Recently, the Central government invited comments on its Draft National Health Policy (DNHP). The DNHP provides an exhaustive coverage of health issues and challenges facing this much neglected sector. Its major recommendations are making health a justiciable right and denial of care an offence; provisioning of health services through a strengthened public health delivery system in partnership with the private sector; enhancing public spending from the current level of 1 per cent of GDP to 2.5 per cent; mobilising resources through enhanced taxation on alcohol and tobacco, extractive industries, medical tourism and a special health cess, etc. Essentially, the DNHP reiterated the continuance of existing strategies.
The DNHP is the usual please-all document and is cost neutral. Basically, since the last national health policy in 2002, over six well-researched reports have been published, stating the ills that plague India’s health system and providing solutions. The non-implementation of the several excellent recommendations is on account of the lack of political will and the institutional incapacity to reform.
The DNHP needs to, however, be read against the backdrop of reduced funding for health. In the first three years of the 12th Plan, health got less than 25 per cent of the resources against its allocation of Rs 3 lakh crore provided for the five years, not to mention another 20 per cent cut imposed recently. Read with the composition of the Niti Ayog, which consists of macroeconomists, and given that the deliberations of its first meeting did not mention health, there is concern whether this government, in its hot pursuit of growth, may continue the past tradition of ignoring social sectors like health and education.
The argument to enhance public spending on health rests on two grounds. First, the centrality of health to development and economic growth. While 12 per cent of absenteeism among industrial labour is on account of ill health, the demographic dividend can be reaped only if the youth are healthy and productive. Second, the state’s primary obligation is to deliver public goods as an entitlement. This cannot be left to the market. A more comprehensive redefinition of poverty, to imply not just employment and incomes but also access to good quality health, education and nutrition, is essential for building capabilities. Clearly, health and wellbeing is not just a question of doctors, hospitals and free drugs but open parks, clean air and water, uncontaminated food and a safe and clean environment as well.
The DNHP needs to take a position on important policy issues — Centre-state relations and greater decentralisation. The DNHP does not mention this aspect and, instead, merely points out that the Central share needs to increase from the current level of 34 to 40 per cent of total public health spending. With the actual implementation then dependent on the fiscal positions of the states, a view needs to be taken on how to enhance their capacity to achieve health goals. In such an environment of constrained finances, prioritisation becomes inevitable, giving rise to two issues: One, to what extent the Centre should lay down principles and goals for states to achieve as conditional for its grants, leaving states to design their implementation strategies. And two, what such national goals should be — worry about the remuneration to community workers or to capacitate the states’ technical and administrative abilities to deliver the wider definition of comprehensive primary care as an entitlement to all its citizens as a first immediate goal? Or, neglecting this primary responsibility, to assist states to launch hospital insurance programmes?
As India’s disease burden is not spread equally among all socio-economic population groups or regions, there is a need for differential strategies. If two-thirds of maternal, infant and under-five mortality and the burden of communicable diseases are concentrated in less than 200 of the 670 districts, and if these districts have no infrastructure for delivery of services, the people are poor, illiterate and have no access to basic goods, where even a sub-centre takes more than an hour to reach due to no road and transport connectivity, and since infectious diseases do not respect boundaries, should the Centre take the primary responsibility of helping such states to achieve a measure of equalisation? It could decisively intervene with a differentially funded strategy to be implemented in a mission mode, Centrally-monitored and directed till requisite capacity at the local level is developed. Or should it continue to treat all states equally and allow the disparities to widen, with no significant window for the catch-up of historical inequities? What principles must guide the Centre in making such choices?
Finally, the DNHP is full of contradictions regarding the role of the private sector. A public-private mix entails reforms in the way financing and governance are structured in health. To begin with, bodies like the Medical Council of India, constituted in 1933, need to be revamped to meet human resource challenges. Besides, laws need to be put in place to make the private sector more accountable. There are, at present, neither grievance redress mechanisms nor malpractice or fraud laws to regulate unscrupulous providers gaming the system. Governing the private sector will then require financial and institutional reform, a set of skills and competencies that governments and public authorities at all levels of administration seriously lack and need to develop. These need to be clearly addressed, with a roadmap.
The issues facing the health sector are politically sensitive. These need a political and not bureaucratic response. We need to build a political consensus to rectify distortions that have undermined India’s health system, not another national health policy giving a wishlist of ideal scenarios. The time has come to make hard choices and take the big leaps for transformative change.
The prime minister should appoint a high-level committee under the chairmanship of the health minister consisting of representatives of all major political parties to draft the national health policy, reflecting the combined vision of what we want our health system to be 15 years hence. Only then will the policy carry credibility, be an implementable document and one that state governments can be held accountable to. Anything less will be yet another bureaucratic exercise with no political traction. The health sector, more than ever, requires political leadership at the highest level to pull it out of its dire straits. The common citizenry expects this and more from a government elected on the promise of delivering development and wellbeing.
The writer is former secretary, ministry of health and family welfare.