NHP 2017: Grand vision but timid steps
The National Health Policy has its heart in the right place but it fails in making commitments or providing a roadmap to realise its ambition
India shares a large burden of the world’s communicable and non-communicable diseases. The public health sector is beset by a number of problems ranging from lack of infrastructure, human resources and corruption to a chronic lack of funding. Our health indicators lag behind peer nations and out-of-pocket costs account for over 70 percent of the total health expenditure. The National Health Policy (NHP), which got a nod from the Cabinet on March 15, addresses all these issues on the surface but fails to provide a roadmap to achieve the goals laid out by the policy.
Emerging from a conference on the use of technology in tackling non-communicable diseases, Dr K Srinath Reddy, president of the Public Health Foundation of India and the World Heart Federation, says that the National Health Policy is high on intent but does not make the commitments that he expected the government to make. He says, “I believe that the policy has brought in a fairly strong vehicle for transforming our health system. It attempts to remedy the level of public financing which is very low right now, although not to the level I would have liked. However, I think it is better to promise less and deliver more than to promise more and deliver less.”
The policy may have its heart in the right place but the promise to raise public health expenditure from the current 1.15 percent to 2.5 percent of the Gross Domestic Product (GDP) by 2025 is one that compromises the vision of the policy. According to Santosh Mehrotra, an economist with Jawahar Lal Nehru University (JNU), the figure projected by the government in the policy is something that we should aspire to achieve in the next three years. “China already spends 2.5 percent of its GDP on health today. We need to note that China has better health outcomes than us and also its GDP is higher in comparison to ours. So, the NHP’s commitment to increase allocation between now and 2025 to 2.5 percent of the GDP is simply not good enough.” He points out that despite good economic growth over the 2000s, the health indicators did not rise as much as the income and education indicators because of our failure to commit more funds to healthcare. “The overall Human Development Index (HDI) of the country is being held back by health indicators,” says Mehrotra.
Dr Reddy, however, thinks that the bigger question is not about how much money has been allocated but how it is going to be utilised. The plan to spend two-third of the total money on strengthening primary healthcare is a pivotal shift, he says. “The NHP is talking about comprehensive, continuous healthcare with suitable linkages to secondary and tertiary care—this is a significant shift in emphasis,” Dr Reddy notes. According to him, states have so far shrugged off their responsibility to provide primary healthcare, saying that it will be taken care of by the Central schemes and they should instead focus on secondary and tertiary care. However, if primary healthcare is neglected, then there will be a spike in preventable diseases and health conditions that could have been treated earlier. These then spill over like a flood to secondary and tertiary care framework, overloading the systems.
Mehrotra says that at the centre of the problems besetting the healthcare sector in India is the fact that health is a concurrent subject and majority of the expenditure on public health is borne by states. “We may pontificate until the cows come home but what happens on the ground is going to be determined by state government commitments,” he notes and adds that in such a scenario, what is the meaning of a National Health Policy. Dr Reddy too reckons that the problem is one that needs to be addressed by the Centre and asserts that a discussion with states is the only way to go. He says that the government should get the states to adopt state health policies which are in consonance with the NHP. “We may travel in different lanes, based on our current situations, but we must all be moving towards the same goals. There has to be a consensus that this is the road to travel,” the PHFI president says. While Mehrotra appreciates the promise within the policy to create Health Management Information System to ensure district-level database of information on health system components by 2020, he stresses on the need for the state governments and the Centre to arrive at Memorandums of Understanding (MoU) with concrete deliverables, not just in the form of inputs but also outputs and outcomes.
An important omission made in the policy over the draft that came out two years ago in 2015 is that it fails to recognise health as a right and instead advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realising healthcare as a right in the future. While asserting that health should be a right because it enables the state to bring in better legislation and regulation, Dr Reddy says that if we do enough to provide services that help us to move rapidly on the path to universal coverage then that means we are actually realising that right even if we have not stated it. But he underlines the need to recognise health as a right in future as it codifies the commitment of the society and could also be used to mobilise social solidarity required for achieving universal coverage. “The rich have to subsidise the poor and the healthy have to subsidise the sick,” remarks Dr Reddy.
In an editorial published in a leading English daily, Union Health Minister JP Nadda, while lauding the strides made by India in healthcare, admitted, “While we have much to be proud of, we know that we can do much better. Health outcomes can improve further and out of pocket expenses on health can reduce, to better protect citizens from financial risk. We can build on our progress to reach the goal of an India in which every citizen lives a healthy and productive life.”
To bring down out-of-pocket expenditure on health, the NHP aims to align the existing government-financed health insurance schemes to cover selected benefit package of secondary and tertiary care services purchased from public, not for profit and private sector, in the same order of preference. However, Mehrotra believes that regulation goes to the heart of the matter at all places wherever the government hopes to involve the private sector. Dr Reddy, who has worked all his life in the public health sector and has never taken any fee from any of his patients, agrees that the government will have to make space for private players because the public health system is just not adequate. “You have to engage them (private sector) in a responsible manner. It should be a decision born out of deliberation and not desperation. The private sector should be an extension of the public healthcare system led by the public sector,” he notes.
Appreciating the intention to involve the private sector, Rachna Mantri, a Health Communications Consultant, points out another problem with the idea, “Private facilities barely exist in underserved areas where the gap in healthcare services is the worst. This lacuna has not been addressed in the document. This also raises the question whether the government is moving gradually towards a ‘payor role’ alone as against a ‘provider role,’ thereby outsourcing the ‘provider role’. In case that is the long-term vision, this welcome step is likely to strengthen the private sector but further neglect government-run healthcare facilities.”
Mehrotra, on the other hand, believes that if the Rashtriya Swasthya Bima Yojana (RSBY) is going to scale in the absence of a transparent mechanism, it will do little to change things on the ground. “Please remember that the RSBY will be funded by the general tax revenues. So, if all it does is to improve the profits of insurance companies or of private providers, the effort will not translate into improved health outcomes and low out-of-pocket expenditure,” he notes. Mehrotra also sounds a warning: if the government does not reform the Medical Council of India and the Dental Council of India, then regulation is not possible. He goes on to add that apart from framing guidelines to control the participation of private players in the public health framework, the regulation would also mean improving manufacturing capacity for pharmaceuticals, making drugs available at government hospitals, creating procurement procedures and infrastructure.
One of the positive highlights of the policy, according to Dr Reddy, is related to public health cadres. The NHP places emphasis on the creation of an empowered public health cadre to address social determinants of health effectively. The PHFI chief says that other than Tamil Nadu, no other government had defined public health cadre. He believes that for professionals managing health programmes, having public health expertise that can support policy development is necessary. “If you have an exceptional orthopaedic surgeon, obstetrician or radiologist coming in as a district health officer or a malaria control officer, whatever else they may deliver, this is something they can’t,” Dr Reddy remarks. Therefore, the intention to create a public health cadre in every state is a very important step that will go a long way in improving health outcomes.
India is already lagging behind its peer nations in meeting the global Sustainable Development Goals. One of the major problems with the policy is that while its vision is grand, it pushes the targets of meeting key health indicators, which should have been met a decade ago, farther away. Mehrotra points to the demographic dividend and warns that time is running out. A demographic dividend is a period that comes once in the life of any nation when the share of the working-age population increases and the share of the dependent population decreases. When the share of the working population rises, the growth rate of the economy can rise. “We are at the midpoint of our demographic dividend. It will end by 2040, which is barely 23 years away. As the population ages between now and 2040 and even faster after 2040, we must improve the health outcomes of those who are alive today so that they become more productive and generate more income. If during this intervening period, we have not improved the health outcomes for our entire population, our health expenditure will only increase.”