3/12/2015 AsketchyroadmapforhealthpolicyTheHindu

http://www.thehindu.com/todayspaper/tpopinion/asketchyroadmapforhealthpolicy/article6983864.ece 1/2

Today'sPaperOPINION

Asketchyroadmapforhealthpolicy

NidhiKhuranaMuchoftheNationalHealthPolicydocumentreadslikeareportofhealthissuesandsystemicchallenges,andissorelywantingonpolicydetail

INADEQUATEACTION:Theswinefluepidemicwasmetwithashoddyresponsefromthepublichealthmachinery.PictureshowsschoolchildreninMumbaiwearingmaskstoprotectthemselvesfromtheinfection.PHOTO:VIVEKBENDRE

Healthimpoverishmentfallingintopovertyduetohealthcarecostsaffects63millionindividualsinIndiaeveryyear.Thisisadamningstatistic,especiallywhenreadwiththefactthat18percentofallhouseholdsfacecatastrophichealthexpenditures(healthexpendituregreaterthan10percentoftotalhouseholdconsumptionexpenditureor40percentoftotalnonfoodconsumptionexpenditure).WeareatanurgentprecipiceintimeformakinghealthpolicyworkforthepoorinIndiathedeependofdirestraits.The2015draftNationalHealthPolicy(NHP)ispregnantwithpossibilities.ThefirstfederalhealthbilltocomeoutinmorethanadecadeisasalientopportunityfortheNarendraModigovernmenttopresentacoherentplantodeliverequitable,efficientandsustainablehealthcaretoIndiasbillionpluscitizenry.ThecliffnotesversionoftheNHPrecommendationsreadsthus:makehealthafundamentalandjusticiablerightincreasepublicexpenditureonhealthfrom1percentofGDPto2.5percentofGDPraiserevenuesmainlythroughgeneraltaxationwhileexploringthepossibilityofsintaxes(mainlytaxesontobaccoandalcohol),andearmarksforhealth(akintotheeducationcess)andstrengthenhealthservicesprovisioningthroughstrategicpurchasingfromthepublicandprivatesector.JumpingthegunBymakinghealthajusticiableright,theNHPappearstojumpthegun.Whilstanexcellentpropositioninprinciple,itisunrealisticasthebasicinstitutionalframework,infrastructureandpersonnelneededtodeliverhealthcareforallislacking.Sequencematters.Anefforttomakecomprehensiveprimarycaredeliverableneedstoprecedethedeclarationofhealthasajusticiableright.Otherthandefiningcomprehensiveasnotselective,thegovernmentmightlooktolearnfrominnovativeexperimentsinintegrateddevelopmentinresourceconstrainedsettingselsewhereintheworld.Forinstance,theMillenniumVillagesProjectinruralAfrica,aninitiativeofColumbiaUniversitysEarthInstitute,hasachievedpromisingyetcosteffectivehealthoutcomesinalittleoveradecade.However,muchofthestolid57pageNHPdocumentreadslikeasituationalreportofhealthissuesandsystemicchallenges,andissorelywantingonpolicydetailpertainingtoconcreteinstitutional,operationalandregulatorymeasures.Caseinpointisasectionexpoundingkeypolicyprinciplesequity,universality,pluralism,accountabilityanddecentralisationtenetsnoonecandisagreewith.Buttheroadmaptoachievetheseissketchytononexistent.Additionally,whilerecognisingweakhealthsystemscapacityasamajorimpedimentinachievingdesiredhealthoutcomes,theNHPiswoefullysilentonaugmentingstategovernmentstechnicalandadministrativecapacitytodobetteronhealthmetricslikechildandinfantmortalityrates,especiallyinthelaggardStates.Further,thesectiononqualityofcareisappallinglyoffpoint.Insteadofdiscussingstandardsofcare,thepatientcentredhealthcareparadigm,regulationsagainstmedicalmalpracticeandcounterfeitmedicines,andaccreditationofhealthcareproviders,itarbitrarilyfocussesonsuboptimalutilisationofhealthservicesbypregnantwomen.Besidesthebefuddlingtaciturnityonissuesofpolicyrelevance,theNHPmakesseveralcircuitousarguments.Whileclaimingthatefficiencyconsiderationsgiventhelimitedpublicspending(at2.5percentofGDP)mandatethatmostofthepurchasingwillhavetocomefrompublicproviders,theNHPisreluctanttojettisontheprivatesectorinmentioningpurchasingfromprivatesectoronlyforsupplementation.This,readwiththefactthattheprivatesectoralreadyprovides80percentofoutpatientcareand60percentofinpatientcare,ishardtofathom.Theconvolutedargumentdoesnotendhere.TheNHPwaxeseloquentabouttheroleofgovernmentpolicyandtaxconcessionsinactivelyshapingthegrowthoftheprivatesector.Whyshouldforegonerevenuesfromtaxsopstotheprivatesectornotbetransferredtoaugmentingpublichealthexpenditureinstead,especiallywhenthecomparativeefficiencyofthepublicsectorishigherandtheprivateindustryisalreadybooming?Lowerthanneededpublicfinancingforhealth(2.5percentasopposedto4to5percentofGDP)ispremisedonafallaciousargumentoflowabsorptivecapacityandinefficientutilisationoffunding.TheNHPrefutesitselfwhiledescribingthemainreasonfortheNationalRuralHealthMissionsfailuretoachievestrongerhealthsystems:

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3/12/2015 AsketchyroadmapforhealthpolicyTheHindu

http://www.thehindu.com/todayspaper/tpopinion/asketchyroadmapforhealthpolicy/article6983864.ece 2/2

Strengtheninghealthsystemsforprovidingcomprehensivecarerequiredhigherlevelsofinvestmentandhumanresourcesthanweremadeavailable.Thebudgetreceivedandtheexpenditurethereunderwasonlyabout40percentofwhatwasenvisagedforafullrevitalisationintheNRHMframework.Ifthisisnotthecaseagainstdiminishedpublicfundingforhealth,whatis?Inessence,theNHPisdoomedtorepeatpastmistakeswithnonethewiseroutcomesifitsubscribestothestatusquoofshorngovernmenthealthspending.TheModigovernmentwaswidelycensuredforarecent20percentcuttothehealthbudget,andtheditheringintheNHPdoesnothingtoinspiretrustorquellfearsoffuturecutsinhealthallocations.ThisabstractfromtheNHPisparticularlyworrying:Atcurrentprices,atargetof2.5percentofGDPtranslatestoRs.3,800percapita,representinganalmostfourfoldincreaseinfiveyears.Thusalongertimeframemaybeappropriatetoevenreachthismodesttarget.ThreatofpandemicsAsidefromaggravatingdiscrepanciesanderrorsofcommission,theNHPsuffersfromanotherglaringmiss.Itentirelyskipsmentionoftheglobalhealththreatposedbypandemics.AccordingtoWorldBankestimates,therecentEbolavirusoutbreakinWestAfricacouldcosttheregionthousandsoflivesandasmuchas$32.6billionbytheendof2015.Closerhome,theragingswinefluepidemicwasmetwithashoddyresponsefromthepublichealthmachinery,withmisinformationandrumourshavingafielddaythatshouldserveasastridentwarningfortheneedtoinvestinepidemicpreparednessandresponse.Othergripesrelatetovagueprioritysettingforachievingspecificpolicyaimsandabsenceofstandardsorlegalprovisionsforregulatingtheprivatesector.Asanexample,theNHPputsforthamultitudeofcriteria,ostensiblytodeterminetheagendaforreducinghealthdisparitiestotheendofachievinggreaterhealthequity.Thisincludestargetingvulnerablepopulationsubgroups,geographicalareas,healthservices,andgenderspecifichealthissues.Italsoaddsdifferentialfinancialability,developmentalneedsandhighprioritydistrictstothisboggysoup.Thepolicyprovidesanunhelpfullaundrylistwithoutsomuchasaperfunctoryattemptatmakingsenseofit.Thiscanbeaddressedbyproposingcontextualpriorityweightsforvariouscriteriaaswellasbyoutlininganinstitutionaldecisionmakingframework.Thepolicyalsofailstolocatehowcompetingprioritieswillberesolvedandhowfartheywillbedeterminedbycontext,ifatall.Further,inrespectofprivatesectorregulation,themissingdiscussionongivingmoreteethtotheNationalAccreditationBoardforHospitalsandHealthcareProvidersandenforcingtheClinicalEstablishmentsActof2010,whilemakingitmoreparticipative,isdisconcerting.TheNHPpresentsacomprehensiveproblemstatementbutfallsshortonpracticablestrategy.Anevidenceinformedpolicywithanintersectoralethoscleareyedprioritysettingconsideredstandsonmattersofpolicysaliencesensitivetocontextualdifferencesandreformsaimedatpluggingleaksandinefficienciesistheneedofthehour.Mostofall,theNHPmustbepersuasiveandunapologetic.Cogentargumentshelpbuildpoliticaltractionthatisimperativeforrealisingpolicygoals.(NidhiKhuranaisahealthsystemsresearcherattheJohnsHopkinsBloombergSchoolofPublicHealth.Theviewsexpressedarepersonal.)TheNHPisdoomedtorepeatpastmistakeswithnonethewiseroutcomesifitsubscribestothestatusquoofshorngovernmenthealthspending

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