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National Health Policy 2017
Our public health system is bursting at the seams as it struggles to accommodate millions of people, especially those who have no other alternative. With health insurance a rarity, over 62 per cent of the family health expenditure goes from the personal savings1 of an average Indian household. This is abysmally high when compared to 13.4 1 per cent in the US and 10 per cent in the UK, and just above 54 per cent in China.2
In a recent study on Global Disease Burden, India ranked 154th among 195 countries surveyed.3 One would expect a nation so deep in a health crisis to be driven by an urgency - both in terms of a speedier response and better financial resources. The National Health Policy (NHP), released early this year, is in many ways a step forward. It imagines a robust health system in tune with the constitutional aspirations contained in Article 47 to raise the standard of living and improve public health.”
This NHP comes nearly 15 years after the previous major health policy of 2002. Much has changed in the years passed. This article examines some of the key proposals of the NHP, including its emphasi on generic medicines, to assess whether it fares well on the international standards of economic and social rights.
Availability, Accessibility and Acceptability Standards
International economic and social rights jurisprudence delineates a three-fold criteria of Availability, Accessibility and Acceptability (AAA) to gauge states' action to secure economic and social rights for their subjects.4 The AAA criteria entails that the goods, services and facilities provided by the state pursuant to its covenant obligations should be Available, Accessible, physically, economically and without discrimination, and Acceptability of the way this right is being upheld for the population it is being provided to.
With the focus on a 'comprehensive primary healthcare' system, the policy gives its fair share to the concern of availability of quality health facilities in the country. There is an honest assessment of the state's capacity to fulfill all the health needs of the country's vast population.
Acknowledging that our public health delivery systems may be sub-par, it introduces the idea of 'strategic partnerships' with private commercial and charitable institutions in multifarious ways for a short-term solution to the problem of availability of medical care facilities. For instance, in a welcome move, implicitly acknowledging the deplorable state of public infrastructure on mental health, the policy envisages 'mental health'5 as one of the collaborative spheres where private expertise and reach may be utilized to develop sustainable networks in community.6
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The policy undertakes the obligation of ensuring 'comprehensive primary healthcare system' upon the state, while leaving the window open for PPP models of partnership and purchase to fill in the gaps in secondary and tertiary care services until the public health system is equipped to bear the burden. The policy does not however shed more light on what services are to be expected from this 'comprehensive' package.
Collaboration with Public Sector Hospitals, Non-Profit Entities
Preference for such collaborations would be given to public sector hospitals, followed by non-profit entities and lastly to private commercial ventures to minimise 'moral hazards'.7 Collaboration with private providers already working in remote and underserviced areas has also been suggested as an immediate and temporary measure to fill critical gaps in primary care services and address demands for specialised personnel or domain-specific organisational experience.
This said, the devil lies in the implementation of these strategic partnerships. Public-private partnership models have in the past been notorious for flouting the standards of quality, exploiting contractual workers for profit maximisation as well as raising questions about extent of state and private accountability. Health rights advocates have expressed deep concerns over this 'strategic partnership' against the backdrop of a weak regulatory and deeply litigious environment for such partnerships to operate in a sector as sensitive as health.8 A breakdown of relationship between state and private provider may have catastrophic consequences on the health delivery systems they operate in. It may lead to delays and glitches in availability of health services as well as additional fiscal burdens on the state.9
Failure of PPP Models in Rajasthan, Karnataka
If anything, recent experiences from Rajasthan and Karnataka reflect the failure of over-reliance on PPPs, especially in primary healthcare. Last year, in Karnataka, the government abruptly scrapped the Arogya Bandhu scheme of collaboration with various NGOs, charitable trusts and private medical colleges to run and administer 52 Public Health Centers (PHCs), with financial assistance from the state, for their inability to meet the requisite quality and resource standards. 10
This year, health rights activists in Rajasthan have expressed deep displeasure at the PPP model in primary healthcare11 and challenged it before the High Court for being exploitative.12 They are concerned that reliance and expenditure on PPPs to deliver healthcare in PHCs is chipping away from the state's capacity to build and strengthen its public health delivery system in the long run.
The NHP further suggests independent mechanisms with institutional autonomy at state and central levels for regulating need-based purchase of secondary and tertiary care from empanelled private sector-in priority from public, not-for-profit and lastly, commercial establishments, subject to due standards of quality. This is where scepticism for the policy creeps in. The merits of such independent purchase commissions cannot be denied in the interest of transparency and fairness. However, without a roadmap into a legislation and regulations governing this authority, we may be pushing the PPPs on health into muddy waters.13
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Over-Reliance on Private Sector
Furthermore, even though strategic partnership seems a plausible answer to the immediate demands of our public health system, crumbling under population burden and inadequate infrastructure, the policy is eerily silent on what this 'short-term' is.14 In absence of clear attainable targets, we may be moving towards a model of over-reliance on private sector, where addressing the inadequacies of the public health system takes a backseat.
It is to be borne in mind that moving towards a purchase model/insurance-based system for secondary and tertiary services makes sense only as far as adequate parallel attention is given to building and strengthening the state-supported infrastructure. Hospitalisation and other tertiary care related services are those which compel people to break their banks, and beyond a point, the expenditure towards insurance and buying services from private sector would rather be invested in the state hospitals to strengthen and upgrade their services.15
The policy also speaks of compulsory rural postings for doctors, the viability of which as a sustainable solution is yet to be established.16 Even though the Policy discusses 'financial and non-financial' incentives, medical colleges in rural areas, preferring students from under-served areas and bringing 'rural needs' to the centre of the medical curriculum, it seems to be leaning towards either “measures of compulsion” or voluntary “giving back to the society” initiative to service the rural healthcare needs of the country. This may be an answer to the immediate manpower crisis in primary healthcare sector, but may not do much to create a sustainable and fair system of incentive to encourage doctors to service rural sectors, unless exhaustive infrastructural improvements are made.
1. Accessibility Physical Accessibility
The WHO understands physical accessibility as “the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organisation and delivery that allow people to obtain the services when they need them”.17 It also extends to “a safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS, including in rural areas”.18
In terms of physical accessibility of health services, the policy aspires for districts to be the centres for quality secondary care, and basic secondary services like caesarean sections and neonatal care to be made available at least at sub-divisional levels in a cluster. Identifying human resource as integral to developing secondary care sector, it speaks of a scheme to develop human resources and specialist skills. Though the policy does not categorically lay out a blue print for this scheme, suggestions can be found in the document concerning systematic improvement of medical education and examination process in the country as well as developing a special public health cadre for management, among others.
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The policy expects to set up medical colleges and institutions like All India Institute of Medical Sciences on the model of regional, zonal and apex referral centres to increase the access to health services. It also makes a special case of partnership with empanelled private commercial and charitable institutions and integration of AYUSH19 as well as indigenous medicinal practices of quality to diversify the health portfolio - which has obvious positive implications on accessibility of health facilities to all.
The policy is also conscious of the serious gaps in access to health services in the tribal regions of the country. It suggests increase in outreach through special 'mobile medical units' to mitigate the geographical and infrastructural challenges faced by the 100 million tribal population.
It suggests that decision making should be decentralised and community be involved in health planning. It emphasises on the special role of Panchayati Raj Institutions and echoes the viability of Community-Based Monitoring Systems which were brought into place through the National Rural Health Mission in 2005.
WHO understands 'economic accessibility' as “a measure of people's ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation to and from facilities and of taking time away from work).” Affordability is influenced by the wider health financing system and by household income”.20
In terms of affordability, the policy speaks of affirmative action to bridge the gap due to gender, poverty, caste, disability, social exclusion and other geographical barriers by bringing in systems for better investments and financial protection. India currently faces an excessive out-of-pocket expenditure on health constituting nearly 40 per cent of the monthly non-food household expenses. The policy speaks of ambitious targets of not only increasing the health budget from the current 1.8 per cent to 2.5 per cent by 2025, but also the states increasing their health expenditure to the north of 8 per cent. It also aims to reduce the out-of-pocket health expenditure of households by one fourth by 2025.
The policy envisages a strong National Health Accounts System to bring efficiency in resource allocation in public sector in health. It urges that standards for treatment of patients be the same for public and private hospitals and patients not be denied their right to information about their treatment and process.
Though much has been spoken about continuing insurance schemes like Arogyashree and Rashtriya Swasthiya Beema Yojana (RSBY), providing cashless insurance for hospitalisation in public and private hospitals and bringing India's BPL population under a state-sponsored insurance mandate, critical and immediate attention needs to be given to the implementation of these schemes. Making these schemes
workable requires addressing the deep chasms of class, caste and gender that cut through our health delivery system.21 Further, information asymmetry between hospitals and patients can open soft-spots for patient exploitation for claiming insurance by public or private service providers.22
For any insurance scheme to be a success in making health care 'affordable', it would have to be acknowledged that real access goes beyond enrolment and into empowerment - where patients with a RSBY card can claim insurance as a state sponsored right and not gratis at the hands of care-givers.
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Drug Pricing and Affordability23
The policy picks up on the flavour of 'generic drugs' and 'Make in India' in the 2017 budget. It suggests streamlining the drug procurement systems and bringing in strong purchase policy to procure drugs in bulk. Jan Aushadhis, or the low cost medical stores housing generic variants of expensive branded drugs, are to be opened in larger numbers across the country for access to affordable drugs.
The National Health Policy 2002 advocated the use of generic drugs only in the rubric of essential medicines - the idea was to limit the use of proprietary drugs both by private and public establishments and ensure that basic treatments used only price-controlled essential drugs to keep the cost of healthcare low.24 The new policy, however, substantially departs from this approach and focuses on generic variants of all drugs, and not just those in the essential lists. It also goes a step beyond infrastructural support for low cost drugs, into educating masses about branded and non-branded drugs and busting myths about quality of the latter, if they meet all prescribed standards.
The movement for integrating low-cost generic drugs to the very fabric of the public health delivery system has seen traction with the incumbent government. Previously known as the Jan Aushadhi Scheme, the Pradhan Mantri Jan Aushadhi Yojna has currently opened nearly 700 Jan Aushadhi stores, though it is still far from its ambitious plans to open 3,000 stores as declared in the 2016-17 Budget.25 In fact, recently a potential collaboration with Indian Railways was explored26 and it was decided that railway's broad geographic catchment would be utilised to open such stores and make them more accessible to all.
The ambitious scheme of flooding the market and the minds of the patients alike with generic drugs can go a long way in decreasing the expenditure of medicines other than essential medicines, whose price is already statutorily regulated. However, adequate advertisement/information, clarification of doubts, sufficient supply to meet the increase in demand27 and a water-tight system of quality control28 are prerequisites to generic drugs being accepted as a viable alternative for patients and doctors in the country.29 There are also initiatives in the pipeline to mandate doctors to compulsorily prescribe generic drugs. Such initiatives would have to ensure that they are structured in such a way that they are not a mere lip-service to the cause and the decision-making power is not passed on from the doctors to the pharmacist, and the patient continues to bear the heavy cost burden. The state also needs to be cognisant that the generic drugs policy cannot be an isolated attempt at making health accessible. It needs to be coupled with an increase in allocated health expenditure and timely policy interventions for strengthening the public health delivery system.
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The policy also speaks of a pluralistic public health system by integrating, where appropriate and chosen by the patients, AYUSH care into mainstream health delivery practices. It also pushes for research on tribal medicinal practices to broaden the health service basket. This is an optimistic acknowledgement of indigenous health practices, which, if of the requisite standard and quality, can suit the unique health needs of the community in a trusted way.
In another significant move to increase acceptability of treatment, the policy expresses its discomfort with camp-based sterilisation services, given the dubious concerns of quality, safety and dignity of women and to make sterilisation services available generally in public facilities. Similarly, it aims to increase male sterilisation from the current 4 per cent to at least 20 per cent.
The NHP is generally optimistic about building a public health system which will be able to tackle the heavy disease burden in India. It also advocates increasing the health expenditure from the current 1.8 per cent to 2.5 per cent of the GDP by 2025, which, though much below the global average of 5 per cent, will still a progress, provided it gets done.
It talks about putting in place by 2020 a district level data systems as part of the Health Management Infrastructure. The focus is on a preventive and promotive healthcare. The policy is also unclear about many crucial areas, like a hesitant reference to adolescent and sexual health education, bunching it with recommendations for prevention of common chronic illnesses, ambitious targets of disease elimination. Its divisions of responsibility between the centre and the states is at best vague. The fact that the policy follows an incremental assurance-based model instead of giving 'health' its due status as a 'right' leaves much to be desired.
*Pallavi is a legal consultant with Common Cause.