When the National Health Policy steered clear of a rights-based approach, what gave you the confidence of such an approach in the Mental Healthcare Bill?
The Mental Healthcare Bill has been passed to harmonise the country’s mental health laws to the UN Convention on Rights of Persons with Disabilities, to which the country is a signatory. Mental healthcare is relatively a small part of overall healthcare, and therefore resources and systems by appropriate governments could be put in place to provide accessible, affordable mental healthcare services of quality across all geographies in a relatively short time. As regards right to health, besides the issue of public health being a state subject, it is also to be seen whether all states have reached the level of economic and health systems development to make this a justifiable right — implying that its denial is an offence. Right to healthcare would need to cover a wide canvas, encompassing issues of preventive, curative, rehabilitative and palliative healthcare across rural and urban areas, infrastructure availability, health human resource availability, as also issues extending beyond health sector into the domain of poverty, sanitation, nutrition, drinking water availability, etc. Right to health cannot be perceived unless the basic health infrastructure like doctor-patient ratio, patient-bed ratio, nurses-patient ratio, etc are near or above threshold levels across the geographical frontiers of the country. The National Health Policy, therefore, while supporting the need for moving in the direction of a rights-based approach to healthcare, advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realizing health care as a right in the future.
Why was it essential that mental healthcare be made a right?
Mental health is significantly different from general health issues. Mental illness remains the only health sector where, in certain cases, people may not be in a position to make decisions for themselves and may need to be treated without their own consent. Historically too, persons with mental illness have been subject to abuse, neglect and marginalisation in our society. Thus persons with mental illness are an especially vulnerable section of our society and need special support and protection. It is therefore the responsibility of the government to ensure that people receive appropriate and quality treatment early in their illness. This is only possible if quality treatment is available in sufficient quantity and accessible to people near their homes. In addition, given the past history of abuse in the mental healthcare system, we need to assure persons with mental illness and their families that treatment will be provided to them in an acceptable manner, so that they access modern medical healthcare rather than go to faith healers and religious healers for treatment of mental illness. If people receive early and appropriate treatment, they will make an early recovery and return to normal life in the society quickly. This is not only good for them and their families, but will also change society’s attitude towards mental illness and reduce the stigma associated with mental illness. In the unlikely event that people get a severe illness and need to be treated in hospitals when they are unable to give informed consent, the government would like to assure them and their families that their rights will be protected and they will receive quality care in these mental health establishments. Otherwise we have a situation where people don’t have a choice of refusing treatment while the treatment being provided is not of good quality. Unfortunately this has been the situation in many mental hospitals in our country and our government is very keen to change this. Hence the government felt the need to take a rights-based approach to mental health. This is a historically marginalised and vulnerable group with very special circumstances which don’t necessarily apply to the rest of the health sector.
Do you have any targets for increasing mental health infrastructure?
With an aim to address the requirement of qualified manpower in mental health, under the Tertiary Level Activities of the National Mental Health Programme, the government has supported establishment of 21 centres of excellence in the field of mental health and strengthening/establishment of 39 postgraduate departments in specialties of psychiatry, clinical psychology, psychiatric social work and psychiatric nursing. The support includes funds for capital works, purchase of technical and non-technical equipments, staff support etc. During the next three years, the government proposes to establish eight additional centres of excellence and 16 postgraduate departments. Providing support for these centres and PG departments would serve a dual purpose of creating additional PG seats for adding qualified manpower to the current workforce in the field of mental health in the country as well helping establish tertiary-level mental health care services in various parts of the country. Under the district-level activities of the National Mental Health Programme, district hospitals are being strengthened to provide mental healthcare services through establishment of psychiatric OPD and IPD services along with support for providing ambulatory services for mentally ill persons and setting up of state/district-level mental health helplines.
The health policy envisages PPP, yet your Clinical Establishment Act has not been accepted by most large states.
The National Health Policy envisages strategic purchase and engagement with the private sector for critical gap-filling at secondary and tertiary levels. The main mechanisms of strategic purchase are insurance and through trusts. Schemes like Arogyasri and RSBY have been able to increase private participation significantly. Payment is by reimbursement on a fee-for-service basis and many private providers have been able to benefit greatly from these schemes. The aim would be to improve health outcomes and reduce out-of-pocket payments while minimising moral hazards. Private-sector engagement goes beyond contracting and purchase. Private providers, especially those working in rural and remote areas, or with under-serviced communities, require access to opportunities for skill upgrade to meet public health goals, to serve the community better, for participation in disease notification and surveillance efforts, and for sharing and support through certain high-value services — like laboratory support for identification of drug-resistant tuberculosis or other infections, supply of some restricted medicines needed for special situations… and even social recognition of their work. This would greatly encourage such providers to do better. Hitherto all public training and skill provision have been only to public providers. The policy recognises the need for training and skilling of many small private providers. A few states have adopted the Clinical Establishments Act 2010. Advocacy with the other states would be made for adoption of the Act. Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices.
You are also looking at CSR (corporate social responsibility) to get the private sector involved in public health.
CSR is an important area which should be leveraged for filling health infrastructure gaps in public health facilities across the country. The private sector could use the CSR platform to play an active role in awareness generation through campaigns on occupational health, blood disorders… screening of children and antenatal mothers, psychological problems linked to misuse of technology, etc. The policy recommends engagement of the private sector through adoption of neighbourhood schools/colonies/slums/tribal areas/backward areas for healthcare awareness and services.
How will you address recent violence against doctors and doctors’ strikes?
This is a very serious issue. I have written to the chief ministers and health ministers of the states to ensure that a safe working environment is provided to the doctors and the medical staff.
Do you feel your government is in a position to address malpractices or negligence by doctors?
As I mentioned earlier, we are talking to the states on various issues such as these. I would also like to appeal to doctors that theirs is a very noble profession where they treat the patients and give them a new lease of life. There needs to be respect and restraint on both sides.
Can you prevent strikes by doctors?
We are making efforts in this direction.
Since in most health issues it is the state that prevails, any plans of bringing health on the concurrent list ?
There has been some argument in favour of bringing public health and hospitals under the concurrent list. It could facilitate comprehensive and improved response for achieving SDG (sustainable development goals) 3 to which India is a signatory. The SDGs require significant inter-sectoral convergence, which is likely to be effective with health in the concurrent list. It could also help provide patient-centred care in health facilities through appropriate regulation and better partnership of private sector to achieve national health goals. Further, it would also help in disease surveillance and concerted and timely response to emerging disease threats such as Ebola, Zika, H1N1 etc, which adhere to no borders. Nevertheless, our government is a strong votary of the principle of “cooperative federalism” and any change in this regard will only be brought after thorough consultations with the states and only if the majority of the them also so desires.
What is the status of the health protection scheme? It has already been with the cabinet for four months.
The national health protection scheme is under active consideration of the government. It is utmost priority for the government, as it is a mega social welfare programme, giving enhanced health protection to the identified socially and economically deprived sections of the society.
The Medical Termination of Pregnancy Act too has been with the cabinet a long time, while couples keep going to court.
It is true that recently there has been an upsurge in cases approaching the court to seek permission to undergo medical termination of pregnancy beyond the upper limit of 20 weeks of gestation, set by the MTP Act 1971. These pregnancies were detected with foetal abnormalities and the women had desired termination of pregnancy. Some major congenital malformations may be detected around or beyond 20 weeks, hence the present restriction of 20 weeks may force a woman to terminate the pregnancy in haste, or continue the pregnancy against her wishes even after being aware of the condition of the foetus, thus adding to her mental and physical anguish. The Ministry of Health & Family Welfare has recommended doing away with the gestational limit for seeking abortions on grounds of foetal abnormality that is incompatible with life.
What are your goals for 2017-18?
The goals have been reflected in the budget speech of the finance minister and also in the NHP 2017. The year 2017 will be the year of major reforms in respect of drug and medical device regulation. The ministry has already notified the Medical Devices Rules, 2017 on January 1. The measure will, besides improving the quality of medical devices, also provide clear, transparent and predictable pathways for the industry to invest and do business in India. The required framework for these rules including the e-platform, accreditation, registration of notified bodies, guidance documents, classification of medical devices, etc. will be ready before these rules are implemented from January 1, 2018. These rules dispense with the requirement of renewal of licences and for the first time, provide for third-party conformance assessment. Though the rules relating to clinical trials and research have already been amended in 2016 to bring clarity in the related areas, the ministry proposes to bring out a new set of rules to regulate clinical trials and new drug approval during 2017. The focus of the new rules will be the safety of patients and clinical trial subjects, expeditious decision-making to approve/reject the proposals on the basis of clear and concise principles enunciated in the rules, and providing an impetus to clinical research in the country. A separate set of rules are proposed to be brought out to regulate the quality of cosmetics, e-pharmacy/sale of medicines and stem cell therapy. The new rules will be in place before the end of 2017.