On the 31st December 2014, the Ministry of

On the 31st December 2014, the Ministry of Health and Family Welfare released the third of the Draft National Health Policy (NHP) 2015. The first such document was presented in 1983 and second came 19 years later in 2002. Like its predecessors the document promises universal health coverage but what sets it apart from the previous document is the promise to create a fundamental right to health which essentially means that if implemented denying health care would be an offence. The goal of the draft policy is to create ‘highest possible level of good health’, ‘well-being’, via a ‘preventive and promotive health care orientation’ and ‘universal access to good quality health care’ (paragraph 3.1). By recognizing priority areas like cleaner environment and its role in health, the draft accepts that ensuring health of the population goes beyond the hospital. The document was opened to public consultations and inputs were accepted till 10th March 2015. The grand vision of ‘health’ and ‘health for all’ stated in the document is commendable. Additionally the document also highlights huge gaps and policy challenges in the health sector. However, it has failed to adequately prescribe policy solutions for the same. This cover story provides an overview of key challenges identified in the document and further tries to show its inadequacy in providing conceptual guidance to address them. Key Concerns:1) Unclear Provisions Regarding Financing Health Care The out of pocket (OOP) spending on health is nearly 70 percent, one of the highest in the world (CBGA, 2015). This pushes about 63 million persons in India to face poverty every year due to healthcare costs (EPW, 2015). There is a need for the government to step in and finance health in the country. The NHP 2015 accepts that the health expenditure of the government in India is well below the acceptable rates. In paragraph 2.18 it states “government spending on healthcare in India is only 1.04% of GDP which is about 4 % of total Government expenditure, less than 30% of total health spending.” The total government expenditure of India on health is lower than all of the BRIC countries (Brazil- 8.9%; China- 5.1%; Russia- 6.1% and South Africa- 8.7%) (Page 12, NHP). To address such issues the draft prescribes that government needs to increase spending in health to about 2.5% of the GDP, which shall translate into about INR 3800 per capita, a four-fold increase (paragraph 4.1.1) Draft accepts that even the 2002 draft health policy, which saw an increased expenditure failed (paragraph 2.18). Recognizing this, the draft sees health financing, as a two-way process i.e. raising finance is one challenge and spending it the other (paragraph 6.2). It proposes that the finances for health can be raised via a health cess, on lines of the education cess (paragraph 4.1.2). However, it is difficult to see how one tax can bear the burden of such costs (EPW, 2015). Spending resources on health raise questions of optimum utilization. Moreover, doubts regarding engaging private sector to provide health care still remains. With regards to involving the private sector to finance health, the document is not clear in its stand. On one hand it says it will buy direct services from the private sector but on the other it says that there is a need to develop a public-private partnership to provide services. Moreover, the document relies too much on the insurance model to generate funds. There are significant issues with insurance based financing many of which the document accepts. These include fragmentation of funds, selective allocation to secondary and tertiary care over primary care services, denial of services, frauds, additional costs due to layer of profit and unaccountability. (Phadke, 2015) 2) No Evidence of Health Infrastructure Priorities The NHP 2015 understands that the health infrastructure needs significant improvement. Currently, there is a shortfall of about 6700 of Primary Health Centers (about 23%) and Community Health Centers of about 2350 (about 32%) (CBGA 2015). Moreover, even in areas where health centers do exist there is significant shortage of human resources in them. As per estimates, “One Primary Health Centre with a single doctor is responsible for the health of 30,000 people. In Brazil, a comparable centre has four doctors for every 10,000 people”(Devadasan, 2014). Understanding such inadequacies, the policy, among others, outlines plans to upgrade 58 district hospitals, build 600 medical colleges and more ‘AIIMS’ like institutions in the country (paragraph 5.3). For enhancing primary health care delivery systems, among others, it hopes to give impetus to the efficiency of ASHAs to act as a between bridge first level of health facility and the community (paragraph While the aspirations to strengthen health infrastructure is creditable, there is no sense of priori with regards to what health centers is going to be prioritized i.e. whether primary health centers will be given priority over large hospitals. Moreover, the document is silent on creating a balance between creating health infrastructure and producing human health resources. The 2015 budget clearly shows the preferences for building ‘AIIMS like institution’ in the country, with six being promised in states of Jammu and Kashmir, Punjab, Tamil Nadu, Himachal Pradesh, Assam and Bihar. (India Budget, 2015) Expenditure on building huge institutions like AIIMS would mean a diversion of resources available for primary health centers. Such centers tend to attract specialists for surrounding primary centers and deplete the human resource pool for district and referral hospitals. Patients also prefer larger hospitals rather than the smaller ones, which lead to an increased pressure on the larger hospitals as is evident in example of AIIMS in Delhi. This compromises quality of healthcare. Strengthening primary centers on the other hand will ensure quality care closer to residence (Devadasan, 2014). The documents accepts that human resources tend to crowd around urban areas (paragraph 5.2), but offers no plan to change this by creating better priorities with regards to health infrastructure. Responding to emergencies and traumas is a crucial to assure health care in the country. Being able to provide pre-hospital care may also be integral to patient’s life. In India, the infrastructure to provide emergency services needs attention. EMS (Emergency Medical Service) system in India can be best described as ‘fragmented.’ The basic fundamental principal behind EMS systems worldwide is to have a common emergency communication number connected to responsive agencies. Although India has the emergency number 102 for calling ambulances, the responsiveness of the emergency service system has not always been reliable. In 2007, Ramanujam et al. reported that nearly 50% of trauma victims admitted to a premier hospital in an urban Indian city had received no pre-hospital care (Subhan and Jain, 2010). The draft health policy does not provide clear guidelines with regards to trauma policy and emergency care. In rural areas, their reach is worse. The draft hopes to create an emergency response i.e. an ambulance linked to trauma management centers per 30 lakh population in urban and one for every 10 lakh population in rural (paragraph 4.3.9). To enhance the ambulance service, it hopes to engage the private sector via contracts (paragraph 6.6). But what kind of engagement will that be and the role private sector will play is still undefined. 3) Silent on Reorganization and Regulating Private Health Sector . Paragraph 2.13 notes that the private health sector provides 80% of the outpatient care and about 60% of inpatient care making it a $40 billion dollar industry. Kumar et al point out that India’s private sector does not offer quality health care at affordable prices. At one end are the five star hospitals attracting foreign clients while at the other end doctors without training are practicing medicine. Apart from these two options there are several clinics and low-cost for-profit and not-for-profit private hospitals, which are accessed by those who can afford them. There is no effective regulation of the state at any stage. The draft recognizes that ‘without a regulatory structure in place, it would be difficult to ensure public- private partnership…much greater emphasis needs to be given to making regulations work.’ However, instead of pointing out changes to be made in the Clinical Establishment Act, 2010, it just broadly says that the act needs to become ‘more effective and user-friendly’. “It notes objections of ‘some stakeholders’ that the act is “intrusive” etc, but does not mention the objections of civil society groups to the absence of a standard charter of Patient’s Rights, of grievance redressal, of autonomous regulatory structure, etc.” (Phadke 2015) NSSO data shows that as much as 40% of private care is likely to be provided by informal unqualified providers. The document recognizes this fact (paragraph 2.13), however the response to curb it is negligible. No guidelines regarding making the private practice more accountable is listed. As of now, While the policy recognizes that the government needs to ‘intervene and (has) to actively shape the growth of this (health) sector’ (paragraph 2.12), it does not elaborate the intervention needed and planned in the private health sector there is a significant lack of grievance redressal mechanism and laws to prevent malpractice or fraud by private sector (Rao 2015). Moreover, there is no pledge to ban capitation fee or donation collecting private colleges that are negatively affecting the entire health sector (Phadke 2015). Because of lack of regulation in private practice unnecessary tests and procedures, rewards for referrals, lack of quality standards, irrational use of drugs, over diagnosis, over treatment, and maltreatment are common (Kumar et al). No policy response or intervention has been highlighted to curb these practices. 4) No Action Plan on Changing Approach to Population Policy Health system in India is centered around and obsessed with population control the burden of which has been placed on women. The draft mentions the success India has had in stabilizing population but is silent on the price women paid for it. As per World Contraceptive Pattern 2013, female sterilization for married women (or in a relationship) in India is about 35.8% while for male it is only 1.1%. “When compared to other countries, only Puerto Rico, the Dominican Republic and El Salvador ranked higher. Even China, notorious for its one child policy and forced sterilization policies, ranked lower than India.” (Adam, 2014) “Population Stabilisation Fortnight” organized between July 11, 2013 to July 24, 2013 saw 1.57 lakh women sterilization while the number for men was only 8,130 (Ministry of Health and Family Welfare, 2013-14). Most times sterilization is carried out in camps that are not equipped with adequate equipment and results in disastrous consequences and even death of those undergoing sterilization. The most recent example of this disaster was the death of 19 women in Chattisgarh camp (Daily News and Analysis, 2015). The draft states that the challenge of population control is now left in six states but does not reflect any desire to transform from the current trend of putting the weight of population control on women and sterilization to do so. Significant void still remains in changing the view that population policy is not just about meeting sterilization targets. The draft aims to increase sterilization among men from the current 5% to 30% (paragraph However, while trying to reduce the burden on women, it becomes crucial that men are not subjected to same coercive methods. Women rights and gender perspective that involve ensuring complete information, undue external influence and decision to opt out of sterilization are significantly important to change the way population policy is practiced in the country. Alternate options such as mass distribution of free condoms have helped bring down the birth rate over the last three decades (Pandey, 2014). While the draft does promise to take steps on these regards but does not have any policy direction or action plan for the same. 5) Missing Talk on Disability in the Country According to the 2011 census data there are about 26.8 million people with disability in the country, which was a rise from 21.9 million in 2001. As per the Disabled Rights Group the numbers could be much higher as many people in rural areas do not reveal disability in their family. Disabled have a greater need of medical assistance (Dhar, 2013). The need to provide them with aid/appliances has become crucial to ensure their social, economic and vocational rehabilitation. However, the current system is severely compromised and has inadequate health services to offer them, which makes them a particularly vulnerable group. “Research in Uttar Pradesh and Tamil Nadu states of India found that after cost, the lack of services in the area was the second most frequent reason for people with disabilities not using health facilities” (WHO, 2011). The document fails to deal with the special needs of disability in the country. A comprehensive plan or direction towards making health accessible to disability is missing in the policy. Budget and the National Health Policy 2015 Successive governments have consistently failed to live upto their commitments of spending in health sector. As per the Twelfth Plan the government commitment was to provide Rs 3,00,018 crore. However, the budgetary releases over the first three years have been only 56% of the plan allocation (Chowdhury, 2015). The budget presented to this year, 2015,also shows that the government’s priority towards health is not as significant as is promised in the health policy. The decreased budget allocations to different departments of health ministry clearly reflect this. As per demand for grants, the allocation for Department of Health and Family Welfare was INR 38445.79 crore in 2014-15 (BE). This was decreased to INR 32368.67 crore in 2015-16 (BE). Similarly, Department of AIDS Control saw a decline from INR 1785.00 crore in 2014-15 (BE) to INR 1397.00 crore in 2015-16 (BE) (India Budget, 2015). One may attribute this decline to changing pattern of fund sharing with the state government on certain schemes of the health ministry. Transferring money to the state government without ensuring accountability to health sector does not guarantee that the sector will get the necessary funds it requires. However, to meet the target of expanding health expenditure to 2.5 percent of GDP, health should have been given a greater impetus. As per Centre for Budget and Governance Accountability, the Union Budget 2015-16 should have increased the total allocation in the health sector by at least 1 percent of GDP from the present 1.2 percent. Conclusion The concept of Right to Health is not new in India. This idea was conceptualized in the Draft National Health Bill 2009, which did not move beyond the draft stage. Moreover, question of universal health care was also discussed in the Planning Commission’s High Level Expert Group. However the recommendations of documents have neither been included nor discussed in the draft bill. National Human Rights Council has stated that the draft lacks a rights perspective. This is especially evident in paragraph 12.2: while it promises a ‘National Health Rights Act’, it goes on to say that states will ‘voluntarily adopt by this by a resolution of their Legislative Assembly’. Meaning, there may not even be a national legal guarantee to the right. An integrated health system needs more than a working health care sector. It also involves providing basic amenities including food, water, clean air, sanitation and freedom from violence. Any promise of universal health has to be based around public action. This requires involving panchayats, local level communities and their coordination with public institutions. The draft recognizes these ideals but offers no operational guidelines on financing health, managerial inputs on regulating private sector, administrative framework on infrastructure or any comprehensive policy prescription to achieve its grand goals of ‘health for all’. Even when it does so, it is incomplete and offers no commitment for the results. In conclusion, stronger policy plans, formulated in consultation with the public, needs to be adopted to ensure that the goals of the draft become a reality.