Amit Mookim, Country Principal, IMS Health evaluates the draft National health Policy and talks about how it can be improved
The draft policy intends to increase the healthcare budget to 2.5 per cent of GDP in the next five years. Ideally, four per cent of GDP would have been realistic to achieve its stated objectives of universal and affordable healthcare, while reducing the burden of out-of-pocket expenditure. The constraints on government resources makes it imperative to utilise the resources more judiciously by identifying much more focused interventions and policy measures. Robust and good governance mechanisms shall be established to ensure equitable health access to all cadres of population (including vulnerable and marginalised) in order for the country to achieve its goal of universal healthcare.
Engaging the private sector
The role of the private sector in healthcare could be a key, especially in addressing areas of lower coverage. While the NHP recognises the contribution of the private sector in the overall delivery infrastructure and the need for private sector to bridge the gap, the NHP has remained silent on the role of private sector in the same, and outlining concrete steps for involving the private sector and creating a mechanism for deeper partnership and engagement. The role of private sector in health has been acknowledged and engaging them in procuring care such as ambulatory care, imaging and diagnostics, and tertiary care has been spelt out evidently in the draft policy. Conversely, the mode of and mechanisms to engage the private sector in health requires greater clarity.
Globally, many health systems work closely with private practices at GP level, healthcare players and outsourced agencies for managing and operating infrastructure and some of these opportunities need to be assessed and discussed in more detail.
Financing mechanisms
The draft policy intends to levy health cess and sin taxes on tobacco, alcohol, and other products as a means to provide thrust to additional resources for health. However, the impact of such a health cess will be greater on those in the lower income group as compared to those in the higher income bracket. On the other hand, mechanisms to expand the ambit of income tax coverage are a probable alternative to the regressive health cess. Perhaps, the government may explore mechanisms of leveraging the existing taxation pool and expanding the ambit of its tax coverage as currently a mere 2.89 per cent of the population is filing income tax returns.
Expanding the scope and scale of financing mechanism such as social health insurance will offer greater financial risk protection beyond the health services delivered in public health facilities. Schemes like RSBY may be expanded to include preventive and promotive health activities while enhancing the limit of coverage considering the rising healthcare costs. It is critical to re-calibrate the category of illnesses covered under RSBY by scientific means and systematic use of health expenditure data. Additionally, enhancing the provider panel by empanelling more number of private providers which comply with guidelines on service delivery, infrastructure, manpower, etc., is expected to increase access to financial risk protection. Moreover, defining the roles and responsibilities of employer in occupational health/ healthcare worker safety policies is expected to cover under its ambit the large section of people in the unorganised sector.
Pricing and procurement
Healthcare and medical technologies finds a notable mention in the draft policy, highlighting the significant role of technologies in improving health and health system. However, medical equipment along with in-vitro diagnostics continue to come under the ambit of Drugs and Cosmetics Act, 1940, notwithstanding the differences between the medical equipments and drugs industry. Effecting price controls in medical equipments belie the fact that healthcare providers determine the prices far more than the industry.
The current rates of purchasing health services from private sector CGHS and ECHS could cause over prescription of diagnostics and drugs without significant quality of care. Additionally, procurement policy that exclusively relies on lowest bids potentially sidesteps quality, company track record, etc.
Focus on manufacturing medical devices
India is also presented with an opportunity to engineer innovation in the medical devices manufacturing industry. Low-cost quality devices as part of the ‘Make in India’ initiative will further the cause of improving access, affordability and availability of healthcare. Attracting investments in this sector requires improved intellectual patent protection, easing barriers to start a business, setting up of medical devices/ IVDs hubs economic zones and necessary manpower training centers to support the these activities.
Just as India came to be known as the ‘pharmacy of the south’, India has the potential to cater to the needs of the developing world for low-cost medical devices through exports. The government could extend support for exports in areas such as testing, design and development centres and component manufacturing.
Technology
Knowing the patterns and trends in causes of death by age and sex in a population is critical to understanding how to target interventions and maximise population health. Thus, there is a requirement for scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geography for specific points in time. Use of technology tools and health informatics could be encouraged at both central and state level of health planning. Real-time evidences may be generated to determine specific requirements of services/ infrastructure gaps/ manpower constraints/ etc., for a particular geography and then identifying the appropriate intervention.
The NHP talks about alignment with various stakeholders and capacity building in health technology and health technology assessment and also outlines an approach to assessing technology needs for healthcare. This is an encouraging statement but at the same time, there is a need to establish large scale information platforms, core technology infrastructure at the clinic level and linking health infrastructure to the extent possible to create more efficiency in the care pathway.
Quality of Care
A push towards improving quality of care is visible with the guidelines for hospital infection control being made a mandatory. This should ideally spur the creation of a new national data registry (similar to CDC) for data-driven and evidence-based decision making and formulating policies and solutions. Benchmarking standards for quality of care is critical along with mechanisms for effective monitoring to ensure compliance. While NABL and NABH accreditation standards have contributed to the overall quality of healthcare but they are not the panacea for ensuring quality in all types of health facilities. It is imperative to benchmark the quality of care standards against global best practices and healthcare worker safety guidelines on customary basis, along with effective capacity building and monitoring mechanisms to ensure adherence.
Ensuring safe environment for healthcare providers (like prevention of needle stick injuries, unwanted body fluid/ blood exposure, etc) may also be prioritised for efficient healthcare service.
Human resources in health
The gap in demand and supply of healthcare infrastructure and human resources is widening. Provisioning for skill upgradation of nurses, healthcare professionals, para-medical professionals is critical. There should also be continuous focus on the quality of trainings and education through benchmarking and monitoring mechanisms. The requirement of allied health services professionals in the healthcare industry is rising. Investing in creating more healthcare professionals will have a direct bearing on improving availability and access to quality healthcare.
It is important that curriculum and course material for training is approved by authoritative bodies like nursing councils, IMA, etc; coupled with strict selection and monitoring criteria (including accreditation mechanisms) for training delivery centres to ensure highest standards of education and uniform quality across the country.
Other alternatives such as skill-based certification (and not just education based), regular recertification, online courses for continuing professional education, participation in academic conferences for safety measures, etc may also be explored to bridge the skill gap.
Leveraging corporate social responsibility
CSR flows to healthcare may be leveraged in a much more defined and targeted manner. This could be a very important source of funding and management bandwidth across corporate India and needs to be detailed. The government could prepare ‘shelf of projects’ based on the needs for health infrastructure upliftment, improved service delivery, manpower augmentation, etc for a particular region. Private sector could be encouraged to invest and take up some of those projects, based on their willingness and local regional presence.
Fostering industry-academic collaborations
There is a prudent need to create public platforms for promoting higher engagements among industry, academia and R&D labs by encouraging centres of excellence for research and education through private sector participation. A common sector innovation council for the health ministry could be strengthened and made functional.
Innovative strategies of public financing and careful leveraging of public procurement is desirable.
Access to diagnostics under national health programmes
Expanding the disease surveillance and screening programmes to include communicable and non-communicable diseases such as hepatitis, diabetes, cancers, etc., could assist in enhancing the health system’s response to rising burden of diseases. Mandatory annual or two-yearly baseline diagnostic tests could be implemented to create an early alert system for citizens’ health as a step towards preventive healthcare.
Another important aspect is uniformity in diagnostic standards such as types of tests across laboratories in different levels of healthcare that could improve quality assurance, infrastructure, technologies and skills under a new National Lab Strategic Plan.
Moreover, understanding the causes of IMR and MMR through robust health information system could provide the evidence to plan and deliver interventions in minimising these health burdens. Proven interventions such as capacity building for the management of key issues like sepsis (IMR), PPH and obstructed labour could be encouraged at all levels of healthcare. Mandatory screening of new born, including those born inside and outside health facilities, could help in assessing their health status as well as the possibility of genetic disorders in the area of Inborn Errors of Metabolism.
In addition, raising public awareness about key healthcare issues is an important preventive health intervention. The public sector IEC apparatus could be leveraged to mobilise the population for disease screening/diagnosis and subsequent treatment in partnership with key stakeholders such as the media.