AIIMS), New Delhi, the Postgraduate Institute of Medical Education and Research, Chandigarh, and the National Institute of Mental Health and Neurological Sciences (NIMHANS), Bengaluru, provide cutting edge research and teaching. Their funds have been cut in the current year. Only time will tell if they will be able to maintain the quality and scope of services.

Finally, the good news. The government has substantially increased allocation for the 23 new AIIMS it announced last year, under the oddly named ‘Pradhan Mantri Swasthya Suraksha Yojana’ (15 are operational and eight are under development), and to set up medical colleges in district hospitals. These measures should help improve the quality of medical education in India.

Pavitra Mohan is co-founder, Basic Health Care Services, and director, Health Services, Aajeevika Bureau.

Informal Workers Are Bearing the Cost of Inadequate Healthcare Investment

The Indian state must commit to at least some semblance of healthcare for all.

Social security for informal workers has taken centre-stage due to recent budget announcements. While some of the announcements are admirable – such as monthly pensions for workers over 60 – a major gap in social security for all informal workers, and for all Indian citizens, is healthcare.

The acting finance minister had reiterated the government’s commitment to universal healthcare as part of his budget announcements, but this has not been adequately reflected in the latest budget. We are constantly reminded of how far we are from bridging the healthcare divide and moving towards universal healthcare (UHC) or universal health assurance (UHA) from the everyday experiences of Indian citizens. The worst-hit are the 42 crore informal workers in the country, particularly women.

Savitaben is a traditional midwife in Vichchiya, an hour from Ahmedabad. She is a founder-member of the Lok Swasthya SEWA Health Cooperative. Her husband, Jivanbhai, was the village barber and helped Savitaben and others set up the cooperative. Years ago, Jivanbhai had a heart attack and was admitted to a private hospital nearby. Savitaben scraped together their meagre resources in addition to borrowing money to pay Rs 2.5 lakh – the total cost of care.

In January 2019, my mother slipped and fell in Kumaon. She fractured two vertebra and several ribs. Providing her with immediate medical care was a challenge. The nearest hospital was two hours away and diagnostic facilities were limited: she was told she had no fracture at all! Accidental injuries due to the terrain are common, and the emergency services required are often too far to reach in time.

Transporting my mother to New Delhi for tertiary care was very difficult and required a private ambulance, a train journey and the support of many railway workers. Once in the city, she received experienced care, paid for by her insurance. Such recent experiences drive home the substantial divide between those who can afford care and those who cannot. My mother had an accident in a remote village but is already up and walking due to quality care covered by insurance. Savitaben’s family remained in debt for ten years.

While the National Health Policy (NHP) 2017 and the Pradhan Mantri Jan Arogya Yojana (PMJAY) both address healthcare, their implementation is slow. Piecemeal initiatives are not enough. A revamping of our entire healthcare architecture is needed. We need a holistic approach to major public health reforms with increased investment – at least 2.5% of the GDP, for a start.

Also read: With Reduced Access to Healthcare, Demonetisation Deaths Are Likely Far Higher Than Reported

The increased investment must be in primary healthcare, including preventive health action, health literacy and early detection. We need an army of local, front-line health workers: more ASHAs trained as health workers, paramedics, physiotherapists, GPs and technicians. The often-quoted High Level Expert Group (HLEG) estimated that at least six lakh new jobs would need to be created for this.

Rather than struggle to attract talent to rural areas, why not have health personnel trained locally and given the responsibility for their communities? One of the major findings in our own interactions with informal workers is that health systems and procedures must be tailored to local livelihoods, including the location and hours of health centres, and training.

To prioritise local needs and ensure that women’s concerns in particular are addressed, these may be discussed in gram sabhas, village health sanitation and nutrition committees (VHSNCs) and mahila arogya samitis (MASs). A bottom-up push for UHC/UHA, together with a policy change and investment push from the top, will move us towards bridging the gap in healthcare.

After creating local health centres staffed by community members, ensuring these have proper facilities and diagnostic services is key. If we do not invest in quality diagnostic facilities near where people live, we will lose valuable time in treating patients – especially in emergencies. This will add to already overcrowded secondary and tertiary care facilities. Linking medical colleges to the district hospital, to help staff local hospitals and strengthen their infrastructure, was another recommendation of the HLEG report on UHC and has been taken up by the NHP 2017.

All primary healthcare and diagnostic services should be free of cost, as promised in the NHP 2017. Indian states need to develop systems for free medicine similar to the Tamil Nadu state government. Most government primary healthcare centres (PHCs) and hospitals suffer from limited medicine stock and quality.  Most Indians still pay for medicines themselves: about Rs 70 for every Rs 100 spent on healthcare, leading to still unacceptable levels of out-of-pocket expenditure.

Also read: Without Data Security and Privacy Laws, Medical Records in India Are Highly Vulnerable

More holistically, we must invest in the social determinants of health: water and sanitation, nutrition, employment, early childhood care and so on. The recent Swachh Bharat Mission addresses several of these, but the government and private practitioners must create an environment for all citizens to learn about and safeguard their own health.

Finally, financial protection to prevent catastrophic health expenditure and crippling debt must be extended to all Indians. PMJAY is a start but it only covers 40% of the population and will not prevent the remaining 60% from falling into debt from expenditure on health.  There must be a system of screening at the primary level to prevent unnecessary hospitalisations at the secondary and tertiary care levels. Otherwise, we can expect escalating healthcare costs at the expense of primary healthcare.

Why our country never invested in healthcare – especially preventive primary healthcare – is a question that looms large. Most informal workers, and the majority of our citizens, do not press for UHC as a right and the responsibility of the state; they choose a mix of public and private care where available. But the Indian state must commit to at least some semblance of healthcare for all, matched with adequate investments in public health.

Mirai Chatterjee is director, SEWA Social Security.

India Racing to Apply for Nine Million Courses of Elephantiasis Drugs by July

Nine million courses is all that is left from Merck’s donation of 100 million courses, the rest of which have already been requested for and taken by other countries.

New Delhi: With an estimated 31 million people who are infected with what is known as ‘elephant’s foot’ in the country, India has committed to eliminate elephantiasis by 2020. Patients could be benefitted by the drug ivermectin. There are nine million free courses of ivermectin left in pharma company Merck’s donation programme for this year.

But India is short on time and has to race to apply for these courses by the end of this month. Nine million courses is all that is left from Merck’s donation of 100 million courses, the rest of which have already been requested for and taken by other countries.

If India applies in time, the full tranche (27 million tablets for the nine million courses) could arrive by December. If India misses the deadline, India will have to apply for next year’s donation programme by Merck. All of this will slow down India’s efforts to eradicate the disease, by 2020.

Elephantiasis of leg due to filariasis. Credit: Wikimedia Commons

Elephantiasis of leg due to filariasis. Credit: Wikimedia Commons

“It takes time. We had a preliminary discussion on this on June 15. If things work out in time, we can apply and the first tranche could come by August, the rest can come by December. Logistics, packing, shipping, all of this takes time. But we have to clear many regulatory issues for Merck first,” said a health ministry official.

All of this notwithstanding, India went ahead and announced the ‘Accelerated plan for elimination of lymphatic filariasis’ on June 13. Copies of the plan have not been made public or given to the press but The Wire has reviewed a copy of it.

The new medical approach to elephantiasis

Lymphatic filariasis, or elephantiasis (as it is commonly known) is considered a neglected tropical disease. It manifests as massive disfigurement and disability of body parts like the leg, hand and scrotum. It is a parasitic infection which is triggered by mosquito bites.

For years, the medical approach to it was to administer albendazole, either by itself, or in combination with diethylcarbamazine citrate or ivermectin. Now, new research has shown that it is, in fact, a triple-drug therapy of well-known drugs – albendazole, diethylcarbamazine citrate and ivermectin – that could do the trick of stopping the spread of infection. All of these drugs have been known and used for decades. It is the combination of these drugs which has been the breakthrough, in the treatment of elephantiasis.

India receives all three drugs in this regimen, for free, by donation. India’s role is to ensure that the drugs are requested in time and that India clears other regulatory hurdles for the companies donating the drugs. Apart from Merck’s ivermectin, GlaxoSmithKline is donating albendazole to India currently.

The data on the triple-drug therapy has come from recently processed field studies in India, Haiti, Indonesia and Papua New Guinea. Large randomised community studies were conducted in these countries and they found that this triple-drug combination is “as safe as the two drug regimens when used in the mass drug administration.”

In November, the WHO recommended this triple-drug therapy to eliminate elephantiasis. The specifics of this new recommendation have been published in their new guidelines on the disease.

“This new regimen will help improve programmatic impact and lead to the ultimate elimination of lymphatic filariasis in many regions where millions of people are at risk of contracting the disease,” said Dr Soumya Swaminathan, deputy director general of the WHO. She was herself involved in the study, in her earlier role as director general of the Indian Council of Medical Research.

What regulatory problems may slow down the entry of ivermectin?

In 2015, Satoshi Omura and William Campbell were awarded the Nobel prize in medicine for their work on a number of drugs, including ivermectin. The Nobel committee said that ivermectin’s importance was “immeasurable” in treating the health of people in the poorest countries.

These two scientists developed this drug in the late 1970s.

In 1987, Merck partnered with the WHO to distribute this drug in unlimited quantities for free, through their donation programme. In over three decades of this donation, Merck has distributed over two million treatments of this drug.

In dealing with so many countries for this donation, Merck asks countries to simply request for the drug in time and remove regulatory hurdles for the company.

India is currently trying to work fast to do both of these things.

“One formality that needs to be worked out is the question of tax. Merck has said it is a donation and they will not be willing to pay tax. We have to work on that. Secondly, we have to get regulatory clearances from the drug controller. We have applied,” the official said.

The official also said that the ministry is confident of this happening in time. “We have already been getting albendazole which is widely used for deworming, on the same donation mode and without tax implications for the company. Secondly, ivermectin is not a new drug. Eight or nine brands are already approved by the drug controller.”

India’s goals on eliminating lymphatic filariasis have changed several times – The 2002 National Health Policy had fixed 2015 as the goal. This was revised to 2017, even while the global goal at the time was 2020. As recently as March 2017, government officials were saying this target would be achieved in endemic districts at least. India has now changed this to 2020.

If India misses the target on eliminating lymphatic filariasis, it also weighs the world’s burden down – India has 39% of the world’s population at risk of the disease. It is endemic to 256 districts in India.

Budget 2018: India’s Healthcare System Needs More Money and an Urgent Overhaul

This is the last full budget of the present government and the last opportunity for it to demonstrate its commitment to India’s health and nutrition.

This is the last full budget of the present government and the last opportunity for it to demonstrate its commitment to India’s health and nutrition.

The deaths of children in a public hospital in Gorakhpur due to alleged disruption of oxygen supply highlighted the systemic failures in public health provision. Credit: PTI

Slow improvements in basic indicators of maternal and child mortality, double burden of communicable as well as non-communicable diseases, high out-of-pocket expenditure, a failing public sector and heavily commercialised private sector characterise the healthcare crisis in India.

The year 2017 saw a number of incidents in the health sector across the country which highlight each of these issues.

While the deaths of children in a public hospital in Gorakhpur due to alleged disruption of oxygen supply highlighted the systemic failures in public health provision, the cases of excessive billing and negligence in big corporate hospitals (e.g. the case of dengue death in Fortis Hospital, Gurugram) showed that the unregulated private sector is no solution to India’s healthcare problems. The protests against the NEET examination, mainly in Tamil Nadu, brought forth the complexities involved in ensuring a fair and inclusive system of medical education. On the other hand, the resistance to the Karnataka Private Medical Establishments Act (KPME) demonstrated the difficulty in regulating the private sector and the influence of doctors working in the private sector.

The list is long and endless, but what all of these point to is that the health sector in India needs serious overhaul and much greater attention.

Public spending on health

One of the central problems has been the low levels of public spending on health and as a result the poor access to affordable and good quality healthcare for the majority of India’s population. The public expenditure on health at about 1.2% of the GDP is amongst the lowest in the world. Public health facilities suffer from poor infrastructure and human resource inadequacies. For instance, according to the Rural Health Statistics 2017, 13% of the sanctioned health worker (female) posts and 37% of the health worker (male) posts remain vacant. Overall, only 11% of sub-centres and about 13% of primary health centres (PHCs) are functioning as per Indian Public Health Standards (IPHS). There is therefore an urgent need for more resources to be allocated for public healthcare along with measures to strengthen the delivery of health services.

The National Health Policy 2017 aims to “increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5 % by 2025”

Although it has already been reported that the health budget is not going to see a significant increase, it has to be noted that without a substantial enhancement in the allocations much of the needed reforms in healthcare provision will not be possible. Achieving this, requires not just an enhancement in the central budget but also increases in each of the state budgets as well. However, the central government can play an important role.

Further, it also needs to be recognised that a number of states currently do not even have the spending capacity (one big reason for this is also the lack of human resources) and therefore along with the increase in allocations, a number of steps need to be taken towards strengthening the public health system.

A linear projection based on current trends of health expenditure as a percentage of GDP shows that if the current trend continues, then health expenditure will only go up to 1.7% of GDP by 2025, while the national health policy aims to increase it to 2.5%.

High 0ut-of-pocket expenditures

63% of total health spending in India is out of pocket expenditure (OoPE) according to National Health Accounts, 2014-15. As a share of private spending, OoPE is almost 90%. Health expenditure can be catastrophic with one estimate suggesting that OoPE on health accounts for an addition of around seven percentage points to India’s poverty figures.

More recent data from National Family Health Survey (NFHS-4, 2015-16) also show the burden of health expenditure on people, with the average out of pocket cost of a delivery being close to Rs 8,000. The spending is quite high even in the case of public facilities where Rs 3,198 is spent on a delivery compared to Rs 16,522 in private facilities. The Janani Suraksha Yojana which provides a cash incentive of Rs 1,400 to poor women for institutional delivery does not even cover half the expenses that women have to bear. Going by previous budgets, it seems as if this government hopes to reduce out of pocket spending primarily through insurance schemes such as the Rashtriya Swasthya Bima Yojana (RSBY) although there is ample research now available which shows that RSBY has not contributing towards reducing OoPE. Currently, the coverage of insurance is also very low. NFHS-4 shows less than one-third (29%) of households have at least one member covered under health insurance or health scheme.

The high dependence on private healthcare is also because of the absence of accessible and good quality public provision. NFHS-4 data show that 55% of households do not generally use government health facilities. As reasons for the same, 45% of them state that there is no nearby facility and 48% feel that the quality of care in government facilities is poor.

Cost of inaction

Poor nutrition is the underlying cause for many health problems. Along with increasing health budgets and improving delivery of public health services, the government’s commitment of health for all also needs to be reflected in the budgets for nutrition interventions. One important new initiative in this regard is the Pradhan Mantri Matritva Vandana Yojana (PMMVY) which provides Rs 5000 cash benefit to pregnant and lactating women (PLW). This is supposed to be the scheme through which the entitlement of at least Rs. 6000 for PLW under the National Food Security Act (NFSA) is ensured. While the scheme itself is truncated, covering only the first live birth, it has been slow to take off with hardly any woman yet to have benefited from it.

Maternity entitlements serve multiple purposes including enabling women to exclusively breastfeed, an important nutritional input for young children. In India where more than 95% of women work in the informal sector, such a cash entitlement is the only maternity benefit available. It has been argued by many that restricting this to only one birth excludes the most vulnerable women. Further, the amount also needs to be pegged to minimum wages as well as include the principle of inflation indexing. The upcoming budget must make adequate allocations for the scheme so that it can cover all PLW and not just a small proportion.

Over the last few years, the central budget on other nutrition schemes such as the ICDS and school meals has been reducing with new cost sharing norms putting a greater burden of expenditure on these schemes on state governments. Both these schemes, especially the ICDS, are already under-funded and desperately need more resources. With the setting up the National Nutrition Mission and the announced increase in the unit costs for supplementary nutrition, the budget should reflect substantial increases in the allocations towards ICDS as well.

This is the last full budget of the present government and therefore also the last opportunity for it to demonstrate its commitment to the health and nutrition of people.

However, given the slowdown in growth and revenue receipts not matching expectations, the outlook for health and nutrition budgets is not very positive. Here, it has to be remembered that these expenditures must be looked at as investments with very high returns. Improved nutrition and health will contribute to a more productive workforce and hence higher national incomes in future.

According to a recent paper by Assocham and consultancy firm EY, India loses nearly 4% of GDP due to different forms of malnutrition. The delivery of health services also creates much needed employment opportunities. For instance, the Niti Aayog’s three-year action agenda states that according to a report by the National Skills Development Corporation, healthcare in India has the potential to generate an additional 7.5 million direct job opportunities by 2022.

Dipa Sinha teaches at School of Liberal Studies, Ambedkar University Delhi.

Why Primary Healthcare in India Needs a New Delivery Model

India has made reasonable progress in improving access to last-mile healthcare over the last decade. However, the improved access has not reached the 29 states equally.

India has made reasonable progress in improving access to last-mile healthcare over the last decade. However, the improved access has not reached the 29 states equally.

An auxiliary nurse midwife undergoes training at Bokarhatti in Palghar district. Credit: ITT

An auxiliary nurse midwife undergoes training at Bokarhatti in Palghar district. Credit: ITT

We met Sangita (name changed) at the crowded sub-district hospital in Jawhar in Maharashtra, which routinely sees about 200 out-patients every day. Her baby had been sick for a few days, and had developed skin rashes which worsened after a home-made ointment was administered by a local quack. Terrified of her child’s condition, she had to rush to the nearest hospital, about 20 km from her village.

But distance was not the only hurdle in getting basic healthcare for her child. After waiting for nearly two hours, she met the doctor who told her the child had a minor heat rash. While she felt relieved that her child’s condition was not serious, she was worried about the amount of money and time they had to spend to see a doctor. Her husband had lost a day’s wage, and they had spent almost Rs 100 to travel to the hospital.

Stories like Sangita’s are widely quoted and talked about as one of the key challenges in delivering primary healthcare to the remote populations in developing regions. In these regions, people living in the last-mile areas lack the most basic facilities required for human development and growth. Their villages are not connected by roads; they do not have access to reliable water or electricity supplies; mobile towers have not yet reached their villages; and access to primary healthcare, a fundamental right of every citizen, is severely missing in their lives, forcing families like Sangita’s to travel a long distance for medical treatment. These are villages of a few hundred or thousand people, which are too small for economies of scale to benefit them, and unfortunately, current programmes are heavily focused on higher levels of care.

Fixing the broken continuum of care

India has made reasonable progress in improving access to last-mile healthcare over the last decade. However, the improved access has not reached the 29 states equally. In addition, existing facilities, both public and private, face acute shortage of qualified personnel (fully trained doctors, lab technicians) as well as facilities and medical supplies.

An ANM treats patients at a Bokarhatti clinic in Palghar district. Credit: ITT

On the other side, auxiliary nurse midwives (ANMs) who are posted at sub-centres are clinically trained and qualified to treat ‘minor ailments’ and provide first aid. However, they remain grossly under-utilised, with their majority of their time dedicated to field-based data collection. The sub-centres are mostly non-operational due to the lack of facilities and clarity on services to be provided. In many cases, they end up being used to store medicines, or serve as living quarters for the ANMs.

What Sangita and her baby really needed was a primary healthcare clinic within a walking distance from their house. In the Indian healthcare system, these clinics are called sub-centres, typically catering to a population of about 5,000 people and with up to two ANMs and support staff. The ANM, when aided with simple, easy to use POC diagnostic tools, therapeutic devices and a simple mobile-based software to track patient data, can be effective tool to improve care delivery at the last mile.

Learnings from the field

Trying out one such integrated approach, the Institute for Transformative Technologies (ITT) is working with the Zila Parishad in Palghar district of Maharashtra, and regional partners. The approach combines technology, improved clinical protocols, and patient engagement at the last mile, and over the last few months been deployed in two sub-centres of Palghar.

ANM treating patients at Pavarpada clinic in Palghar district. Credit: ITT

At the centre of this model are the sub-centres, which function as spoke clinics, where the ANM is empowered with the best-in-class technology (a software platform to track patient data and point-of-care diagnostics), and standardised clinical protocols. PHCs, that are staffed with medical officers, serve as the hub for the sub-centres. The current pilot programme has been running in Jawhar block, Palghar district, with more than 300 consultations and 90% patient satisfaction rate recorded to date. There has also been a noticeable improvement (greater than 40% improvement in pre- and post-training test scores) in the ANM’s clinical skills, such as providing out-patient care for minor ailments, such as fevers, infections, ante-natal care etc.

As ITT continues to expand work across Palghar, we have identified a few key lessons. First, technology is a great enabler in changing people’s lives, but for it to be effective and result oriented, it needs the right delivery model with operational blueprints, training and clinical protocols. Second, for technology to be deployed for human development, an iterative, data-driven and user-centric approach is required. In our work, we have conducted multiple cycles of user-testing and research activities which help us identify challenges that rural healthcare providers and patients truly face. Without this, technology will be seen as the “enemy” that hinders them and adds to their burden.

The National Health Policy (2017) calls for upgradation for all 150,000 sub-centres in the country as ‘Health and Wellness Centres’ to provide improved primary care, with basic preventive, diagnostic, curative and referral facilities. As the required policies come through, it is time we define the right models to empower nurses and paramedics to deliver more at the last mile.

Krisha Mathur and her team are trying to create a financially sustainable healthcare model for the last mile in rural India. She is a senior manager at Institute for Transformative Technologies.

In 2017, India Was Caught Between Private Exploitation and Public Sector Callousness in Healthcare

Should the focus be on improving public health systems or should we instead strengthen and support the development of the private health systems?

Should the focus be on improving public health systems or should we instead strengthen and support the development of the private health systems?

The deaths of infants at the Ahmedabad Civil Hospital brought Gujarat’s healthcare system into question. Credit: Reuters

As we bid farewell to 2017, The Wire looks back at some of the markers of disruption that affected different spheres, from politics and economics to technology and films.

Two contrasting media images haunt me as this year comes to an end. First, of the health minister of Uttar Pradesh explaining away mounting children deaths at a government-run Gorakhpur hospital as a normal annual phenomenon. Second, a private hospital near Delhi terming the nearly Rs 16 lakh in charges for two weeks of care of a child suffering from dengue as not being unusually high. Do we have to choose between private exploitation and public sector callousness? Or is there a way out?

As individuals living in any part of India, we remain vociferous critics of our public health systems for their inability to deliver, especially on quality. Our criticism is justified inasmuch as we desire that our own public systems should do better. At the same time, we are forced to access healthcare in the private system, not because we find them to be inherently better or desirable, but because we don’t have a choice.

In the year gone by, the state of healthcare provision in the country has been debated upon fiercely in the context of various issues, which include newborn and children deaths, private sector regulation, the re-emergence of diphtheria, the lack of life saving medicines, privatisation of health services and Aadhaar. The confidence in the private sector too that it can deliver has been shaken. Concerns about blatant profiteering, ‘cut practice‘ and bad conduct of hospitals in the private sector has rocked the country and made us think about healthcare systems in place. This is not to say that there is any return in faith or trust in the public health systems.

Private vs public healthcare

In such a situation, should our focus be to remedy the imbalance and improve the public health systems to become the quality-assured, free and predominant healthcare provider? Or should we instead strengthen and support the development of private health systems?

This year, the National Health Policy (NHP) was released, which brought out the tensions of this polarised debate and yet had prescriptions for strengthening universal health coverage through a strengthened public health system where ‘strategic purchasing of secondary and tertiary services’ from the existing private systems has been proposed without mentioning the specifics of implementation. But the question that we need to ask is: do these initiatives in any way impact current situation of health and healthcare in the country?

Since a large number of people in our country are still under abject poverty with no financial reserves for sickness, we need the provision of free healthcare for them. And the quality of this care can only be assured if all people, especially the middle class, accesses it. Or else, any programme that provides care only to the poor runs the risk of becoming poor in quality. Even now, we know that in the states of Mizoram, Sikkim and Goa, the bulk of care – which includes primary care – is provided by the public system since the private one is not strong or overbearing. Can other states learn from these examples?

This year, we saw the sad spectacle that is our public hospital system, with the district hospitals in central India reporting an unacceptably high proportion of newborn and children deaths among those who sought secondary-level care, with proportions of dead to those admitted sometimes reaching 25%. These included large hospitals like in Gorakhpur, Ranchi, Jamshedpur, Nashik and Banswara. While much of this could be attributed to poor primary preventive care, these tragedies largely reflect the neglect of our institutions that provide curative care. These deaths were avoidable, but were also in a certain sense waiting to happen. These tragedies brought out the problems plaguing our public systems – financial corruption and incompetence. This situation cannot be remedied by more private care providers in these areas.

Re-emergence of diphtheria

This year, several states also reported the re-emergence of a deadly disease – diphtheria. Diphtheria is an uncommon illness these days and when such uncommon illnesses re-occur, their management becomes neglected as the health systems are not ready for it, and due to the non-availability of life saving drugs for rare diseases, as the market dynamics ensure their poor production, sale and distribution.

Due to this, not just diphtheria, but other conditions such as rabid animal bites, snake bites, scorpion stings, rheumatic heart disease have also been neglected. Orphan drugs like antidiphtheritic serum, crystalline penicillin for its treatment, anti rabies antiserum, anti-snake venom, benzathine penicillin are either not available or are frequently out of stock in the most marginalised areas. This highlights the need for production of and access to life saving drugs for neglected diseases, where the responsibility of the state is paramount.

Universal health coverage

The NHP suggests that universal health coverage (UHC) should be attempted through comprehensive primary healthcare, where we aim to provide care for the triple burden of communicable diseases such as tuberculosis, malaria and HIV, maternal and child health problems as well as the non-communicable diseases (NCD) such as hypertension, diabetes and heart diseases.

The policy recommends development of health and wellness centres serving the population in groups of 3,000-5,000, as well as supporting a cadre of mid-level care providers to man these centres supported by good use of information technology. And all this is supposed to be supported by referral hospitals such as community health centres and district hospitals. The NHP advocates an “assurance-based approach” which abandons the idea proposed in the draft policy of 2015 – that of a National Health Rights Act aimed at making health a right.

Nine of India’s poorest states account for 62% of maternal deaths. Credit: Reuters/Mukesh Gupta

Representative image. Credit: Reuters/Mukesh Gupta

There is good evidence that mere hospital-based care for NCDs leads to only half of people continuing their treatment with the others dropping out. This can be remedied only through community-based programmes for these chronic illnesses. The private healthcare systems would be structurally incompetent to do this. Here it is disconcerting to see this NITI Aayog’s proposal for sub-contracting part of the district hospitals in tier two and three cities to private providers to provide care for selected NCDs on their own terms without any financial risk taking. This is clearly a regressive step for UHC. One is not sure whether the private sector would find this arrangement lucrative enough to consider this idea.

The biggest charge against the private healthcare systems is the humongous profiteering that it does at the cost of people’s pockets. And we know it very well, that private health systems don’t like to be regulated by anyone, even if they don’t show any self-regulation. The recent Karnataka private medical establishment regulations amendments debate were construed as a draconian measure by the protesting private providers, though the major objection was regarding price caps of medical procedures. We also saw a huge protest to the government’s capping of prices for cardiac stents and for knee implants, all of which was unjustified.

A valid objection course, that was voiced by some of the private providers against those supporting their regulation was their moralistic position of the public systems being their regulators despite being poorly-regulated themselves, and their posturing as predominant care providers to people at large. I think this objection regarding the moral position of a regulator is a strong reason in itself for the development of a strengthened public health system. How can a public health system regulate others without itself becoming an example of a provider of good healthcare?

Similar debate also emerged in the recent failures of the private providers in and around Delhi either providing care of unacceptable quality, or indulging in extreme profiteering or being patently inhuman. There is no getting away from the need to regulate the large private sector. And it can be only be done effectively only if we have a strong public health system.

Also read: For Hundreds of Leprosy Patients in Andhra, Aadhaar a Stumbling Block in Availing Monthly Rations

Another axis of debate, at least in the public system, that threatens access to social support programmes including healthcare has been making Aadhaar seeding and biometric verification mandatory for accessing its services. While this is being contested in the highest court of the country, insistence of this in the first place is a worrisome development and makes one question the seriousness of the intent of ensuring access to healthcare, especially in the public systems. At present, the mandatory linking to Aadhaar seems to be depriving people of social schemes in the garb of limiting corruption of a minuscule amount.

What is the amount of funding needed for universal health coverage? While WHO has recommended a minimum of 5% of GDP allocation to healthcare by the government, it has been argued that in light of our cheap drug prices and good manpower, we can arguably get UHC with even 3%. The NHP has recommended 2.5 % of GDP allocation for health, but only by 2025. Not only will that be too little too late, it will also prevent any serious allocation for strengthening public systems, which is a crying urgent need. Especially if the audacious declaration by the government that we will eliminate tuberculosis (prevalence of less than one in a million) by 2025 has to be taken seriously at all from a present rate of 220 per 100,000 people now and almost a million people not being started on correct anti-tubercular treatment after being diagnosed each year. The fact that budgets of the National Rural Health Mission have been sized down by 20% on grounds of fiscal discipline and poor absorption capacity does not enthuse anyone of the political commitment towards a welfare state.

Are we defending the undefendable when we make the case for the public health systems? It is not from past performance by the public systems that one gets strength to defend this. But from a moral stand, as well as from the fact there is no alternative situation to having strong public systems, do we claim that this is the only way. Will 2018 be the year we settle this question and implement the NHP in the right earnest?

Yogesh Jain is a public health physician at Jan Swasthya Sahyog, Chhattisgarh.

Seven Health Secretaries in Seven Years – Where Is the Accountability?

The government should keep the secretary of the health department unchanged for three years for him/her to be able to show results. But that has not been happening.

The government should keep the secretary of the health department unchanged for three years for him/her to be able to show results. But that has not been happening.

A health worker (R) weighs a child under a government program in New Delhi, India

A health worker (R) weighs a child under a government programme in New Delhi. Credit: Reuters

The NDA government had promised good governance and policy stability. Yet we have a fourth secretary in the health department in the last three years – the seventh in the last seven years. Since both the outgoing and the incoming officers have sterling reputations, the reason for this mid-course change is unclear.

Why it matters

Health is a complex sector, and a highly contentious one, with several stakeholders working at cross purposes, requiring focused leadership, undistracted by the noise – something similar to the journey of Odysseus when he was tied to the ship’s mast to keep himself from being distracted by the lovely music of the sirens and in the process wreck the ship on the rocks. But such focused leadership requires knowledge of the purpose of the journey, the direction to take, the end to reach. And such clarity comes with years of engagement, absorbing the nuances, developing an intuitive grasp of matters and most importantly, building a team and assessing the political environment within which to steer policy. It is for this reason that the Second Administrative Commission suggested that the tenure of Secretary should be three years. Every change at the top then means a loss of a few months till new equations are formed, trust developed, and understanding gained.

Also read: Why India’s Poor Are Still Paying for Healthcare Despite the National Health Insurance Scheme

Matters of importance

In line with predecessor governments, the NDA too accorded lukewarm priority to health. It sacked a knowledgeable minister, wound up the National AIDS Control Organisation, that had a global reputation of being a best practice, stopped the reform process of the Rashtriya Swasthya Bima Yojna, shifting it instead to the already overburdened Ministry of Health, and reduced central funding to states in real terms. Instead of swift action to reform the Medical Council of India, in response to the scathing report of the Parliamentary Standing Committee on Health, a Committee was constituted. Two years later, the draft bill is still awaiting action.

On the positive side, the NDA articulated a bold health policy framework that is significant for adopting a more comprehensive health system approach. Rather than being coy about the participation of the private sector for achieving welfare goals, the policy makes its cooperation vital to the achievement of Universal Health Coverage through a National Health Assurance Programme. Undoubtedly, the National Health Policy, 2017, notwithstanding its several loopholes, flaws, gaps and contradictions, provided a way forward. But not without the risk of the health system being hijacked by corporate sector lobbies to the detriment of the poor, as seen in the cluttered policy framework that the NITI Aayog came up with – and was met with nation wide criticism – including state governments. Likewise, the NDA introduced the NEET that have some lessons to build upon. The government also sought to make drugs and diagnostics more affordable by capping prices – this is likely to provoke a reaction from vested interests.

India at crossroads

As can be seen, India is clearly standing at crossroads. Even as the agenda of unfinished tasks grows long, new challenges are emerging from the shadows. Inadequate budgets and the non-availability of well trained human resources are two problems that need to be addressed without further prevarication. Medical and paramedical education has been brazenly commercialised. In the race for profits, quality has been severely compromised. This needs to be rectified. And solutions are available.

Likewise, through dialogue, reforms to remove bottlenecks, and facilitate partnering with the private sector to achieve national goals, needs to be carefully put into place. As a process, this requires patience and negotiation skills, but is more sustainable than the lazy option of selling off government assets.

Also read: India’s New National Health Policy is Ambitious on Paper But Lacks Clarity

Finally, the scope for exploring non budgetary financing to meet the huge capex needs of the primary health system needs to be looked at to bring about the architectural correction. Conclusive evidence shows that a cost effective and sustainable health system is possible only when built on the foundations of an accessible and free at the point of use, primary care. India’s health system is based on the more expensive model of specialist-led hospital treatment. The various government sponsored health insurance schemes cover only surgeries. This needs to be expanded to cover other services, and with time the out patient treatment as well.

The government, like Odysseus, needs to be tied to the mast to focus, uncompromisingly, on eliminating and effectively containing the load of infectious diseases that still accounts for a third of the disease burden and hurts the poor disproportionately. Universal access to nutrition, tap water, sanitation and clean air are the vital ingredients of such a strategy. This basket of public goods then must be made universally available to all without discrimination as the first charge on government finances.

The list of what needs to be done is endless, posing a challenge to the most well meaning of governments. A beginning needs to be made by keeping the Secretary unchanged for three years and making him/her accountable to results – the precedent for the wisdom of such a policy being Tamil Nadu.

K. Sujatha Rao is a former union secretary of the Ministry of Health and Family Welfare, government of India, and the author of Do We Care: India’s Health System.

National Health Policy Reflects Conflict Between Public Health and Neoliberalism

The policy falls somewhere between a comprehensive plan for major expansion of public health services, socialisation of the private sector and extreme privatisation.

The policy falls somewhere between a comprehensive plan for major expansion of public health services, socialisation of the private sector and extreme privatisation.

A paramedic distributes free medicine provided by the government to patients inside a ward at Rajiv Gandhi Government General Hospital (RGGGH) in Chennai July 12, 2012. REUTERS/Babu/Files

NHP 2017 takes a major step backward on the commitment to enacting a National Health Rights Act. Credit: Reuters/Babu/Files

The National Health Policy (NHP) 2017 has been remarkable for the time that was required for its finalisation. While the draft policy was displayed for comments on the health ministry website in December 2014, it took over 26 months for the final policy to see the light of the day. This should not be surprising to those aware of some of the debates that took place during the finalisation of this document, often beyond public gaze. The chief reason for the major delay was a lack of consensus between two key stakeholders – the health ministry and Niti Aayog – around certain key provisions in the policy. The former is the natural locus of health sector policymaking, the latter a recent political creation with limited official powers or proven expertise in the health sector.

A third player – the general public, represented through many civil society formations like Jan Swasthya Abhiyan, as well as thousands of groups and individuals who gave comments on the policy draft – has also played a role, not only through direct inputs but also as a referent stakeholder and putative ‘target’ of policy. The health ministry received an unprecedented 5,000 submissions related to the policy draft which were systematically analysed and certain suggestions have also been included in the final draft.

Given this background, rather than commenting on the important aspects of this policy like has been done here, here and here, the aim of this article is to rather take an institutional approach to analysing the policy.

Contentions in the broader context reflect in tensions in the policy document

The final policy document has certain core tensions that result from interplay between wider neoliberal logic and institutional public health logic. One is the tension between the aspiration to achieve public health goals in line with the needs of India’s people in early 21st century and the constraints imposed by neoliberal ‘fiscal conservatism’ and ‘minimum government’. The second is the tension between aspirations to achieve some form of health coverage for the entire population based on public health logic and the compulsions of involving a largely profit-driven private medical sector to achieve this goal.

These tensions have led to something of a compromise where each of the stakeholders has obtained something – a moderate plan for public health system development with a promise of modest increase in resources (for public health officials), promise of improved access to care and accountability oriented provisions (for people) and formulations of so-called ‘strategic purchasing’ of care, potentially opening the window for further expansion of outsourcing-type support to largely unregulated private providers (for privatisers).

Without going into all undeniably significant aspects of the policy, we examine four major health policy components that reflect the mentioned tensions and would together decide whether the current health system architecture, which is today heavily skewed towards the private sector, will be brought fully in line with public health goals or will undergo further distorted development in the coming period.

Public health system strengthening and expansion

Regarding public health system development, what is being proposed is rather modest, though not insignificant. Most of the public reform recommendations – increasing health sector financing to 2.5% of the GDP by 2025 (in the earlier draft this was to be achieved by 2020), developing comprehensive primary health care, providing free medicines and diagnostics, moves for better inter-sectoral action for health – have been already proposed in earlier policy documents in some form. There are some relatively new and significant formulations such as section 3.3 (seven key policy shifts in organising healthcare services), which are positive, yet need further elaboration and translation into sets of concrete actions.

However, we need to correlate the stated objectives of the policy with the possible plans and linked levels of expenditure that would be required for achievement of these goals. It is here that the tension between public health aspirations and neoliberal policy compulsions becomes evident. For example, let us take just one goal: increase utilisation of public health facilities by 50% from current levels by 2025.

For this admirable goal to be achieved, assuming current utilisation of inpatient care in the public health system is 38% of total (NSS 71st round). Increasing this by 50% would mean moving to levels of around 57% of all hospitalisation care being sought by people in the public health system in next eight years. Similar projections could be made for outpatient care. To achieve this laudable goal implies a concrete and time-defined plan for massive strengthening and expansion of public health services – including doctors and staff, infrastructure, equipment – so that during the coming decade, various forms of public provisioning would become the major player in hospitalisation care. Such plans would need to be developed keeping in view the growing population and existing gaps that need to be closed along with projecting the relevant financial implications for each action component.

Such a systematic exercise could provide both a concrete roadmap for public health system strengthening and evidence-based projection of resource needs, which might even necessitate upward revision of figures for desired levels of public financing. However, it is worth questioning whether this scale of expansion is compatible with the mentioned ceiling on health financing (2.5% of GDP), current policy blockade on regular appointments in the public system as well as constraints imposed by the existing private sector. Failing parallel major policy changes to address these wider issues, such key goals in the policy would remain unfulfilled.

Regulation of the private medical sector

The mentioned public health goals cannot be achieved while the dominant private medical sector remains unregulated. Nominal regulation (registration of hospitals) or regulation limited to peripheral aspects (like biomedical waste disposal), though important, are insufficient. We must move forward to regulation which tackles the manner in which medical care is organised and provided by private facilities. This needs to deal with quality, rationality and costs of care and observance of patients rights – all of which are interlinked and are areas of massive concern in context of India’s private hospitals today.

Reflecting the tensions between public health and private medicine, on most of these fronts the policy provisions are muted and focus mostly on promoting adoption of the Clinical Establishments Act, which has so far been at a snail’s pace. Some bright areas are clear exposition of standard treatment guidelines, the need to protect patients rights (rights to information, access to records and reports, second opinion), proposed empowered medical tribunal to address various disputes and regulatory body for medical devices. Standard regulatory framework for lab services, imaging centres, specialised services such as surrogacy and organ transplantation is also mentioned.

Significantly missing is regulation of rates charged by private medical establishments, which appears in the rules of the national Clinical Establishments Act, but seems to be officially disowned subsequently since even transparency of rates by private establishments is not mentioned in the NHP 2017. Given the pernicious influence of private medical colleges and the background drama regarding the Medical Council of India, the policy is inadequate in spelling out how the regulatory system related to medical education must be overhauled. Overall in this key area of policy, we can see that the ‘public’ oriented forces plan some inroads but the line seems to be drawn by ‘private’-oriented policy influencers.

Interface between public system and private providers

This is where the contention between ‘public’ oriented forces (public health officials and people) and ‘private’ oriented influencers (privatisers) has been the sharpest. To effectively achieve public health goals, one grand challenge is bringing the ‘wild elephant’ of private medical sector under public direction. Here a Jan Swasthya Abhiyan document notes:

“… we need to decide how to deal with the existing private medical sector while moving towards health care for all. In this context, two diametrically opposing approaches are available to us today. Either public resources would be made to serve private benefit, or private resources would be made to serve public benefit.”

The currently dominant option, observed in most current public-private partnerships and health insurance schemes, is handing over major public resources to weakly regulated private providers without rationalising their practices, making them systematically accountable to public or scrutinising their impact on existing public provisioning. The counter-trend proposes making sections of private providers work as extension of public health services and rationalising their functioning while ensuring their public accountability.

For example, individual private doctors working in the NHS in UK function more like public actors than profit driven private entities. The latter approach would also require taking a differential strategy to the private medical sector in India since individual practitioners and smaller providers are more likely to work with publicly organised systems while corporate and large private multi-speciality hospitals will be least inclined to abandon their profit-driven mode of functioning. With this background, the final NHP 2017 again reflects an uneasy compromise between positions taken by public health officials and people versus prescriptions of privatisers.

Here we may note that certain pro-privatisation proposals keep asserting themselves like resistant bacteria that refuse to vanish despite treatment; like bacteria these also mutate over time, changing form but not essence. The Planning Commission’s draft chapter on health for the 12th Five Year Plan (July 2012) had recommended a ‘managed care’ type model, indicating that private networks could bid for providing multiple levels of care, and such networks could be handed over substantial responsibility for provisioning. The Niti Aayog has recently circulated an internal document with somewhat similar formulations exploring the formation and involvement of networks of public, private and not-for-profit providers for provision of care at primary, secondary and tertiary levels.

With this background in view, it should be acknowledged that NHP 2017 has avoided such extreme pro-privatisation formulations, though leaving critical areas unclear. The situational analysis of section 2.19 states that with projected level of public health expenditure increasing to 2.5% of GDP, “purchasing” would have to be mainly from public providers for efficient use of resources, with purchasing from private providers only for supplementation. This reasonable formulation seems to be the baseline position of public health officials. In sections 12 and 13 of the policy document, the so-called ‘strategic purchasing’ from the private sector is presented, the sequence of preference being from public providers followed by not-for-profit and then for-profit private providers. How this approach will roll out in practice in various areas remains to be seen. Yet this welcome differential approach would need to be followed by developing objective criteria to differentiate between not-for profit and for-profit facilities, defining ceilings on rates and examining demonstrated provision of free or highly subsidised care to people.

Insurance schemes appear relatively briefly in section 13.6.2, mentioned as option along with purchasing of care by trusts. Another expectation is that private providers would offer expanded free services for the poor (section 13.7), which appears either naïve or ill-informed given the experience of so-called charitable hospitals, which have systematically subverted even their legal obligations to provide such care.

Hence this policy creates a window for ‘strategic purchasing’, and the scale and forms it might take are undefined which can allow the ‘devil to enter in the details’. Most importantly, it is not clear what proportion of the projected increase in public finances (supposed to be increasing from 1.15% of GDP now to 2.5% of GDP by 2025) would flow towards expansion and strengthening of public health facilities, what proportion would be dedicated to care from demonstrated not-for profit entities and what proportion would flow to for-profit providers. If gap-filling is the sole criterion, then given the dominance of private provisioning especially at higher levels and in urban areas, the bulk might flow to private providers. However, if correcting public-private imbalance to achieve public goals and ‘socialising’ sections of the private sector are explicit strategies, then public-system strengthening options would emerge foremost.

Strengthening the ‘public’: rights, accountability and people’s participation

Reorientation of the health system to bring public health logic centre stage requires people’s voices to radiate through the entire health system. For this, governance must be transformed and the public needs to be systematically empowered. NHP 2017 takes a major step backward on the commitment to enacting a National Health Rights Act (mentioned in the 2015 draft), being replaced by the vague ‘incremental assurance based approach’, which is a major disappointment. The reasons cited are financial constraints, again reminding us of the larger neo-liberal framework. This is a circular argument. Without committing to fulfilling the right to healthcare, when will governments get around to allocating sufficient finances for the health sector? At least a start should have been made, as in the case of South Africa, of initiating a rights-based framework for health focussed on levels like primary care and then progressively expanding this over time.

Positively certain provisions for community accountability have been included, particularly in the section on governance (section 26). It is stated that community based monitoring and planning of health services should be made mandatory along with grievance redressal systems. Institutionalising patients rights in clinical establishments and medical tribunals to address patient complaints are steps in the right direction. Regarding protection of clinical trial participants, adoption of global good clinical practice guidelines and independent monitoring mechanisms to safeguard the health and rights of trial participants are positive inclusions.

Overall, due to external constraints and internal tensions, NHP 2017 falls somewhere between a comprehensive plan for major expansion of public health services and socialisation of the private sector and extreme privatisation and corporate sector oriented policy proposals. From the people’s perspective, a mixed bag has emerged through contention between key actors with promise of modest public health system reform, but with questions about levels of resources and how these resources will be allocated between public and private sectors combined with possibilities of further privatisation. Whatever is positive in this policy will need to be actively monitored for implementation along with campaigns for further expansion and accountability of the public health sector. Privatisation oriented measures will need to be challenged while presenting counter-proposals for effective regulation and socialisation of private providers towards public health goals. Developing the expected implementation framework would be a next crucial step, which would decide how some of the open-ended statements are actually interpreted and implemented (or not implemented).

Ultimately, we must view health policy making as one evolving terrain of struggle and popular intervention, among many others. Although one phase is completed, the story of health system changes linked with this policy is just beginning. All social actors concerned with public health will need to join hands and assert themselves to ensure that positive spaces opened up by the policy are actualised and enlarged while constraints imposed by the neoliberal framework are frontally challenged.

Abhay Shukla is a public health physician and health activist associated with Jan Swasthya Abhiyan and Alliance of Doctors for Ethical Healthcare.

India’s New National Health Policy is Ambitious on Paper But Lacks Clarity

The policy has proposed institutional reform, and steps to improve and upgrade the quality of services. But there is no correlation between the ambition targets and the public investment proposed.

The policy has proposed institutional reform, and steps to improve and upgrade the quality of services. But there is no correlation between the ambition targets and the public investment proposed.

A nurse tends to a woman, who underwent a sterilization surgery at a government mass sterilisation "camp", at Chhattisgarh Institute of Medical Sciences (CIMS) hospital in Bilaspur, in the eastern Indian state of Chhattisgarh, November 13, 2014. REUTERS/Anindito Mukherjee

National Health Policy 2017’s weak commitment to regulations, disproportionate to the aggressive policy stance taken towards collaborating with the private sector, is worrisome. Credit: Reuters/Anindito Mukherjee

The growing perception of the healthcare system – both public and private – as being corrupt and uncaring, and the accompanying loss of trust in it, has created a crisis that no government can afford to ignore. The increasing cost of care and the failure of the recent initiatives in providing financial risk protection against catastrophic expenditures have impoverished people, widened inequities and created a dual system of care – one for those with ability to pay and access medical help of international standards and those who cannot and only access suboptimal care.

The sharp budget cuts and policy neglect witnessed over the past five years have further compounded the problem. It is in this backdrop of a universally felt dissatisfaction that the new National Health Policy (NHP) has recently been released, evoking a level of interest that corresponds with the level of people’s frustrations with the broken health system.

The new policy architecture

The are four reasons for formulating a new policy – the growing burden of noncommunicable diseases and infectious diseases, emergence of a vibrant health industry growing in double digits, increasing impoverishment due to high cost of care and an enhanced fiscal capacity due to economic growth. While the policy goal is to ensure universal access of comprehensive services (defined to consist of primary, secondary and tertiary and covering the full spectrum – preventive, promotive and curative) by enhancing access and improving quality and lowering costs, the key objective is to focus on preventive, curative and palliative care to be provided through ‘the public health sector with focus on quality’. The policy also lists out 30 targets to be achieved in a time bound manner.

Under the organisation of public healthcare delivery, the policy thrust is on comprehensive care, system of referrals for regulating patient flows, output-based purchasing of private services to fill gaps, supply of free drugs, diagnostics and emergency services in all public facilities, scaling up urban health, strengthening of infrastructure and manpower in underserved areas, and integrating all national health programmes and making Ayush services an option.

The NHP then elaborates the components of the policy architecture, which consists of a strengthened public sector capacity to be able to, in the long run, provide to all comprehensive services and an incentivised private sector to fill the gaps in the short run. To address the various implementation challenges, the policy has proposed the much needed and long overdue institutional reform such as the establishment of the National Institute for Chronic Diseases, National Health Standards Organization, National Allied Professional Council, medical tribunals, National Digital Authority, a system for health technology assessment and at the Centre and in states a multi-stakeholder institutional mechanisms in the form of autonomous societies or government-owned trusts to purchase services from the providers – government, not-for-profit and for profit, in that order –  and a Common Sector Innovation Council as a platform for a more effective collaboration with the departments engaged in medical research and discovery. In addition to institutional reform, the policy also recognises the need to strengthen the regulatory frameworks related to medical devices, clinical establishments and certification of public hospitals for ensuring adherence to quality benchmarks.

A clear departure from the previous two policies of 1983 and 2002 is the detailed elaboration of areas in which private sector services will be contracted: training, skill development, community training for mental health, disaster management, purchase of services to fill gaps and preferentially for Central Government Health Scheme members, and primary healthcare in urban areas. There will also be collaboration with the private sector for infectious disease control, immunisation services, disease surveillance and health information and manufacture of medical devices. The policy also seeks to take steps to improve, upgrade and incentivise the quality of services being provided by the private sector in rural and remote areas and among underserved populations and provisioning of diagnostic laboratory support.

Another interesting and positive feature of the policy is the acceptance of the need for differential financing in three ways: per capita funding for primary care services, performance based funding to facilities and fiscal allocations to states on a differential bias guided by fiscal ability, development needs and number of high priority districts. A very interesting feature is also the proposal to institute financing mechanisms for incentivising innovation and fundamental research in diseases like TB and malaria that are highly relevant to us.

The policy concludes with an admission that the health system is too dysfunctional on the supply side to declare health as a right. Hence, it prefers to treat these policy commitments as an assurance with government being held accountable on the basis of an implementation plan containing milestones and targets.

Concerns

On a quick reading, the NHP does seem to be a revved up version of the 2002 policy. A closer reading, however, indicates, as detailed above, several new opportunities and approaches. The NHP is grounded on the existing situation and is to that extent more realistic. A welcome feature is that for the first time, government policy has taken its oversight functions beyond government facilities to encompass the private players also.

However, there are many concerns. First, there is no correlation between the ambition in the text and public investment proposed – from the current level of 1.15% of GDP to 2.5% of GDP by 2025. This level of public investment is inadequate for achieving the goals, targets and approaches proposed to achieving them. In neither sequencing the reform process nor in prioritising the investment decisions is there any clarity on what is proposed to be done with this little bit of money. For example, the policy liberally mentions the word ‘comprehensive’ throughout the text without any clarity in terms of what it must imply.

Somewhere it is said that primary care, as defined in health literature and the Alma Ata-declaration of 1978, implies basic healthcare and its social determinants. Elsewhere, it seems to include secondary and tertiary care as well. In the primary healthcare space, the policy commits itself to strengthening the public health infrastructure in underserved areas in accordance with the Indian Public Health Standards (IPHS). Estimates of the ministry indicate a financial requirement of 1.4 lakh crores (2014 prices) for meeting the gaps in IPHS. Of this, over 75% is required in just the 300 districts that would qualify as underserved. Against such a huge deficit in capital investment, over the last ten years not more than Rs 10,000 crores may have been incurred and that too by the better off states.

Secondly, the health sector has faced chronic underfunding. Be it in times of 3% or 9% growth rate, public health spending has always been in the range of 0.9-1.2% of the GDP. These meagre funds are then responsible for the under performance and dysfunctionalism of the public health sector that struggles with poor infrastructure, obsolescent equipments, understaffed and overworked personnel and so on. Optimising this infrastructure to achieve the quality standards that the policy proposes will require substantial investments again.

Thirdly, and more significantly, international experts have estimated a requirement of $85 or 5% of GDP for providing the comprehensive primary care as envisaged in the Sustainable Development Goals. Against that, our current spending is about $17. Due to this underfunding, estimates of PGI, Chandigarh, show that the public sector provides a mere 15% of the services that primary care ought to ideally be providing. This is backed by an exercise done for the ministry in 2014 that showed that of the 30 and more set of services that ought to be available in any primary care facility, hardly 12 are being provided partially.

The question then arises that if comprehensive primary care, which must be the foundation of a health system in order to, in the long term, contain costs and ensure a healthy population itself, requires a five-fold increase in investment, how do the rest of the policy aspirations get funded?

A fourth concern is the liberal use of strategic repeatedly in the context of purchasing services from the private sector to fill gaps in the public healthcare service delivery chain. This is a concept co-opted from the High Level Expert Group report of 2012. The issue that arises is the propriety of the word in an environment where private sector provides 80% of out patient care and 60% of inpatient care. Gap filling is a term used only when the deficit is about 20%.

An added concern is that the policy envisages that such purchasing will be in the short term, though it nowhere defines how short the term is likely to be. Evidence shows that public and private sector cannot coexist in the same space given the highly competitive environment. Evidence also shows that in such environments, the public sector has always lost out, more in the area of perception and non-provision of level playing fields. We have seen this in all sectors of development where the private sector has been co-opted under the public-private partnership mode. In all these frameworks, the risk is borne by the government with little liability on the private provider and necessitating action for non-compliance entailing elaborate litigation.

The further incentivising of an already highly privatised system within a weak regulatory framework that is incapable of enforcing the private sector compliance to rules, regulations and standards set by the government, will undoubtedly entail long term adverse consequences both in terms of denial of care and huge fiscal implications for government as is being witnessed in the US. For example, under the Rajiv Aarogyasri programme, 133 procedures were delisted for private contracting as the government hospitals had that capacity and were performing them at a fifth of the rates being paid to the private sector, particularly corporate. The concerned officer got transferred and the proposal shelved. In such an environment, further incentivising the for profit sector is like riding a tiger it will not be able to dismount. In fact, it is already too late and retrieval of the government in the secondary and tertiary spaces itself quite difficult. It is in this context that the proposal to actively collaborate and encourage the for profit private sector in the primary care space also is worrisome. AP has already handed over 135 centres in urban town to the Apollo group. If this example is followed by all states and hospital chains begin to take over all the urban (profitable) centres, not only will the cost of care go up but making them accountable to rational and cost effective care will also be impossible. The treatment of all submarkets in the health sector as homogenous units needs to be reviewed. Given the huge market failures and the multiplayer system, the policy seems to be skirting the issue of a strong interventionist role of the government. This is worrisome.

A fifth concern is the NHP’s weak commitment to regulations, disproportionate to the aggressive policy stance taken towards collaborating with the private sector. There are serious omissions. For example, there is no mention of reforming and restructuring the Medical Council Of India (MCI) or the Nursing and Dental Councils to be more accountable and less corrupt. Despite the scathing report of the Standing Committee of Parliament on Health on the functioning of the MCI and the government constituting an expert committee tasked to suggest reform, it is strange that the NHP does not even mention this issue.

Likewise, the silence of the NHP on establishing an autonomous, independent drug regulator and more importantly dealing with the long pending and contentious issue of bringing drug regulation under the central control. State drug controllers are playing havoc with the licensing and drug quality assurance aspects and in oversight of pharmacies, contributing to the rampant misuse of antibiotics.

A third serious omission is the strengthening of the Clinical Establishment Act to make it mandatory for the display of prices by private hospitals. The National Pharmaceutical Pricing Authority has recently done yeoman service in capping the price of stents. How does this get enforced? In other words, making regulations is one aspect, enforcement is another that calls for substantial expenditures in establishing trained inspectorates and close monitoring. Similar regulations and enforcement are required for ensuring the proper maintenance of the diagnostic equipment, timely calibrations and utilisation. This too requires frequent inspections and monitoring by trained manpower and the co-option of technical institutions. The NHP is silent about this aspect as well, focusing only on the domestic manufacture of medical devices.

A sixth concern is the neglect to incentivise and promote operational research that is now called ‘implementation science’. Health is a knowledge intensive sector. And midcourse correction can only come with feedback loops bases on research studies. India barely has a handful of health economists and persons equipped with skills for concurrent evaluation. It continues to be dependent on international experts and agencies. Without such capacity at all levels of implementation, policies will continue to flounder with inconsistencies. Such research capacity is even more needed in an approach that seeks to decentralise and have states steer the implementation process.

Challenges 

Ernesto Zedillo, former president of Mexico, defines health system policy to stand on four pillars – clarity in objective, clarity in design, clarity in financing and clarity in incentives. The new NHP sadly fails on all these fronts. Being a ‘please all’ document, the challenge will now lie with the technical and administrative bureaucracies to develop implementation plans teasing out the steps and sequencing the change process. This will be a challenge but not one that can’t be overcome. It all depends on the commitment of the leadership to bring in the transformative change, the evidence it will choose to utilise and the consultative processes it will adopt and giving priority to the change agents working at the field level rather than Delhi-centric consultants in drafting the operational plans.

The politicians have spoken. The thrust on the further privatisation of health is in line with the right wing liberal philosophy of the party in power. How to tame the tiger to meet welfare objectives and turn it away from unethical profiteering will now be the challenge for policymakers. These are certainly challenging times and the people will wait to see what happens next and whose interests will be protected – the hapless patients or the private investors in the medical industry.