For ailing health system, a new policy but no cure

The government's 2017 policy is unlikely to deliver better than the 2002 one

India’s health scene is marked by a highly inadequate public healthcare system and, what usually goes with such a situation, patients having to spend huge amounts of their own money. So when a new national health policy is announced (National Health Policy 2017), it is eagerly scanned to see if it has been able to put its finger on the pulse — list what needs doing for things to work where they must.
 
But hope is tempered by the fact that health is a state subject and most of official spending, low by normative standards, is done by state governments. Simultaneously, the country is marked by huge differences in both the quality of healthcare and human development attainments between states. Additionally, the goals set by the 2002 policy were not achieved and have in good part been adopted by the 2017 policy along with a setback in target dates.
 
Hence the impact of a new national health policy is best judged by posing two questions. One, where did the 2002 policy go wrong? Two, is there anything in the new policy which is targeted at bringing up the laggard states? Since in 2002 also the National Democratic Alliance was in power as it is now and in between there were 10 years of Congress rule, it may be useful to look for deeply entrenched realities to which politicians, across the board, do not have ready answers.
 
The 2002 policy is a remarkably honest document that finds the then existing structure far from satisfactory. If rural public healthcare services are inadequate, they are non-existent in unrecognised urban slums where migrants from rural areas usually turn up.
 
It said there was a need to train nurses (have more and better nurses and nurse practitioners) and paramedics to fill the skills gap and guidelines were needed for training and performance of paramedics. Also, there was a great need for doctors with specialisation in public health and family medicine. To take care of the rise in private healthcare, there was a need for regulation to ensure adequate standards.
 

A key element of the policy was the call to rope in civil society. It proposed to engage civil society, more particularly in disease control, where action at the individual level was needed.
 
The declared objective of the policy was to promote equity and this could be done by promoting and strengthening the primary health sector and free supply of drugs. It proposed that a revival could be kick-started by providing some essential drugs under central government funding through the decentralised health system.
 
The policy readily declared that the Centre would give more for state healthcare so as to reorganise and facilitate more equitable access. Interestingly, the policy welcomed the private sector only “in principle” in all sectors of healthcare. A publicly funded and privately delivered social health insurance scheme could be tried out as a “pilot”.
 
It was alert to the threat to health security that could be posed by drug prices going up in the post-TRIPS era. As a backup, it was proposed to source at least 50 per cent of vaccines from public sector institutions. This would keep going treatment regimens based on generic essential drugs.
 
To answer the second question, let us now look at the National Health Policy 2017. It is on the dot about the centrality of public health services in which public hospitals are a part of the healthcare system. On spending priorities in public healthcare, the policy strikes the right note by affirming that two-third of spending will go to primary healthcare.
 
The strongest element of the policy is the call to strengthen the public procurement system for drugs, essential for supplying free medicines to the poor. It solidly favours drug price control and recommends its extension to diagnostics and equipment but does not recognise that efficient procurement achieves the same results as price control without the bureaucracy.
 
Where the policy clearly contradicts current policy is to recommend strengthening pharmaceutical public sector units to ensure the country is self-sufficient in essential medicines and vaccines. (The 2002 policy held similar views.) The government on the other hand is busy either selling or closing most of these undertakings.
 
It is odd that adoption of global good clinical practices for clinical trials is recommended by the policy but no mention is made of enforcing good manufacturing practices to address the Indian deficiency in drug quality. The frequent pulling up of Indian drug exporters to the US by that country’s Food and Drug Administration is an issue which a new heath policy should have addressed.
 
The policy devotes considerable space to using resources with not-for-profits and the private sector to expand the healthcare infrastructure and strengthen healthcare delivery. But engaging the private sector by contracting and strategic purchasing of health services can be fraught. Beginnings can be made, but caution is advisable.
 
On the critical issue of the government buying services from private practitioners and hospitals, the public is bewildered. The media is periodically hit by scandals like unnecessary hysterectomy procedures being done on poor illiterate women by unscrupulous private healthcare providers to plug into state reimbursement processes. Stories also abound of gullible people with minor ailments being admitted and put through elaborate investigations by chasing a non-existent major condition simply to utilise a chunk of the patient’s insurance cover.
 
Not unexpectedly, views among healthcare professionals differ widely. A doctor, who is familiar with both government and private hospitals, feels that “for a population the size of India and with current levels of impoverishment, state healthcare cannot develop adequate capacity in the foreseeable future. So the solution is to pursue schemes like Rashtriya Swasthya Bima Yojana and in fact open it up to the better off by defining separate rates for them for the same services. This will spread costs and thereby lower funding needs.”
 
On the other hand, a senior executive in a corporate hospital is very sceptical about the government buying services from the private sector. “It is fraught with scope for misuse. To get over the capacity issue in public health services, a strengthening of the primary and secondary infrastructure reduces the need for referrals. This will unclog both secondary and tertiary care institutions.”
 
Of the two policies, the 2002 one scores better. It is honest, direct and mentions the currently unmentionable “civil society”. The 2017 policy is heavier on jargon and marks a policy change in emphasising greater engagement with and purchasing from not-for-profit and for-profit sectors. Will the new 2017 policy deliver better than the 2002 one? Doubtful. It reads like the result of the need to undergo a ritual to produce a document.
 
Policy goals

• Increase life expectancy at birth from 67.5 to 70 by 2025
• Reduce under five mortality to 23 by 2025
• Reduce maternal mortality to 100 by 2020
• Eliminate leprosy by 2018; Kala-Azar by 2017
• Increase utilisation of public health facilities by 50 per cent by 2025
• Increase health expenditure as a percentage of GDP  to 2.5 per cent from 1.15 per cent at present