National Health Policy high on intent, low on implementation

While the NHP 2017 addresses on the surface the entire gamut of challenges by way of advocacy and suggestions, a step-by-step implementation framework that provides a roadmap to achieve the goals of the policy is conspicuous by its absence

Rachna Mantri Delhi

With a fifth of the world’s disease burden, a growing incidence of non-communicable diseases and one of the highest levels of malnutrition in children under five, India has little to boast when it comes to equitable progress in healthcare.

The Indian public healthcare system is plagued by a number of challenges. These include sub-optimal spending on health by the government—1.15 per cent of the GDP—way below peer nations, lagging healthcare indicators, high out of pocket healthcare spending, vast infrastructural gaps in the face of the urban and rural divide, lack of adequate and underutilised health work force and compromised health governance riddled by questions around ‘centre versus state’ responsibility and accountability.

While the much awaited National Health Policy (NHP) 2017, presented 15 years after its forerunner NHP 2005, addresses on the surface the entire gamut of challenges by way of advocacy and suggestions, a step-by-step implementation framework that provides a roadmap with clear deliverables and milestones to achieve the goals of the policy is conspicuous by its absence in the 31-page document.

While the policy proposes to raise the public healthcare spending from 1.15 to 2.5 pecent of the GDP in a time-bound manner, the number of years within which it intends to increase the spending is close to a decade (till 2025), which bearing in mind inflation and other market dynamics, is grossly inadequate. Further, this is still half of what the WHO recommends as optimal public spending on health. What is worrying is that the recent budgetary allocations have not been reflective of this proposed incremental spending (although the draft policy has been floated since 2015).

Accessibility, affordability and quality of care are the three pillars of a successful healthcare system. Given that health is a state subject in India, it is imperative to ensure that these pillars form the basis of each state-run healthcare provision free of bureaucracy and inertia. While well-intentioned statements in the policy seek to pave the way for ‘cooperative federalism,’ they are vague, sans regulatory intent and leave much of the execution to wishful thinking alone.

In the context of India’s targets to meet the global Sustainable Development Goals (SDGs), the policy’s promise to meet key health indicators are a decade or more behind what our South Asian neighbours have already achieved. Among key targets, the policy intends to increase life expectancy at birth from 67.5 to 70 by 2025 and reduce infant mortality rate to 28 by 2019. It also aims to reduce under five mortality to 23 by the year 2025. Besides, it intends to achieve the global 2020 HIV target. These are all goals in the right direction but much more aggressive targets are needed to bridge the need gaps in health outcomes.

The policy has outlined steps to provide affordable healthcare to all, including free access to universal comprehensive primary healthcare, free drugs, diagnostics and essential emergency services in government hospitals. In order to facilitate access within the ‘golden hour,’ the policy aims to ensure availability of 2,000 beds per million population across all geographies. While these are meaningful steps towards transforming primary care, they are only possible when the system is infrastructurally equipped with a qualified health workforce at an arterial level—a gap that is difficult to bridge given the minimal spending capacity the system has been empowered with.

The NHP 2017 indicates the government’s glowing intention to seek private partnerships for secondary and tertiary healthcare services to fill critical gaps in assuring comprehensive healthcare services. But 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.

The subject of health insurance is not sufficiently addressed in the policy. How central insurance schemes are expected to significantly bring down out of pocket expenditures at a state level is not clear.

The NHP advocates the need to incentivise local manufacturing to promote customised indigenous products such that healthcare is made more accessible and affordable, while simultaneously generating employment. This is a positive step focused on leveraging local innovation, technology and ICT capability.

The Policy recommends establishing processes for speedy resolution of disputes and National Healthcare Standards Organisation (NHSO) to develop evidence-based standard guidelines for care. Resource allocation to government hospitals will be made responsive to quantity, diversity and quality of caseloads. This is a concrete step in the right direction and watching this space has much promise.

Finally, a policy is only as good as its implementation. The progressive elements of the policy will need to be actively monitored in a transparent manner for implementation, along with campaigns for further expansion and accountability of the public health sector. To avert the national healthcare crisis, a cohesive and goal-oriented Centre and state partnership under strong political leadership is critical.

The author has a Master’s degree in Pharmaceutical Chemistry and is a Health Communications Consultant.