Monday, January 26, 2015

The draft National Health Policy 2015 needs to pay more attention to the basics of healthcare.

Over 63 million persons in India face poverty every year due to healthcare costs alone with the share of out-of-pocket (OOP) expenditure on healthcare as a proportion of total household monthly per capita expenditure being 6.9% in rural areas and 5.5% in urban areas in 2011-12. In view of this, the central government’s draft National Health Policy (NHP) 2015, which is in the public domain and open to suggestions and comments until 28 February, is particularly significant. The draft NHP intends to make health a fundamental right and therefore its denial a justiciable matter. It hopes that this will “give a push for more public health expenditure as well as for the recognition of health as a basic human right”.
Undoubtedly, this is a welcome proposal but the right to education, which was declared a fundamental right in 2009, comes immediately to mind. The parallels with healthcare are many: the quality of education in government schools and the quality of services in public hospitals and primary health centres; the insistence, as a result, of even poor parents on their children attending private schools, however badly run; the beeline to private hospitals even by poor patients; and the small and large glitches in the implementation of the law. The lesson is obvious: what looks excellent on paper becomes a different proposition when it has to be put into practice.
The draft policy proposes increasing the expenditure on healthcare from its present level of 1.04% to 2.5% of grossdomestic product (GDP) in the next five years. This increase is, however, way below the requirement but what is not convincing is the explanation for keeping it at 2.5%: the healthcare system’s low absorption capacity and inefficient utilisation of funding. Incidentally, the government got a lot of flak for the temporary cut of 20% in the 2014-15 healthcare budget. The draft policy hopes to create a health cess (similar to the education cess) on liquor and tobacco products. One will definitely need to examine whether such a cess will be even close to adequate. Nevertheless, the draft policy promises that there will be universal access to free drugs and diagnostics in hospitals even as it notes the fact that the national health programmes leave out 75% of the non-communicable diseases and not all communicable diseases are covered either.
However, it does seek to broaden the definition of primary healthcare to accommodate reproductive and child health as well as some non-communicable diseases. The draft also seeks to involve panchayati raj institutions in a big way and lists seven “priority” areas to get the community and media to participate. Among these are the Swasth Nagrik Abhiyan (of which the Swachh Bharat Abhiyan is a part), the Nasha Mukti Abhiyan (anti-tobacco and alcohol measures), Yatri Suraksha (prevention of accidents) and Nirbhaya Nari (against gender violence, sex determination tests, etc).
According to the draft policy, the private sector provides nearly 80% of outpatient care and 60% of inpatient care. However, while noting the many concessions by the government to build a “positive economic climate for the healthcare industry” and hoping to “intervene and to actively shape the growth of this sector for ensuring that it is aligned to its overall health policy goals”, the draft does not go anywhere near spelling out the forms of intervention, whether institutional or regulatory. Whether it is the National Accreditation Board for Hospitals and Healthcare Providers or the Clinical Establishments (Registration and Regulation) Act of 2010, the response of the private players has been far from enthusiastic.
The draft has just one paragraph on mental health noting that it needs urgent attention since the gap between service availability and needs is widest here with 43 facilities in the nation and 0.47 psychologists per million people. It includes the Mental Health Bill (there are a few others too) among those that need to be reviewed. Considering the state of the mentally ill in this country, this section needed to be much more comprehensive and well thought out.
Ultimately, the devil is in the detail. India’s public health services need so much more basic infrastructure, medical and paramedical personnel, ironing out of the implementation wrinkles in the health insurance schemes like the Rashtriya Swasthya Bima Yojana, promoting computer-enabled systems to reach out to patients (like Tamil Nadu has done), straightening out of the corruption-ridden system of procurement and distribution of drugs, these among a long litany of requirements. The private sector needs a massive dose of regulation and monitoring in almost all aspects, from pricing to crooked third-party administrators to patient-care standards. At the government level, there has to be a deep commitment to make health-for-all a deliverable right, starting with plugging the leaks and poor utilisation of funds under various schemes. All this must come before the claim to make the right to health a justiciable right.

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