People's Democracy

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!

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.

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.

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.

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.

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 government’s 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.

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 minister’s 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.

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 women’s 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 India—a 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.

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.