|
Vol.
XXV No. 42
October 21, 2001 |
Draft National
Health Policy
Amit Sen Gupta
THE national
Health Policy draft was finally released by the Ministry of Health and Family Welfare,
early this month. The draft is available on the website of the ministry which says that
comments on it will be entertained for a month. The arbitrary manner in which this policy
is sought to be finalised is symptomatic of the lack of rigour that pervades the exercise.
The last Health Policy document by the government was released in 1983. It is true that,
in this intervening period developments in the socio-economic and political spheres, both
within and outside this country, would necessitate the formulation of a new policy. But
one would have assumed that such a process would involve wide ranging discussions at all
levels.
Moreover, as the
draft itself repeatedly states, health is a state subject as per our Constitution. Yet we
have a document foisted upon us that has been put together by bureaucrats sitting in
Nirman Bhawan. From all accounts the state governments have not been involved in the
process of drafting, nor has the Central Council of Health and Family Welfare (the apex
body that has representatives from all State Health Departments) been consulted. And now,
just one month is being provided to give comments on a policy formulated after a gap of 18
years! And one, one gathers which has been at the drafting stage for three years!
COMPROMISE &
CONTRADICTIONS
An examination
the draft shows it to be a compromise effort that marries contradictory concerns. Section
2, titled, “Present Scenario” analyses many of the present initiatives
and their deficiencies and some of the conclusions drawn in this section are premised on
correct assumptions. However, in the operative part of the draft, Section 4, titled “policy
prescriptions”many of these assumptions are either ignored or contradicted It
appears as though the two sections have been drafted by two different sets of individuals.
Thus while
Section 2 makes appropriate references to decentralisation, inadequate funds,
non-viability of vertical programmes, inadequate and dysfunctional infrastructure, etc, in
Section 4, there are either no matching policy prescriptions or these prescriptions are
expressed in vague generalities. Practically the only areas where there are specific
recommendations, are areas that relate to encouragement of the private sector and
legitimisation of privatisation of the health care delivery system.
TOO LITTLE
TOO LATE
A further
perusal of the document throws up many fundamental concerns. Possibly the draft is most
eloquent where it maintains silence about certain areas. We shall return to these later.
Let us first see what the draft does say.
The draft admits
that public health investment has been “comparatively low”. What it does not
admit is that it has, in fact, been abysmally low – one of the lowest in the world. What
it further does not admit is the fact that such public investment, as a percentage of
total health expenditure, is possibly the lowest in the world – in other words that India
has the most privatised health system in the world!
The draft
recommends an increase in public health expenditure from the present 0.9 per cent of GDP
to 2.0 per cent in 2010. While any mention of an intention to increase public expenditure
is welcome, the quantum suggested is too little, and comes far too late. It falls far
short of the 5 per cent of GDP that has been a long-standing demand of the health
movement. Similarly public expenditure is projected as 33 per cent is lower than the
average of any region in the globe today – in other words India is visualised as
continuing to be one of the most privatised health systems in the world, even by 2010!
At the same time
much eloquence is expended on the inability of states to increase expenditure on health
care and much lamenting that the allocation by states has in fact decreased in the past
decade, i.e. a veiled attempt to castigate the states for their inability to increase
expenditure. Such insinuations are uncalled for without a detailed analysis of the manner
in which the liberalisation process has shattered the financial stability of states. They
are all the more objectionable given the fact that the formulation of the draft has seen
no participation from the states, where they would have been in a position to record their
point of view.
TOP-DOWN
PRESCRIPTIONS,
For all the
rhetoric on community participation, the draft is replete with “top down”
prescriptions, whilst admitting the wastage involved in running centrally-sponsored and
controlled vertical disease control programmes. Envisaging their integration in the
decentralised primary health care system, the draft goes on to recommend there would be a
need to retain many of them. But not only does the section on policy formulations, assume
the continuance of vertical programmes, there is repeated assertion that the centre will
continue to plan all public health programmes, and continuously harps on the availability
of expertise with the centre to justify strong central control, though it is not at all
clear where the basis of such assertions lie.
On the other
hand the draft is delightfully vague about actual devolution of responsibility and
financial powers to PRIs, and relocation of accountability to appropriate levels of local
self-governments. In the absence of such clarity there is the danger of the primary health
care system becoming a Collector-driven exercise that is controlled by the centre -
thereby defeating the entire effort at decentralisation.
THRUST TO
PRIVATE SERVICES
Numerous
formulations in the draft, in various forms, clear the way for even greater privatisation
of the health care system. In the garb of encouraging “civil society”
organisations, the draft talks about a greater role being provided to NGOs. Thus “the
NHP will
.. suggest policy instruments for implementation of public health programmes
through individuals and institutions of civil society”. In our view this
constitutes a veiled attempt to clear the way for sub contracting public health to NGOs.
OUSTING
THE POOR
A new concept
introduced is that of user fees, albeit couched in the usual sugar coating of it
being introduced only for those who can pay. Global experience of user fees at any level
shows that they serve only one purpose – to drive out the poor and the indigent. Any
mention of user fees in a health policy draft is objectionable and untenable. The section
that suggests primary health care is the priority for resource allocation needs to be read
along with this prescription for introduction of user fees. Prioritising primary health
care is to be welcomed, but this should not constitute an argument for the legitimisation
of the governments retreat from providing comprehensive and quality secondary and
tertiary care. Unfortunately there are too many indications of this possibility in
different sections of the draft and also hints at “encouraging” the private
sector to occupy the space that would be left vacant by the government.
MORE FACILITIES
FOR THE RICH
Another idea
which could only come from one totally divorced from the dire health needs of the people,
is the suggestion to use Indian health facilities to attract patients from other
countries. The incomes thus generated could be termed “deemed export” and should
be exempt from taxes. The formulation draws from recommendations that the industry has
been making and specifically from the “Policy Framework for Reforms in Health
Care”, drafted by the prime ministers Advisory Council on Trade and
Industry, headed by Mukesh Ambani and Kumaramangalam Birla.
Such a proposal,
termed by many as “health tourism”, will in effect divert our best resources to
serve the interests of the global health market and create islands of brain and resource
drain within the country. It is a proposal that needs to be rejected outright. The draft
presumably drawing inspiration from the same report, also talks of encouraging “the
setting up of private insurance instruments for increasing the scope of the coverage of
the secondary and tertiary sector under private health insurance packages”.
Further, there
are repeated references in the draft about “the valuable” contributions made by
the private sector and the need to “encourage” more such contributions. While
the draft is repeatedly critical of the public health system (justifiably so perhaps, but
for which it must take the greater blame), showing its own bias, there is not a single
word of criticism of the deficiencies of the private medical care system, the only
reference is to the need to develop regulatory norms.
CRUCIAL CONCERNS
IGNORED
It is
symptomatic of the governments attitude the truly urgent and crucial concerns regarding
the people health are either simply ignored or just blandly referred to in passing. For
instance, on womens health, the draft has a four-line section without any specific
proposals being spelt out. Child health is not even afforded a separate section, and is
dealt with through passing references. There is not a word on child nutrition in spite of
the shameful fact that a half of all our children below 5 years are malnourished in
Indiaa shameful distinction that India shares with only one other country in the
world — Bangladesh.
In the area of
medical education a long-standing position of the health movement has been to limit
specialisation and reorient undergraduate education to equip doctors to be able to address
the health needs of the common people. But the draft only talks of the need to introduce
postgraduate courses in “family medicine”. The former purpose cannot be served
by just introducing another speciality called family medicine. Such a suggestion only
betrays a total lack of understanding regarding the need to create a medical education
system oriented to the needs of primary care, Instead it is steeped in the bias of urban
specialist-based health care. Side by side the draft is entirely silent about the bane of
private medical colleges and the need to restrict and regulate these institutions.
Regarding
research, the direction is restricted to “frontier areas” and medical research.
There is no understanding of the necessity to initiate and sustain research on public
health. Even in the case of medical research there is no mention of the necessity of
regulation and to develop ethical criteria in this regard. The question of TRIPS is
discussed in terms of the possible impact on drug prices, not of the crippling effect of
TRIPS on medical research.
ELOQUENT SILENCE
The biggest
omission in the draft is the lack of any discussion on comprehensive and universal health
care. In contrast the NHP 1983 had said: “India is committed to attaining the goal
of Health for All by the Year 2000 A.D. through the universal provision of
comprehensive primary health care services”.
On the contrary
there are no policy prescriptions on the content of the primary health care system. The
new draft, thus, repudiates a fundamental concept of the NHP 1983 and the Alma Ata
declaration. It is also conspicuously silent on the village health worker – the first
contact in the primary health care system. In other words, by its silence, the draft,
provides a framework for the dismantling of the whole concept of primary health care.
On the question
of population control programme, which the health movement has long held to constitute a
major drain on primary health care the draft has nothing substantive to say. It repeats
the usual sophistry that advances in public health have been nullified by the increase in
population. This refrain contradicts all evidence available across the globe, which shows
that population stabilisation follows attainment of certain socio-economic standards and
not the other way round.
The draft is
practically silent about pharmaceuticals and their impact on health care – thereby
relinquishing its role in formulation of the drug policy. This is even more surprising
given the fact that a new Drug Policy is currently being discussed by the industry
ministry and reports about the policy have been available for some months. It is
understood that this new policy will recommend further relaxation of price and production
controls. Are we to understand from this that the NHP believes that increased drug prices
and non-availability of essential drugs have no impact on the health sector?
In brief, the
draft constitutes a return to the concept of centrally-directed, institution-based health
care. If allowed to be enshrined in its present form, the NHP can be used as a tool to
legitimise privatisation of the health sector.
