Health policy: Raising hopes, questions

Healthy India? Unveiled after a long gap, will the draft health policy change healthcare delivery system?

After almost 15 years, the Government of India readies for addressing the ills of the health sector which is crying for attention. India has the world's highest out of pocket expenditure on healthcare and a vast majority do not have access to healthcare while the private sector in the healthcare grew enormously in the last 15 years. As the main article analyses the draft policy, Deccan Herald  brings you a report from Rajasthan, one of the worst-performing states in healthcare besides interview with a noted medical personality.

The draft National Health Policy has been placed on the Union health ministry's website for public comments which can be provided online till February 28. This invitation for wide ranging comments and suggestions is a commendable sign of transparency. To what extent the draft will be modified in response to constructive comments will be an indicator of openness to integrating public contributions to policy making.

The policy starts by profiling the state of India's health and the performance of the health system with unexpected candour. While listing our considerable progress towards the Millennium Development Goals for maternal and child mortality as well as the achievements of the National Rural Health Mission, the document frankly reports how many of our health indicators as well as level of public financing for health lag behind many developing countries.

As a result of the stagnant level of government spending, the proportion of families experiencing catastrophic health expenditure has risen from 15 per cent in 2004-05 to 18 per cent in 2011-12. About 63 million Indians are pushed in to poverty each year because of unaffordable healthcare costs.

While calling for an increase in public financing for health from 1.04 to 2.5 per cent of GDP, the policy calls for the minimum that is required to remedy this. The draft is diffident about achieving this because of anticipated fiscal tightening.

Only the coming Union budget will signal whether the government responds to the urgent need to infuse more funds in to the health sector to strengthen the health system and move the country towards the goal of universal health coverage (UHC).

That such a goal is aimed at is evident from the bold declaration that the Right to Health would be provided a legal framework through a National Health Rights Act which will ensure health as a fundamental right. However, the draft also states that it would be voluntary for the states to adopt this, based on their financial resources and ability to implement.

That dilutes the basic premise of UHC which require that a citizen should be able to exercise that right to access an assured set of healthcare services anywhere in the country. By having a right which extends only to some parts of the country, would this create different classes of citizenship?

The policy appropriately places great emphasis on strengthening both rural and urban primary health services. Comprehensive care is stressed as a key characteristic of these services, with their integration with secondary and tertiary care intended to provide a care continuum. Previously neglected areas like non-communicable diseases will also be drawn into this integrated framework.

The large unmet need for health service providers, which is a major barrier to delivery of comprehensive primary care, is acknowledged. Engagement of non-physician service providers from different categories of allied health professionals, along with AYUSH professionals, is proposed. However, there is no indication of the timeline or the mechanisms for producing the vast numbers needed. A firm commitment is made to provide essential drugs and diagnostics free of cost at public facilities, but specifics on what exactly would be provided are not invisible.

Dependence on private sector

As the policy moves to address secondary and tertiary care, the growing dependence on the private sector becomes apparent. Strategic purchasing of services from both public and private providers is proposed as the new mechanism for ensuring access to quality assured services, wherein the Central and state governments will pay for a defined set of services. While the draft says this will not be competitive, the nature of purchase may put the progressively weakened public sector at a disadvantage if asked to bid for services against the well-resourced private sector.

Ambiguity regarding the role of the public sector is amplified when the draft says that “the mindset must move away from regarding public services as free, and instead to consider them as pre-paid care”.

While this correctly holds the public sector accountability for quality, how will quality improve if resources are not infused to improve infrastructure, recruit more qualified personnel, ensure supply chain efficiency and grant them greater autonomy? How will this happen if the health budget is not increased and governance improved?

The policy calls for all national and state health insurance schemes to be aligned into a single insurance scheme and a single fund pool reducing fragmentation. This is highly desirable and will transform the patchwork quilt of government funded social insurance schemes into a single payer safety net, if it happens.

A beginning can be made when the Rashtriya Swasthya Bima Yojana moves from the Union labour ministry to the health ministry. However, the big question is about the states. Will the states, which operate these government financed insurance programmes for gaining popular goodwill from their constituents,  willingly allow their pet schemes to be subsumed by a Centrally directed single scheme from which they do not draw credit from the voters?

This raises the biggest question of all.  To what extent does this aspirational draft, which espouses several sound principles of desirable health policy, has a buy-in from the states which have the ultimate responsibility for service delivery.  This calls for a country wide consultation to generate a collective commitment to an effective and equitable health system that delivers universal health coverage as a national assurance.

What is the extent of ownership even within the Union government, where the prime minister and finance minister are the final arbiters of how much funds will be allocated to the health sector? While frugal innovation is generally praiseworthy, and is of value even in the health sector, India's new health policy will remain a dream draft if the much-needed system strengthening inputs do not flow in from the exchequer, backed by the political will to position health on the centre stage of India's inclusive and sustainable development.

(The writer is President, Public Health Foundation of India. Views expressed are personal)