India needs to overcome policy paralysis to achieve ‘Health for All’

“Universal Health Coverage is one of the most powerful social equalizers among all policy options.” – Dr Margaret Chan, Former Director-General, WHO

World Health Day is a global health awareness day celebrated on April 7 since 1950 to mark the anniversary of the World Health Organization (WHO). Each year a different theme is designated by the organisation to highlight a subject of vital importance to global health. The goal of the 70th annual World Health Day is universal healthcare: everyone, everywhere. This theme focuses on two crucial areas; providing proper medical care regardless of economic hardships and accessibility – whenever and wherever. Apart from that, it intends to give the people strong primary healthcare care that can cater to the health needs of masses.

The shifts in India’s health policy paradigm

The National Health Policy was not framed until 1983, yet India has built up a significant health infrastructure and initiated many national health programs over the last few decades. The NHP 1983 was announced during the Sixth Plan period, to achieve the goal of `Health for All’ by 2000. It is the first time after the Bhore Committee report that Directive Principles of state policy recommends universal, comprehensive Primary Health Care services.

A report by National sample survey 1987 suggests that private health sector accounts for 70 percent of all primary health care treatment and 40 percent of all hospital care, which is not a healthy sign for a population whose 75 percent lives below subsistence levels. The above analysis indicates that the 1983 NHP goal, Universal, comprehensive, primary health care services are far from being achieved.

The seventh plan (1985-90) scaled up investment in family planning and opened up to private sector partnerships and NGO’s under the enhanced pressure of neo-liberal policies. The introduction of health sector reforms leads to cutbacks, private investments in public hospitals, purely techno-centric public health interventions and an introduction of user fees.

During the eighth plan (1992-97) slogan of ‘health for all‘ was changed to ‘health for underprivileged‘, it reduced the comprehensiveness and talked about the privatization of medical care. The conditionality imbibed in the reforms unfolded further over the ninth and tenth FYP results into an expansion of an unregulated growth of the subsidized medical market. The introduction of user fee further marginalized the mass. In the late 1990s despite improved economic growth rates and a flourishing middle class, it did not bother to provide a national insurance system, health co-operatives, health cess or free services for the poor.

During the 10th Plan, the Draft National Health Policy 2001 was announced. For the first time, feedback invited from the public. No mention of NHP 1983 goal of Universal, comprehensive, primary health care services were made in the NHP 2001.

The primary objective of NHP 2002 is to achieve a reasonable standard of health amongst the general population of the country. Again the goals given in the policy document are laudable but no specific time frame was provided to achieve them. In sum NHP 2001 is a mere collection of unconnected statements, it unabashedly promotes the private health sector and dilutes the role of public health services envisaged in the earlier policy.

Universal Health Care 

The National Health Bill-2009 grants health as a fundamental human right, and the 65th World Health Assembly in Geneva recognized universal health coverage (UHC) as the urgent imperative for all nations to unite the advances in public health. Consequently, the Planning Commission of India instituted a high-level expert group (HLEG) on Universal Health Coverage (UHC) in October 2010.

The committee rejected user fees in both public and private institutions. It argued that Universal Health Care founded on social solidarity, and cross-subsidization can be a success. Hence, it proposed a universal method of financing via general and differential health taxation and suggested that 70 percent of it should go to PHC.

The 12th Five Year Plan Approach Paper makes it clear that ‘publicly financed health care does not necessarily mean provisioning of services.‘ It mentions regulation of private players and illustrates the importance of Public-Private Partnerships (PPP) such as social security scheme: Rashtriya Swasthya Bima Yojana, outsourcing diagnostics and of a UHC system on the same lines.

The National Health policy draft 2015 was being introduced almost 13 years after the last health policy was drafted. The new policy determines that the present concept of primary healthcare hardly covers 20 percent of the health needs and accounts for hefty out of pocket expenditure. Although bringing down expenses has been listed among the essential objectives of spending of the new proposed policy, it has no ideas on how to do it.

After a gestation period of about two years that face extensive public dictum and strident debate within the government, the policy finally emerged. The recommendation in the NHP 2017 to increase the government‘s expenditure on health from the existing 1.15 to 2.5 percent of the GDP by 2025, it finds no replication in the Union budget 2018-19.

Where does India stand?

The current status of the national programs was it only provides universal coverage on specific interventions like maternal ailments that result from less than 10 percent of all mortalities. Around 75 percent of the communicable diseases are outside their purview, and only a limited number of non-communicable diseases were covered. As it stands, health will be recognized as a fundamental right only when three or more States request for it. Since health is a State subject, therefore, adoption by the respective States will be voluntary. The very objective of universal health coverage that hinges on portability will be defeated in the absence of uniform adoption across.

The announcement of the world‘s most extensive health care programme- the National Health Protection Scheme accounts for a massive insurance scheme for 50 crores of India’s most unfortunate, sound impressive. Conversely, what appeared less important was the promise of Universal Health Coverage and what went utterly missing was health as a fundamental right. The emphasis is shifting from public provisioning of services to merely ensuring universal access to services. While there is a lot that needs to be said about the shortcomings and directions for our Health System, the points above have been the primary thematic rationale of the system that can respond to the needs of the majority.

The excerpts were taken from one of the papers published by the author.