The National Health Policy 2017, approved by the Union Cabinet on 16 March, came after a hiatus of nearly 15 years. It was last introduced in 2002 by the then Atal Behari Vajpayee government. Once the current government came to power around three years ago, the drafting of the policy started in 2015. The draft that has been made public in 2017, envisages the goal of achieving the “highest possible level of healthcare” by raising public health expenditure to 2.5% of the GDP from the current 1.15% by 2025, optimise primary healthcare by allocating two-thirds of its resources to it, and increase collaboration with the private sector/non-government organisations for strategic purchasing, capacity building and skill development among several other stated promises. However, many health experts see the policy as a “half cure” and are worried about the implementation.
The focus of NHP 2017 is more on “preventive” healthcare than on “curative” healthcare. So the policy advocates an incremental assurance-based approach, by increasing the public health budget to 2.5% of the GDP. The existing spending, at 1.15%, hovers well below the global average of 5.4%.
However, Dr Shyam Ashtekar, former Director, School of Health Sciences, Maharashtra Open University said, taking the route of taxing to raise the required revenue may not be feasible: “Target of health allocations cannot be done with states reeling under financial hardships, and especially when the NHP talks about government as the single-payer system, banking on taxes solely. This is infeasible, unrealistic and needless. The 2025 target of 2.5% of GDP amounts to postponing the task. There is little regulation of the sector, especially with diverse players such as profit to non-profit, informal to corporate care.”
“Two per cent of the allocation would be required just to fill vacant seats (posts of doctors, nurses, etc) and to ensure payments through Seventh Central Pay Commission. The middle class should be roped in for the pocket private expenditure, without putting the burden solely on the government,” he added.
According to Jyotsana Pattabiraman, Founder and CEO of Growfit—a health-based enterprise based on preventive healthcare—the economic burden of lifestyle diseases in India is alone US $54 billion, which cannot be met with a meagre 2.5% of the GDP.
Dr Shailaja Chandra, former secretary in the Ministry of Health and Family Welfare, and former Chief Secretary of Delhi, admitted that while the government usually faces difficulty in giving resources with contending priorities, however, exceptions get made. “When the subject of reproductive health was given prominence, National Rural Health Mission was formulated and a huge infusion of resources was made. It has been sustained over the last 12 years. So if the government decides to accord priority to specific health concerns, additional funds could be given. But it is uncommon for sudden block grants based on percentage of GDP being made,” she told The Sunday Guardian.
Another major takeaway from NHP 2017 is bringing in greater private partnership for strategic purchasing in fields where the government alone cannot manage to dole out the desired facilities. While there is concern over increasing public-private partnership falling prey to shoddy and unregulated market mechanisms, Dr Ashtekar called the partnership inevitable, required to plug the gaps in the public systems.
“They (the Union Cabinet) have chosen a pragmatic way, since many states are struggling with their systems. Market mechanism failure is an issue, but so is the failure of the public system. They term ‘strategic purchasing’ and this could be in the area of tertiary care, and how honestly states do this will set the tone for the future,” he said.
The private sector already provides 60%-70% of both inpatient and outpatient treatment.
Dr Shailaja Chandra cited the success of previous such partnerships, but called for transparency and strict monitoring for a proper supervision of the strategy. She gave the example of the Jansankhya Sthirata Kosh, which is dealing with the acceleration of population stabilisation. In this, private organisations are given the contract for performing a package of 100 sterilisations in districts with high unmet need for contraception. “Private hospitals were paid in advance, subject to acceptance of given conditions. In return, the (government) organisation got the private hospitals to take complete charge of the sterilisation camps, including local publicity, engaging surgeons and arranging equipment and consumables. A similar PPP model was adopted by Gujarat’s Chiranjeevi scheme, in which the state contracted private hospitals to conduct 100 deliveries—by giving advance payment and with no extra charges for caesarean deliveries. So, such models can certainly work, provided the schemes are legally and financially sound,” she said.
The National Health Policy also talks about bridge courses that admit graduates from different clinical and paramedical backgrounds like BSc, nurses, pharmacists, and AYUSH doctors and equip them with skills to provide healthcare services. Likewise, the policy also recognises the need to improve regulation and management of nursing education by establishing nurse practitioners and public health nurses to increase their availability in the most needed areas.
The healthcare system grapples with a severe paucity of doctors, considering which the policy calls for a constant effort to increase the total sanctioned posts of doctors in the public sector to ensure their availability at all times. It talks about expanding the postgraduate training up to the district level and converting district hospitals to new medical colleges to increase the number of doctors and specialists.
“Students need to observe and participate in giving medical treatment in field conditions and the OPDs of hospitals, casualties and emergency centres are better places to learn than in colleges and attached hospitals, many of which have a poor turnover of patients. This will need agreements and close coordination with MCI and a slew of hospitals. The policy also speaks of increasing postgraduate seats and using the channels available through the National Board of Examinations,” added Dr Shailaja Chandra.
Dr K.K. Aggarwal, Director, Indian Medical Association, said the one thing that the policy lacks despite its good intentions is the inclusion of universal care for patients in both government and private hospitals. “It is just the 20% of the population that goes to the government hospitals. The responsibility of the rest that goes to private institutions should be borne by the government in the same manner. Hence, emergency care and primary care, essential medication and investigation, should be free in government as well as private hospitals,” he said.
The policy also touches upon the reduction in out-of-pocket expenditure due to healthcare costs. But it does not state how it plans to achieve this target. As per a World Health Organization study, India features among the countries with high out-of-pocket expenditure, where 89.2% of the expenses of medical treatment are borne by the patients. Advocate and civil rights activist Ashok Aggarwal said that the expenditure is doubled or tripled if the patient is denied treatment at one hospital as the entire process has to be re-initiated to get the patient treated.
Among other unaddressed issues, the policy talks of the Clinical Establishment Act 2010—which aims for quality control and regulation of standards in all clinical establishments—but only in terms of advocacy, or recommendation, with other states for its adoption. The Act has taken effect only in the four states of Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim and all the Union Territories except for Delhi NCT.
Dr Chandra emphasised that the Act should be picked up by all states: “Although there is a general mention about advocacy with the states, that alone is not enough. The government must create a regulatory authority to regulate clinical establishments when there are so many complaints of over medication, inflated costs and malpractice. That would require that the subject is approached through consensus, but keeping consumer interest uppermost. It even merits an examination of the possibility of regulation of medical establishments on the concurrent list of the Constitution, because it affects so many problems that consumers face in both public and private sector hospitals.”