3/12/2015

AsketchyroadmapforhealthpolicyTheHindu

Today'sPaperOPINION
Asketchyroadmapforhealthpolicy
NidhiKhurana
MuchoftheNationalHealthPolicydocumentreadslikeareportofhealthissuesandsystemicchallenges,andissorelywantingon
policydetail

INADEQUATEACTION:Theswinefluepidemicwasmetwithashoddyresponsefromthepublichealthmachinery.Pictureshows
schoolchildreninMumbaiwearingmaskstoprotectthemselvesfromtheinfection.PHOTO:VIVEKBENDRE

Healthimpoverishmentfallingintopovertyduetohealthcarecostsaffects63millionindividualsinIndiaevery
year.Thisisadamningstatistic,especiallywhenreadwiththefactthat18percentofallhouseholdsfacecatastrophic
healthexpenditures(healthexpendituregreaterthan10percentoftotalhouseholdconsumptionexpenditureor40per
centoftotalnonfoodconsumptionexpenditure).Weareatanurgentprecipiceintimeformakinghealthpolicywork
forthepoorinIndiathedeependofdirestraits.The2015draftNationalHealthPolicy(NHP)ispregnantwith
possibilities.ThefirstfederalhealthbilltocomeoutinmorethanadecadeisasalientopportunityfortheNarendra
Modigovernmenttopresentacoherentplantodeliverequitable,efficientandsustainablehealthcaretoIndiasbillion
pluscitizenry.
ThecliffnotesversionoftheNHPrecommendationsreadsthus:makehealthafundamentalandjusticiableright
increasepublicexpenditureonhealthfrom1percentofGDPto2.5percentofGDPraiserevenuesmainlythrough
generaltaxationwhileexploringthepossibilityofsintaxes(mainlytaxesontobaccoandalcohol),andearmarksfor
health(akintotheeducationcess)andstrengthenhealthservicesprovisioningthroughstrategicpurchasingfromthe
publicandprivatesector.
Jumpingthegun
Bymakinghealthajusticiableright,theNHPappearstojumpthegun.Whilstanexcellentpropositioninprinciple,it
isunrealisticasthebasicinstitutionalframework,infrastructureandpersonnelneededtodeliverhealthcareforallis
lacking.Sequencematters.Anefforttomakecomprehensiveprimarycaredeliverableneedstoprecedethedeclaration
ofhealthasajusticiableright.Otherthandefiningcomprehensiveasnotselective,thegovernmentmightlookto
learnfrominnovativeexperimentsinintegrateddevelopmentinresourceconstrainedsettingselsewhereintheworld.
Forinstance,theMillenniumVillagesProjectinruralAfrica,aninitiativeofColumbiaUniversitysEarthInstitute,has
achievedpromisingyetcosteffectivehealthoutcomesinalittleoveradecade.
However,muchofthestolid57pageNHPdocumentreadslikeasituationalreportofhealthissuesandsystemic
challenges,andissorelywantingonpolicydetailpertainingtoconcreteinstitutional,operationalandregulatory
measures.Caseinpointisasectionexpoundingkeypolicyprinciplesequity,universality,pluralism,accountability
anddecentralisationtenetsnoonecandisagreewith.Buttheroadmaptoachievetheseissketchytononexistent.
Additionally,whilerecognisingweakhealthsystemscapacityasamajorimpedimentinachievingdesiredhealth
outcomes,theNHPiswoefullysilentonaugmentingstategovernmentstechnicalandadministrativecapacitytodo
betteronhealthmetricslikechildandinfantmortalityrates,especiallyinthelaggardStates.Further,thesectionon
qualityofcareisappallinglyoffpoint.Insteadofdiscussingstandardsofcare,thepatientcentredhealthcare
paradigm,regulationsagainstmedicalmalpracticeandcounterfeitmedicines,andaccreditationofhealthcare
providers,itarbitrarilyfocussesonsuboptimalutilisationofhealthservicesbypregnantwomen.
Besidesthebefuddlingtaciturnityonissuesofpolicyrelevance,theNHPmakesseveralcircuitousarguments.While
claimingthatefficiencyconsiderationsgiventhelimitedpublicspending(at2.5percentofGDP)mandatethatmostof
thepurchasingwillhavetocomefrompublicproviders,theNHPisreluctanttojettisontheprivatesectorin
mentioningpurchasingfromprivatesectoronlyforsupplementation.This,readwiththefactthattheprivatesector
alreadyprovides80percentofoutpatientcareand60percentofinpatientcare,ishardtofathom.Theconvoluted
argumentdoesnotendhere.TheNHPwaxeseloquentabouttheroleofgovernmentpolicyandtaxconcessionsin
activelyshapingthegrowthoftheprivatesector.Whyshouldforegonerevenuesfromtaxsopstotheprivatesectornot
betransferredtoaugmentingpublichealthexpenditureinstead,especiallywhenthecomparativeefficiencyofthe
publicsectorishigherandtheprivateindustryisalreadybooming?
Lowerthanneededpublicfinancingforhealth(2.5percentasopposedto4to5percentofGDP)ispremisedona
fallaciousargumentoflowabsorptivecapacityandinefficientutilisationoffunding.TheNHPrefutesitselfwhile
describingthemainreasonfortheNationalRuralHealthMissionsfailuretoachievestrongerhealthsystems:
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3/12/2015

AsketchyroadmapforhealthpolicyTheHindu

Strengtheninghealthsystemsforprovidingcomprehensivecarerequiredhigherlevelsofinvestmentandhuman
resourcesthanweremadeavailable.Thebudgetreceivedandtheexpenditurethereunderwasonlyabout40percentof
whatwasenvisagedforafullrevitalisationintheNRHMframework.Ifthisisnotthecaseagainstdiminishedpublic
fundingforhealth,whatis?Inessence,theNHPisdoomedtorepeatpastmistakeswithnonethewiseroutcomesifit
subscribestothestatusquoofshorngovernmenthealthspending.TheModigovernmentwaswidelycensuredfora
recent20percentcuttothehealthbudget,andtheditheringintheNHPdoesnothingtoinspiretrustorquellfearsof
futurecutsinhealthallocations.ThisabstractfromtheNHPisparticularlyworrying:Atcurrentprices,atargetof2.5
percentofGDPtranslatestoRs.3,800percapita,representinganalmostfourfoldincreaseinfiveyears.Thusa
longertimeframemaybeappropriatetoevenreachthismodesttarget.
Threatofpandemics
Asidefromaggravatingdiscrepanciesanderrorsofcommission,theNHPsuffersfromanotherglaringmiss.Itentirely
skipsmentionoftheglobalhealththreatposedbypandemics.AccordingtoWorldBankestimates,therecentEbola
virusoutbreakinWestAfricacouldcosttheregionthousandsoflivesandasmuchas$32.6billionbytheendof2015.
Closerhome,theragingswinefluepidemicwasmetwithashoddyresponsefromthepublichealthmachinery,with
misinformationandrumourshavingafielddaythatshouldserveasastridentwarningfortheneedtoinvestin
epidemicpreparednessandresponse.
Othergripesrelatetovagueprioritysettingforachievingspecificpolicyaimsandabsenceofstandardsorlegal
provisionsforregulatingtheprivatesector.Asanexample,theNHPputsforthamultitudeofcriteria,ostensiblyto
determinetheagendaforreducinghealthdisparitiestotheendofachievinggreaterhealthequity.Thisincludes
targetingvulnerablepopulationsubgroups,geographicalareas,healthservices,andgenderspecifichealthissues.It
alsoaddsdifferentialfinancialability,developmentalneedsandhighprioritydistrictstothisboggysoup.Thepolicy
providesanunhelpfullaundrylistwithoutsomuchasaperfunctoryattemptatmakingsenseofit.Thiscanbe
addressedbyproposingcontextualpriorityweightsforvariouscriteriaaswellasbyoutlininganinstitutionaldecision
makingframework.Thepolicyalsofailstolocatehowcompetingprioritieswillberesolvedandhowfartheywillbe
determinedbycontext,ifatall.Further,inrespectofprivatesectorregulation,themissingdiscussionongivingmore
teethtotheNationalAccreditationBoardforHospitalsandHealthcareProvidersandenforcingtheClinical
EstablishmentsActof2010,whilemakingitmoreparticipative,isdisconcerting.
TheNHPpresentsacomprehensiveproblemstatementbutfallsshortonpracticablestrategy.Anevidenceinformed
policywithanintersectoralethoscleareyedprioritysettingconsideredstandsonmattersofpolicysaliencesensitive
tocontextualdifferencesandreformsaimedatpluggingleaksandinefficienciesistheneedofthehour.Mostofall,the
NHPmustbepersuasiveandunapologetic.Cogentargumentshelpbuildpoliticaltractionthatisimperativefor
realisingpolicygoals.
(NidhiKhuranaisahealthsystemsresearcherattheJohnsHopkinsBloombergSchoolofPublicHealth.Theviews
expressedarepersonal.)
TheNHPisdoomedtorepeatpastmistakeswithnonethewiseroutcomesifitsubscribestothe
statusquoofshorngovernmenthealthspending

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