Articles

The semantics of commitment

By and on January 16, 2015

Radhika Arora is an EV 2012 & ITM MPH alumnus.  
Upendra Bhojani is an IPH Bangalore faculty member.  

India has undertaken several significant health reforms in the last decade, many under the National Rural Health Mission. Many of these recent reforms were driven by the Millennium Development Goals, going beyond the targets outlined by the MDGs to address other aspects of the health system. Thirteen years after India’s last National Health Policy (2002), the New Year brought it with the Country’s third and, perhaps most ambitious health policy yet – the draft National Health Policy 2015, by the Ministry of Health and Family Welfare, Government of India. This draft Policy differs dramatically from previous editions in the scope of its objectives, evidence-based content and interestingly, in its articulation of the role and commitment of the government in health care. It presents a broad perspective on the challenges, opportunities and solutions on the path to ensuring health for all, reflecting the globally-trending values of universal health coverage (UHC). The draft policy document was made available online, in the public domain, at the end of December 2014. Comments on the draft policy from the public are invited, until the end of February 2015.

The draft National Health Policy 2015 makes for an interesting read. There is a distinct difference in the tone and semantics of the 2015 draft NHP as compared to the existing version of the policy. Its primary objective as stated by the draft document, “is to inform, clarify, strengthen and prioritize the role of the government in shaping health systems in all its dimensions – investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and legislation for health.” A long sentence, reflecting and articulating, perhaps for the first time in a policy document, the role of the government in the funding and the provision of health services. This is reflected in the acknowledgement that despite a robust private health sector, health outcomes and financial protection for the population are linked to public health expenditure. It’s also expressed in the intention to strengthen the provision of comprehensive care at the primary care level.

The NHP goes beyond presenting a generic statement of the challenges facing health and healthcare in India. Its text reflects research done over the past decade and also ongoing debates and controversies on health care; not missing the opportunity to leverage the incident of the deaths at a sterilization camp in November 2014, to critique the concept of camps as a legacy of past regimes. The draft NHP covers a range of topics from health financing, human resources in health and health research to the challenges presented by the demographic and epidemiological shifts.

To address the changing needs of the population, the draft NHP 2015 outlines seven key policy shifts which include expanding the focus on primary care to one that assures comprehensive care and effective referrals; strategic purchasing in secondary and tertiary care mainly from government providers; assured free drugs, diagnostics and emergency services in all public facilities; focus on infrastructure and human resource development – towards a more equitable distribution of health resources; integrating national health programmes with the broad health systems. In addition, the draft NHP proposes to address urban health issues – including, but not restricted to the social determinants of health. While the Swachh Bharat Abhiyan (or ‘clean India campaign’), did convince some wealthy citizens to pick up the broom and clean their already immaculate neighbourhoods, its broader campaign and awareness created a stir and discussion on the need for the physical cleanliness. It’s a start – but more needs to be done in terms of integrating it with the broader issues of sanitation, access to clean water and issues of planning and developing living and working spaces. One gets to see an explicit need for a social movement for health expressed in the draft. Lastly, the draft NHP 2015 focuses on mainstreaming Ayurveda, yoga, Unani, siddha and homeopathy (AYUSH). With the 21st of June as being declared to be the International Day of Yoga and the formation of the new Ministry of Yoga, this last AYUSH initiative seems well on the road to implementation.

The threat of the spread of Ebola and India’s shaky capacity to be able to tackle an epidemic, if it should so occur hasn’t been lost on the NHP. The need to strengthen health systems and the role of government towards developing the capacity to prevent and address communicable diseases has been reiterated. The document also acknowledges the need to address chronic non-communicable diseases (and brings in the issues of integration, human resources as well as Indian systems of medicine here), as well as the preventable aspects of road safety and occupational hazards. The use of information communication and technology to supplement resources and improve outreach are also included.

There is much in this draft National Health Policy that researchers, activists and those working in the area of public health have been working on over the last few decades. Some of it new, some not. The issue of increasing public financing of health care, for example, has been highlighted by several governments. The draft NHP 2015 too acknowledges the need to increase public financing in health for it to meet the goals outlined, though it remains to be seen if this will actually happen.  This policy document positions health care and health services within social determinants. Equity and quality of care in access to health services underlie almost all recommendations. Perhaps the most significant debate to emerge from the draft policy is that on the right to healthcare and whether a bill should be passed to make access to healthcare a justiciable right, much like moves in education, food and employment by earlier governments in India.

Unlike the general neglect of the private sector in government’s discourse of health in India, the draft policy acknowledges its tremendous growth in India. Acknowledging its contribution to the Indian economy, the draft policy articulates why this sector cannot be counted on to provide what is not favoured by the market: preventive care in general and equitable care to a large majority of Indians who can ill afford it in private sector. While the proposed policy provides a clear rationale for and explicit intention  to  regulate, or rather actively  ‘influence’ the private sector to align its goals with public policy goals, the draft fails to provide even broad directions as to how this might be achieved.

The semantics of the 2015 draft NHP vary from past NHPs. Presented to the public just days after the media reported cuts in the health budget, the draft NHP 2015 throws up some pleasant surprises in terms of its objectives. For the moment, we need to wait and see how much of the content of the draft policy will distil into the final version, and how its objectives will be met. The proposal with rights-based language and centrality of state (government) intervention in health sector does not fit readily into what the new government seems to be up to, with the recent cuts in health budgets and appointment of Aravind Panagariya and Bibek Debroy (possibly the best advocates for market-based approaches to development) to NITI Ayog – a smaller and probably to be the most influential think-tank that replaced the Planning Commission of India a few days ago. As the common man awaits for ‘Acche Din’ or good times, the promise that galvanized the last election and brought the Modi government to power, it is yet to be seen whether the health sector will get enough attention and of what kind.

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