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Resource centre on India's rural distress
 
 

A sketchy road map for health policy -Nidhi Khurana
-The Hindu

Much of the National Health Policy document reads like a report of health issues and systemic challenges, and is sorely wanting on policy detail

Health impoverishment - falling into poverty due to health care costs - affects 63 million individuals in India every year. This is a damning statistic, especially when read with the fact that 18 per cent of all households face catastrophic health expenditures (health expenditure greater than 10 per cent of total household consumption expenditure or 40 per cent of total non-food consumption expenditure). We are at an urgent precipice in time for making health policy work for the poor in India - the deep end of dire straits. The 2015 draft National Health Policy (NHP) is pregnant with possibilities. The first federal health bill to come out in more than a decade is a salient opportunity for the Narendra Modi government to present a coherent plan to deliver equitable, efficient and sustainable health care to India's billion plus citizenry.

The cliff notes version of the NHP recommendations reads thus: make health a fundamental and justiciable right; increase public expenditure on health from 1 per cent of GDP to 2.5 per cent of GDP; raise revenues mainly through general taxation while exploring the possibility of sin taxes (mainly taxes on tobacco and alcohol), and earmarks for health (akin to the education cess); and strengthen health services provisioning through strategic purchasing from the public and private sector.

Jumping the gun

By making health a justiciable right, the NHP appears to jump the gun. Whilst an excellent proposition in principle, it is unrealistic as the basic institutional framework, infrastructure and personnel needed to deliver health care for all is lacking. Sequence matters. An effort to make comprehensive primary care deliverable needs to precede the declaration of health as a justiciable right. Other than defining "comprehensive" as "not selective," the government might look to learn from innovative experiments in integrated development in resource-constrained settings elsewhere in the world. For instance, the Millennium Villages Project in rural Africa, an initiative of Columbia University's Earth Institute, has achieved promising yet cost-effective health outcomes in a little over a decade.

However, much of the stolid 57-page NHP document reads like a situational report of health issues and systemic challenges, and is sorely wanting on policy detail pertaining to concrete institutional, operational and regulatory measures. Case in point is a section expounding key policy principles - equity, universality, pluralism, accountability and decentralisation - tenets no one can disagree with. But the road map to achieve these is sketchy to non-existent. Additionally, while recognising weak health systems capacity as a major impediment in achieving desired health outcomes, the NHP is woefully silent on augmenting state governments' technical and administrative capacity to do better on health metrics like child and infant mortality rates, especially in the laggard States. Further, the section on "quality of care" is appallingly off-point. Instead of discussing standards of care, the patient-centred health care paradigm, regulations against medical malpractice and counterfeit medicines, and accreditation of health care providers, it arbitrarily focusses on suboptimal utilisation of health services by pregnant women.

Besides the befuddling taciturnity on issues of policy relevance, the NHP makes several circuitous arguments. While claiming that efficiency considerations given the limited public spending (at 2.5 per cent of GDP) mandate that most of the purchasing will have to come from public providers, the NHP is reluctant to jettison the private sector in mentioning "purchasing from private sector only for supplementation." This, read with the fact that the private sector already provides 80 per cent of outpatient care and 60 per cent of inpatient care, is hard to fathom. The convoluted argument does not end here. The NHP waxes eloquent about the role of government policy and tax concessions in actively shaping the growth of the private sector. Why should foregone revenues from tax sops to the private sector not be transferred to augmenting public health expenditure instead, especially when the comparative efficiency of the public sector is higher and the private industry is already booming?

Lower than needed public financing for health (2.5 per cent as opposed to 4 to 5 per cent of GDP) is premised on a fallacious argument of low absorptive capacity and inefficient utilisation of funding. The NHP refutes itself while describing the main reason for the National Rural Health Mission's failure to achieve stronger health systems: "Strengthening health systems for providing comprehensive care required higher levels of investment and human resources than were made available. The budget received and the expenditure thereunder was only about 40 per cent of what was envisaged for a full revitalisation in the NRHM framework." If this is not the case against diminished public funding for health, what is? In essence, the NHP is doomed to repeat past mistakes with none-the-wiser outcomes if it subscribes to the status quo of shorn government health spending. The Modi government was widely censured for a recent 20 per cent cut to the health budget, and the dithering in the NHP does nothing to inspire trust or quell fears of future cuts in health allocations. This abstract from the NHP is particularly worrying: "At current prices, a target of 2.5 per cent of GDP translates to Rs. 3,800 per capita, representing an almost four fold increase in five years. Thus a longer time frame may be appropriate to even reach this modest target."

Threat of pandemics

Aside from aggravating discrepancies and errors of commission, the NHP suffers from another glaring miss. It entirely skips mention of the global health threat posed by pandemics. According to World Bank estimates, the recent Ebola virus outbreak in West Africa could cost the region thousands of lives and as much as $32.6 billion by the end of 2015. Closer home, the raging swine flu epidemic was met with a shoddy response from the public health machinery, with misinformation and rumours having a field day - that should serve as a strident warning for the need to invest in epidemic preparedness and response.

Other gripes relate to vague priority setting for achieving specific policy aims and absence of standards or legal provisions for regulating the private sector. As an example, the NHP puts forth a multitude of criteria, ostensibly to determine the agenda for reducing health disparities to the end of achieving greater health equity. This includes targeting vulnerable population subgroups, geographical areas, health services, and gender-specific health issues. It also adds differential financial ability, developmental needs and high-priority districts to this boggy soup. The policy provides an unhelpful laundry list without so much as a perfunctory attempt at making sense of it. This can be addressed by proposing contextual priority weights for various criteria as well as by outlining an institutional decision-making framework. The policy also fails to locate how competing priorities will be resolved and how far they will be determined by context, if at all. Further, in respect of private sector regulation, the missing discussion on giving more teeth to the National Accreditation Board for Hospitals and Healthcare Providers and enforcing the Clinical Establishments Act of 2010, while making it more participative, is disconcerting.

The NHP presents a comprehensive problem statement but falls short on practicable strategy. An evidence-informed policy with an intersectoral ethos; clear-eyed priority setting; considered stands on matters of policy salience sensitive to contextual differences; and reforms aimed at plugging leaks and inefficiencies is the need of the hour. Most of all, the NHP must be persuasive and unapologetic. Cogent arguments help build political traction that is imperative for realising policy goals.

(Nidhi Khurana is a health systems researcher at the Johns Hopkins Bloomberg School of Public Health. The views expressed are personal.)