Unveiling the National Health Policy 2017 on Thursday, Union Health Minister J.P. Nadda called it a new milestone in India's public health history. A summary of what he said in the Parliament, although not rich in specifics, indeed indicated a certain paradigm shift in the delivery of healthcare services in the country in terms of access, goals, financing and the modality itself.
The notable highlights of his statement were "sick-care to wellness", prevention and health promotion, financial protection, stronger partnership with the private sector and raising public health expenditure to 2.5 per cent of the GDP "in a time bound manner" among other things that usually make national health policies look respectable. However, what appeared less prominent was the promise of Universal Health Coverage that guarantees free, cashless health services to all the citizens of the country irrespective of the type of care needed.
And what went completely missing was health as a fundamental right.
Universal Health Coverage (UHC), in which people receive healthcare without suffering financial hardship, is an ideal that many countries in the world are successfully moving towards. It's also a Sustainable Development Goal (SDG) that India has agreed to achieve by 2030, and a promise that the UPA government under Manmohan Singh reneged on. It's the new minimum in global health, without which no policy makes sense.
The new Health Policy indeed makes the right noises in identifying the pitfalls of India's healthcare situation, and which way the country should head. It does acknowledge the extremely poor spending by the state (roughly 1% of the GDP), the catastrophic expenses people suffer because 70% of their needs are met by the private sector, and how poor access to healthcare pulls down the country's development goals.
The policy does promise that it would buy services mostly from public hospitals; but would also use the private players. This is where people and civil society ought to be vigilant.
It does acknowledge that UHC is the way to go, but makes a clear commitment only in primary care. In secondary and tertiary care, which in fact accounts for most of the catastrophic expenses, that push people into poverty - some irreversibly - it's not as unequivocal. Frankly, its commitment is only partial.
While it promises "assured comprehensive" primary care that has continuity with higher levels, for the secondary and tertiary care, "improved access and affordability of services through a combination of public hospitals and strategic purchasing of services from the private health sector" is all that it would offer. It's not good enough.
While access to primary care is extremely crucial, it cannot be compromised in secondary and tertiary care because of its disproportionately higher costs. Strengthening primary care will certainly reduce the burden of secondary and tertiary care, because of prevention and maintenance of overall wellness, but it wouldn't completely obviate it. The policy should have been as sweeping in secondary and tertiary care as well, as it's in primary care.
Even with such limitations, the Health Policy is forward-looking because it does seek to strengthen the infrastructure, capacity, financing and human resources, and envisages a complete overhaul of primary care in a way that will expand its scope and scale to ensure continuity with higher levels of care. The new idea of primary care will include some elements that had been part of secondary or even tertiary care earlier. It also seeks to harness the complementary results of the initiatives by other sectors - such as the cleanliness drive, reduction of train and road accidents, and action against gender-based violence - into the new plan for greater synergy, optimisation of resources and even a social movement for health called "Swasth Nagrik Abhiyan".
In a country with a very poor public health legacy, and development-disparity, universal access across the board might seem unreasonable in the government's point of view; but being unreasonable is the key to transformation because health and education are the fundamental pillars of human development.
Probably, the government could have aimed higher, however unreasonable it may have sounded because a country in our neighbourhood - Thailand - has shown the rest of the world that even with poor resources, UHC is achievable.
Thailand began implementing UHC only in 2002, but in a decade, it had covered 98% of the population. It was a rapid scale up backed by enormous political will, pressure from people and civil society groups, and strategic partnerships. It's completely financed by the government, through general tax, and covers nearly 80 per cent of the healthcare needs of people compared to India's 30 per cent. Obviously, the risk of health catastrophes has dramatically fallen and people feel safe and secure.
Even in its present form, the implementation of the policy will be fraught with formidable challenges because of the disparate health infrastructure landscape in the country.
The per capita expenditure on health in Thailand is nearly four times than that of India, but as a share of the GDP, it's only about 4.1% as against India's 3.9%. The crucial difference, or the secret of optimising costs, is that 80% of this 4.1% is government spending because it mostly uses public hospitals. Clearly, when the government "purchases" services from public hospitals, the cost is very low.
India's new policy also speaks about a single purchaser or payer for health, which essentially means that the government would buy the healthcare services for its people, who need not worry about paying for them. The policy does promise that it would buy services mostly from public hospitals; but would also use the private players. This is where people and civil society ought to be vigilant - the government's priority should be strengthening public hospitals so that it doesn't need to depend much on the private sector except in unavoidable cases. In fact, this is the problem with most insurance based models that both the Government of India and some states promote. Instead of paying insurance companies, that too for incomplete services, the governments could have used the money to strengthen its hospitals and bought the services from them.
The most crucial element for the implementation of the new policy, even with its limited commitment on universal access to tertiary care, is a strong public health infrastructure. The policy builds its optimism on the perceived success of NRHM (National Rural Health Mission) which it believes has strengthened the infrastructure and trained thousands of people. In fact, besides the political will and strategic scale up, what made Thailand's attempt at UHC a success was its health infrastructure that had been built since the 1970s.
A lot has to be seen in fine print and real follow up action. Will there be a new national organisation or state organisations that will purchase all health services for the people? Without new legislation, will such an organisation (or organisations) have adequate mandate and power? How unlimited will be the access to tertiary care? How will the financing work - will the additional resources to meet the target of 2.5 per cent of the GDP will be completely met by the Centre?
Even in its present form, the implementation of the policy will be fraught with formidable challenges because of the disparate health infrastructure landscape in the country, particularly in the poor states, and the need for aligning existing systems in the states with a national plan of action. As Nadda himself had stated in Rajya Sabha last year, public health is a state subject and providing healthcare is a responsibility of the states. Since most state governments are now run by the BJP, perhaps alignment will be easier. But that the new promise of spending 2.5% of the GDP on health is 15 years old makes one a little sceptic.