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The National Health Policy cleared by the Union Cabinet on Wednesday has fallen short of the promise of its 2015 draft. The policy duplicates portions of the Health section of Finance Minister Arun Jaitley’s 2017 Budget speech, reiterates health spend targets set by the High Level Expert Group (HLEG) set up by the erstwhile Planning Commission for the 12th Five Year Plan (which ends on March 31, 2017), and fails to make health a justiciable right in the way the Right to Education 2005 did for school education. India last issued a National Health Policy in 2002.
No Right to Health
On Thursday, Health Minister J P Nadda told Parliament: “…The Policy proposes raising public health expenditure to 2.5% of the GDP in a time-bound manner. The Policy advocates a progressively incremental assurance-based approach. It envisages providing larger package of assured comprehensive primary health care through the ‘Health and Wellness Centres’ and denotes important change from very selective to comprehensive primary health care package which includes care for major NCDs [non-communicable diseases], mental health, geriatric health care, palliative care and rehabilitative care services.
“It advocates allocating major proportion (two-thirds or more) of resources to primary care. It aims to ensure availability of 2 beds per 1,000 population distributed in a manner to enable access within golden hour [the first hour after traumatic injury, when the victim is most likely to benefit from emergency treatment]. In order to provide access and financial protection, it proposes free drugs, free diagnostics and free emergency and essential health care services in all public hospitals.”
The Minister’s reference to an “assurance-based approach” abandons a radical change proposed in the draft policy of 2015 — that of a National Health Rights Act aimed at making health a right. Health Ministry officials said the idea was dropped because state governments felt that health infrastructure was not yet at levels at which health could be made an entitlement, and the citizen could theoretically take a government to court for its denial. Diagnostics, drugs and essential health care services are already free in many states.
Old Targets Restated
Nadda said the 2.5% GDP spend target for Health would be met by 2025. But the HLEG report of 2011, quoted by the 12th Plan document, had set the same target for the Plan that ends at the end of this month.
“Government should increase public expenditure on health from the current level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the Twelfth Plan, and to at least 3 per cent of GDP by 2022. General taxation should be used as the principal source of healthcare financing, not levying sector specific taxes. Specific purpose transfers should be introduced to equalise the levels of per capita public spending on health across different states. Expenditures on primary health care should account for at least 70 per cent of all healthcare expenditure,” the HLEG had recommended.
A health cess was a pathbreaking idea in the Health Ministry’s draft policy; it has now been given a quiet burial, with Nadda maintaining that there is no dearth of funds.
Many of the disease-specific targets announced by the Policy — such as eliminating kala-azar and filariasis by 2017, leprosy by 2018 and measles by 2020 — featured in the Budget. So did the proposed elimination of tuberculosis by 2025, and the action plan to reduce the Infant Mortality Rate to 28 by 2019 and Maternal Mortality Rate to 100 by 2020. The transformation of 1.5 lakh Health Sub Centres into Health and Wellness Centres, announced in the Policy, too had been announced by Jaitley.
Indian Medicine and Yoga
Where the Policy moves forward is in its emphasis on Indian systems of medicine. “The policy envisages a three-dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines. This has a huge potential for effective prevention and therapy that is safe and cost-effective. Yoga would be introduced much more widely in schools and work places as part of promotion of good health,” Nadda told Parliament.
Some of the new targets in the policy are to increase life expectancy at birth from 67.5 to 70 by 2025, reduce Total Fertility Rate to 2.1 at the national and sub-national levels by 2025, and to reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025. To the last end, it proposes universal screening. However, the process to start this in 100 districts was under way long before the Policy roadmap was finalised.
Silent on Health Governance
As per the new Policy, the National Healthcare Standards Organisation (NHSO) will decide the standards of private and public health institutions, and an empowered tribunal will deal with grievances. The policy, however, keeps clear of one of the most vexed questions of health governance in India — whether Health should continue to be in the State List, or be brought, like Education, in the Concurrent List for better regulation.
With Health in the State List, its regulation lies with states; the Centre can only make model laws to which states can voluntarily subscribe. The Clinical Establishments Act, 2010 has been a non-starter — only four among the big states have adopted it until now, with West Bengal recently unveiling its own Act with much fanfare. The rest have either ignored it, or failed to frame Rules that are stringent enough for its effective implementation.
A national health authority like the NHSO cannot work effectively without Health being on the Concurrent List. Even if the NHSO or any other body sets standards, it will be the state government’s job to decide whether those are met by the private sector, with the Centre having little say.
In effect, questions on Health in Parliament will continue to remain unanswered as “Health is a State Subject”.