Since independence, India's national health policies have been aspirational but the end results have been limited. The National Health Policy 2015, which is in the process of being finalised, should, in place of the earlier "broadband" approach, adopt a "narrow focus" on primary healthcare through the National Rural Health Mission. The latter has focused on primary healthcare and has shown visible results. A slew of suggestions as to how this can be done are made in this article.
Javid Chowdhury (javid.chowdhury@gmail.com) is a retired IAS offi cer who has served as the Union Health
Secretary. He is now associated with NGOs and continues to research public health policy issues.
The Government of India is in the process of framing the National Health Policy (NHP) 2015 with the draft already in the public domain for comments and suggestions. This article traces the features of the previous two national health policies of 1983 and 2002 and arrives at some recommendations for NHP 2015. The Health Policy of 1983 drew upon the general ideas of the Alma Ata Declaration, a global milestone in propagating public health, principally through primary healthcare. Its follower, the Health Policy of 2002, was less general in approach, looked at the health terrain from a lower altitude, and made recommendations on strategy and policy that were more pointed. Also, the 2002 policy recommended focus on primary healthcare more forcefully. After the introduction of the 2002 health policy, the Ministry of Health and Family Welfare (MoHFW) adopted a new programme, the National Rural Health Mission (NRHM) which was in the nature of a “ring-fenced,” exclusive, primary healthcare scheme. In the eight years since it has been introduced, its outcomes have been promising. Rural health indices have been seen to be improving as never before. Looking at this background, we would recommend that the “ring-fenced,” primary healthcare scheme be adopted across the country with assured funds, and no possibility under the rules for diversion of these funds. This article also makes some other recommendations on key policy issues relating to this sector.
1 Disease Profile
The NHP 2015 would necessarily have to be set in the existing health scenario. Today we face what is called the “double burden of disease” — a large volume of age-old communicable diseases (tuberculosis, malaria, respiratory tract disorders, gastrointestinal infections, etc), and now increasingly combined with a heavy burden of non-communicable (diabetes, cancer, and cardiovascular), also known as lifestyle diseases. Malnutrition is still widely prevalent in the country with 44% of the children under the age of five being underweight, while 72% of the infants and 52% of the women are anaemic. Even the very inexact estimates of morbidity and mortality for the major diseases that are available indicate a staggering disease burden: TB two million new cases and 0.4 million deaths per year; malaria 15 million cases per year; HIV-AIDS (prevalence) 2.4 million cases. If in a developed country the disease burden was even a fraction of that given above, the concerned government would have immediately declared a “health emergency,” if not a more broad-based “national emergency.”
2 Resources for the Health Sector
As in any other country, the challenge of maintaining a state of good health and well-being of the citizenry has to be met through interventions in the primary, secondary and tertiary sectors. For India, the total health expenditure (THE) is 4.5% of its gross domestic product (GDP), a small fraction of the modest norm of 6.5% of GDP suggested by the World Health Organization (WHO) for developing countries. What the Indian citizen gets in the health sector is a derisory amount compared to that in the developed world: US 16.9%; France 11.6%; Switzerland 11.4%; Germany 11.3%; Japan 10.3%; UK 9.3%. Even more distressing is the fact that the public health expenditure (PHE), which is the state contribution over the years, at 1% of the GDP has hovered close to that of the lowest five countries of the globe. These figures clearly indicate that even in highly developed countries, where the capacity of the average citizen to finance his/her own health services independently is very high, the state considers it a prime component of the responsibility of governance to fund healthcare. Strangely, in India this responsibility has been implicitly abdicated by the state on the specious ground that we cannot afford the required resources for the sector.
2.1 Plan Contributions
As a deliberate departure from the past, the government for the Eleventh Five Year Plan had fixed an enhanced resource allocation target of 2% to 3% of the GDP. This was not overambitious, but as it transpired, even this turned out to be an optical illusion. In the event, the actual release of resources over the plan period amounted to 1.04% of the GDP, no different from the earlier five-year period.
Over the Twelfth Plan period the government commitment was to provide Rs 3,00,018 crore. In point of fact, the budgetary releases over the first three years have been only 56% of the plan allocation. The persistent failure in meeting plan commitments by making commensurate budgetary allocations gives a very poor impression of the sincerity of the government in supporting the social sectors.
3 Health Policies Over Time
The health policy has to be determined in the context of the prevailing health scenario and the existing health organisational structure. Despite some improvement in the health standards of the country in the decades after independence, the strategy of service delivery over much of the period was ad hoc, particularly so in the private sector. At this stage of the discussion it would be appropriate to briefly recall the principle stages through which the health policy has traversed in the years after independence.
3.1 NHP 1983: Base Camp
The paramount need for a well-designed national health policy came to be highlighted after the Alma Ata Declaration. The NHP of 1983 was our first attempt to draw up a structured policy specific to India’s health sector. As it followed the Alma Ata Declaration, the NHP 1983 turned the arc-light on a well-dispersed network of primary healthcare services linked with extension services and health education. However, along with the primary healthcare component, almost every other area of concern was included in the policy document like drinking water, sanitation, nutrition, environmental impact, etc. It is recognised that the various social determinants of health have a significant impact on the state of health of the community, and the contributory impact of the social determinants is crucial to the ultimate quality of the health scenario. However, I believe that to keep the span of the study manageable, the NHP 2015 should cover only the core components of the health sector, while the other social determinants should be left to an independent policy document.
The NHP 1983, after covering at a generalised level almost every possible element in the universe of “health,” did not provide adequate conceptual guidance to the public health administrators as to how they should strategise and projectise. In result, the strategies and projects adopted by the government in the decades after that were at best sui generis and at worst ad hoc. What we now find staring us in the face is that most of the elements of the policy of 1983 were projected at an aspirational level, and these proved to be of limited assistance to the public health administrator in actually strategising schemes and implementing them. If any strategy or scheme achieved an internal coherence with an element of the policy, it was entirely a matter of accident. Improvements achieved in the health sector were of an accidental nature, not linked to any health sector targets, and were helped along by the other contemporaneous developments in the economic sectors.
3.2 NHP 2002: One Step Forward
I had the good fortune of piloting the exercise for drawing up the NHP 2002 and thereby gained first-hand experience of what it involved. In the course of drawing up of the NHP 2002 extensive consultations were held with health experts from academia and administrators of non-governmental organisations (NGOs). But, without in any way denigrating the expertise of these contributors in their own areas of functioning, it was apparent that their exposure to national policy formulation was limited. Most such individuals/organisations are passionate about their own areas of interest, but few have broader exposure to national level issues. Quite often the experts from academia and the administrators of NGOs tend to swing the policy document towards their areas of special interest without being able to stitch together inherent coherence in the broad features of a balanced policy document.
Nearly two decades after NHP 1983 had been adopted, in 2002 a dire public need was felt to draw up a fresh health policy. It was observed that over the period many elements of the earlier NHP had not really been internalised by the public health functionaries, and did not significantly result in practicable strategies. Improvement in the primary healthcare services in the rural health sector was woefully inadequate — the state could not in good conscience claim that it had adequately discharged its responsibilities of governance. The drafting team for NHP 2002, therefore, sought to design a corrective thrust for what was seen as conceptual inadequacies in the NHP of 1983. To make the policy more user-friendly, the NHP 2002 made a conscious effort to pitch it such that the conceptual direction was plain to everyone, and strategies/programmes automatically followed. To put it differently, the attempt in NHP 2002 was to bring the level of discourse down from the stratospheric level to cruising level.
To assist the stakeholders in optimising operational efficiency a road map was set out in NHP 2002, which had the following principle components:
(i) An enhanced quantum of central resources for the health sector, as these were inordinately low. Specific change of the resource allocation suggested was an increase of the PHE to 2% of the GDP and the THE to 6% of the GDP by year 2010. NHP 2002 also advocated an increase of the share of central government expenditure to 25% of the PHE from the existing level.
(ii) Focus on the goal of equity in the health system by increasing the share of primary healthcare, which is the more cost-effective category of expenditure with the suggested ratio of 55% of the resources for primary healthcare, 35% for secondary healthcare and 10% for tertiary healthcare.
(iii) Convergence of all disease control programmes under a single field administration (except the vertical programmes), in order to establish unity of command and economy and flexibility of operations.
(iv) Implementation of field programmes through autonomous organisations at state and district levels to ensure operational autonomy.
(v) Use of only generic drugs and vaccines in primary healthcare services. Providing of essential drugs under central funding in order to kick-start the activities in the otherwise moribund rural health system.
(vi) It was accepted as a situational reality that the contribution of the private sector in providing services had to be factored into the architecture of the health system. Also, it was noted that with such a large portion of the services coming from the private sector, statutory norms needed to be put in place immediately for regulating infrastructure, clinical practice and medical service standards.
Before we set out to make suggestions for NHP 2015, it would be appropriate to assess how much impact the NHP of 2002 had on the health scenario in the decade after its adoption. The overall performance was not impressive in the early period. The allocation of financial resources to the health sector (as percentage of the GDP) was on the same scale as in the pre-policy period. As had been happening in the past, rural healthcare had largely been provided as a diluted form of primary healthcare. The apportionment of allocation of health resources to the primary sector had not changed much, primary: 55%; secondary: 18%; tertiary: 27%. There was an undesirable swing towards the expensive tertiary sector. Pooling of public health personnel for other than vertical programmes has been introduced, but only fairly recently. Autonomous bodies have been set up in many states for managing the health programmes.
4 National Rural Health Mission
While no significant improvement in the national health scenario was observed even till the turn of the millennium, of late there has been a change in the situation which holds out a degree of promise as never seen before. About a decade ago, health administrators came to the conclusion that we needed a radical change in our priorities. It was felt that it was unrealistic to try and meet resource requirements for all desirable elements of the health sector. More serious, “primary healthcare,” our priority, came to be neglected. In this unacceptable situation it was considered necessary to adopt a health programme, which, without any scope for deflection, focused on primary healthcare.
The resources released under previous annual budgets were nowhere near the committed amount and the management attention required for a flagship programme was never made available. In the circumstances, the health administrators felt that they must cut away from the old-style budget-making where everyone is kept happy, and design a rural sector project that is funded and implemented entirely as a “fire-walled” project. The objective of the scheme was to provide primary healthcare to every citizen free of cost and the project was named Universal Health Coverage (UHC) by the United Progressive Alliance (UPA) government (and renamed Universal Health Assurance by the National Democratic Alliance government).
The central government’s NRHM launched in 2005 has completed eight years (2005–06 saw the finalising of the programme and there were no field operations in this period). In my personal capacity, I undertook an evaluation of its performance based on programme statistical returns up to June 2014.1 My analysis on the performance and prognosis is contained in a monograph published by the National Institute of Health and Family Welfare titled “National Rural Health Mission: Performance and Prognosis.”2 I have relied on some of my findings in that monograph in this article. The programme was essentially a time-bound, mission-mode one, with many novel features.
The significant ones are: (i) It is a focused programme to strengthen and improve the rural health organisational structure, thereby radically improving the quality of primary healthcare service delivery, particularly relating to women and infants; (ii) increased deployment of the requisite skilled human resources at the different levels of the rural health system; (iii) increased allocation of financial resources on a sustained basis for consumables, infrastructure and for emergent situations; (iv) redesign of the matrix of administrative and financial procedures, particularly including delegation of adequate powers at different levels; (v) creation of community-based entities at different levels of the rural organisational structure for increasing community participation in planning, execution and monitoring of the rural health services. Some of these are old-time elements of the existing rural healthcare system, and it is only that they are to be strengthened by large infusions of the human, financial and material resources. Others like those relating to the co-option of community-based entities in the process of planning, implementation and supervision of the healthcare services have been introduced for the first time.
So far under the NRHM the health structure has been substantially reinforced with infrastructure, technical staff and an additional management module. Another module that was introduced in the NRHM was of community participation through voluntary workers and community institutions. The volunteers were called accredited social health activists (ASHAs) and were paid a nominal honorarium of Rs 500 per month, plus any other amount they could pick up from other government schemes on a piecework basis. These ASHAs were put through an elementary orientation course for: diagnosing/treating simple medical conditions, mediation between the patient and the health administration, and interceding in matters relating to advocacy in public health and hygiene.
More budgetary items permitting flexi-funding have been introduced in the NRHM, and reproductive and child health (RCH) budgets. Under the NRHM administrative processes have also been modified delegating much more administrative/financial powers to the lower formations. In sum, much more flex has been brought into the organisation of the rural health system, both at the level of service delivery and at the administrative/management level. It has also been noticed that these additional powers and facilities have been widely and beneficially used under the programme.
In addition to the organisational changes, significant changes have been made by way of providing substantial additionalities of infrastructure and consumables. Deployment of graduate doctors and clinical specialists has also improved noticeably in the primary health centres/community health centres (PHCs/CHCs), even though they are still short of the norms. The improvement in service delivery over the period 2005–06 to 2013–14 has been marked. There is much more evidence of activity at the rural service centres. The outpatient department (OPD) attendance in certain parts of the country, where the additional inputs have reached, has increased dramatically. Along with the impact of the Janani Suraksha Yojana, institutional deliveries under the NRHM have also increased dramatically. From the limited statistics available at this stage, it is clear that there is a very encouraging trend in the improvement of infant and maternal mortality rates (IMR and MMR) during the period of the NRHM programme. The growing trend in the annual decline rate over the previous year in MMR has increased from 2.6 to 6.4 in the period 2007 to 2012; and, the under-five mortality rate (U5MR) decline trend has ranged from 7.8 at the highest to 5.4 at the lowest in the same period, i e, from 2007 to 2012. This marks a significant breakthrough in the outcome of services delivered in the rural health sector.
Despite the improvements in many areas, for the NRHM to establish itself over the entire country, more time is required. For the first time in memory the primary healthcare services had been energised and the rural health sector seemed to have acquired a new life. In this promising situation, it is imperative to ensure that the programme does not slacken for any reason. The NRHM has completed eight years and would need at least another eight years to stabilise. This estimate should not discourage anyone. The programme is nothing but primary healthcare services delivered in a more efficient and tight management structure, and this is a fundamental duty of state governance. So far very small amounts of resources have been made available for it.
Since it has a bearing on the NRHM, it again needs to be highlighted that the aggregate resources for the health sector are grossly inadequate. In monetary terms, the per capita THE in 2011–12 was Rs 3,000, out of which Rs 900 (30%) was PHE. The figure of PHE is the state commitment for all manner of activities, out of which that for primary healthcare at 50% of PHE, would be Rs 450.This is the situation in respect of availabiity of resources when the NRHM initiatives of largely covering primary healthcare have been rolled out unevely and thinly over much of the country. To implement the scheme on the scale it was planned, we would require a much higher quantum of THE, and a much higher share of PHE out of that THE. To bring the PHE somewhat closer to that in developed countries, it must be raised to at least 50% of the THE (i e, Rs 2,800 per capita) by 2016–17.
Though the NRHM was launched in 2005–06, which was quite proximate to the launch of the NHP 2002, it is not my claim that the outcomes of the NRHM were necessarily the direct result of only the conceptual elements of the NHP 2002. It needs to be recognised that any transformation in the social sectors is a creeping change through an osmosis-like process. With our changing perception over time, change would be expected to be creeping into the mindset of the public health administrators. The conceptual strands contributed through the NHP 2002 may also have to some extent contributed to the outcomes of the NRHM. The progress made by the programme in the first eight years can be said to be substantial, even if it has been slow. The experience of the NRHM seems to indicate that it would be best to conceptually frame the NHP 2015 around primary healthcare, as incorporated in the NRHM.
5 NHP 2015: Two Steps Forward
5.1 Broadband or Narrow Focus
As we have moved from the NHP 1983 to the 2002 Health Policy, and now move towards NHP 2015, the conceptual concerns of the new policy seem to suggest themselves. The policy should lean heavily towards primary healthcare. The claims from the other sectors, no matter how pressing, would have to be declined. Some of the central elements required in the NHP 2015, as I assess them, are discussed below:
(i) As the first strand of NHP 2015, I would suggest that, to discharge its minimal responsibility of governance, the central government must very substantially increase its contribution of resources to the health sector. Looking to the success in the NRHM, it is very much in our national interest to honour the resource commitments earlier made under this programme. The country now has a real opportunity to pull itself out of a situation of permanent ill-health. The Twelfth Plan allocation is 2.5% of the GDP. Inadequate though this is, we naturally have to work within it. However, plan commitments in respect of resources cannot be allowed to be illusory on an indefinite basis. The budgetary allocations in the first three years have been about 56% of the proportionate entitlement for the Twelfth Plan period. There must be a quantum jump in the last two years of the plan period if the government can defend its sincerity in making plan allocations. Since the NRHM has markedly picked up momentum, it would be possible for the sector to gainfully absorb double the allocation in 2016 and 2017, i e, Rs 80, 000 per year. This allocation would bring the per capita allocation in the last two years of the Twelfth Plan to about Rs 650 per capita. The additional allocation would make it possible to give a significant boost to the NRHM which is presently being choked for want of funds.
(ii) It has been observed earlier that the health status over different parts of the country varies greatly. As was explicitly emphasised, one key element of the NHP 2002 was the objective of bringing about equity in the health status over the country as a whole. There is no evidence to show that this has been achieved to any extent even after eight years of the NRHM. Primary services are much more cost-effective than secondary and tertiary services. As a result of this, the outreach of primary services is much more per unit cost than secondary and tertiary services. Currently, the primary sector is getting only about 55% of the health sector resources. This adverse skew needs to be corrected. Considering that the policy imperative is that an unwavering focus be placed on the primary sector, I would suggest a distribution of resources, thus primary: 70%; secondary: 20%; and tertiary: 10%. This normative allocation of resources between the categories should be treated as unalterable under the budget so that resources are not arbitrarily diverted.
Currently, the state provides about 20% of the OPD services and 40% of the inpatient department (IPD) services in the health sector. The goal of providing equitable services from the state sector requires that the share of OPD and IPD at least be increased to 50% each, to make access of the state services available to the vulnerable sections.
A review of the NRHM indicates that the expenditure has been more or less the same in states with inferior health status (high focus states for the purpose of the NRHM) as that in states with superior health status. Such a continuing situation will never ensure a levelling of unequal health standards. I am of the view that in order to ensure improved equity in the underserved areas, the health policy statement could even go to the extent of recommending a budgetary allocation norm for weaker health states that is twice that for the stronger health states.
It is widely accepted that there is over-medicalisation in the health sector, and much of the use of drugs is unscientific. While there should be no corner cutting, it is beyond doubt that there would be no compromise to the quality of treatment if primary healthcare is restricted to a limited list of generic drugs. In these circumstances, I would advocate that, in order to minimise the cost of the primary care package, only generics from a limited list be used as therapeutic drugs. In the course of time the compulsory use of generic drugs could be extended to private sector primary healthcare also.
(iii) There is no escaping the fact that the Universal Health Assurance (UHA)would place an enormous burden on the resources of the state as compared to what is provided today. It is therefore imperative that the primary care package which is finalised and offered be realistically limited. Emphasis should be placed on the “preventive” and “promotive” components of primary care as these are “low-cost” and are largely based on community participation. There is always a populist demand for “comprehensive” healthcare. I am of the view that this should be resisted till the NRHM, with a modest primary healthcare package, has stabilised.
(iv) There is a significant shortage in the country of trained health service providers. At the highest level — the graduate doctors — there is a severe shortage in the public sector. In our system staff nurses/auxilliary nurses and midwives/ multipurpose workers are supposed to discharge only those limited duties for which they have been specifically trained. At least in the near future, it cannot be expected that their skills can be enhanced to cover much greater responsibilities. The prevailing problem of non-availability of graduate doctors is virtually disabling the rural health system. For quite some time now the health administrators have been considering a scheme of starting a short-term graduate course of two and a half years with one year internship — BSc (Community Health) — with a service domain limited to primary healthcare. These short-term graduate doctors will be from the rural areas and they will come to replace the totally untrained practitioners who are today the only service providers there. All in all, at a policy level, there seems to be no conceptual danger in the introduction of the scheme for starting of the short-term graduate course.
(v) For a balanced national health system, the contribution of the state sector, both by way of financial resources and services, should not be less than 50%. For the state to make a contribution to the health sector, the public health service specialisation must be available in an adequate quantum. Currently, the number of public health specialists is extremely low. For the public sector to discharge its role, a minimum of 25% of the certified health insurance specialists should belong to the public health sub-cadre. In this backdrop, it seems essential to correct the disproportionately low presence of public health specialists in the health system in the shortest possible time. In sum, it can be recommended that the public health specialists be recruited against vacancies on an overriding basis till the share of the central health services cadre reaches 25%.
(vi) Our national health system had a unique organisational structure for the programmes relating to the heavy burden diseases like the Revised National TB Control Programme, vector-borne diseases, leprosy, cataract blindness and HIV/AIDS. To have any impact on the burden of these diseases, it was felt necessary to have independent health service teams and budgets. The NHP 2002 had observed that, where the need for vertical programmes had reduced, these could be wound up and merged with the unified rural health administration. Pursuant to that recommendation in the NHP 2002, the RNTCP was removed from the vertical programmes, though recent field reports indicate that this move may have been a little premature. Both leprosy and cataract blindness are diseases which have come down to manageable levels and, perhaps these could be removed from the category of vertical programmes. In the light of the above, it is recommended that the diseases to be retained in the category of vertical programmes be reviewed.
(vii) The health services in the country, both in the public and private sectors are virtually unregulated. While there are professional councils (of doctors, dentists, nurses, and pharmacists), to oversee the professional ethics and conduct of the service providers, these councils are riven with corruption and are practically dysfunctional. Also, there is no institution to technically regulate the quality of services provided by these practitioners. Since the NHP 2015 is likely to make several recommendations entrusting service responsibilities to lower order health personnel, it is necessary to put in place robust institutions to supervise the ethical standards and technical performance of the health practitioners. In sum, I would recommend that regulatory bodies be set up at the centre and the states at the earliest to oversee the service delivery and ethics of the professional service providers in the health sector.
(viii) The spread of medical colleges is very uneven over the country. To improve the spread and create quality standard-setting institutions, it would be necessary to set up government colleges in states in which very few exist. In the circumstances, it would be appropriate to increase the number of government medical colleges so that the total number in the country is equally divided between the public and private sectors.
6 Summation
Over decades we have pursued an aspirational health policy but with very limited outcomes. For the last eight years we have seen a shift in tack. Through the NRHM, the health system has attempted to turn the single-minded focus to primary healthcare in its well-structured format. The programme has shown visible results and the system seems set for a makeover. In a parliamentary democracy public policies are often determined on the basis of voter response rather than technical assessment. In areas where the NRHM has been implemented the voter enthusiasm has been immense. In addition to an improved primary healthcare system for the citizenry, the political executive could hope for a windfall of votes! With these promising circumstances, it is recommended that the NHP 2015 adopt the singular conceptual stance of promoting primary healthcare through the NRHM, even if it be at the cost of some other areas of the health sector. I would recommend that this policy, in categorical terms, declare that in place of the earlier “broadband” approach, it would be desirable to adopt a “narrow focus” approach — on primary healthcare through the NRHM. It would be a realistic assessment that in a decade, with a modest amount of financial resources and some operational hand holding, we should be able to achieve UHA in the country in respect of primary healthcare.
