National Health Policy: Nailing it right!

The need for planning and policy in health was felt about seven decades ago in British India, when a committee was appointed under Sir Joseph Bhore. The Bhore committee recommended the formation and execution of a ‘National Health Policy’ (NHP) in 1946 (Health Survey & Development Committee, Vol II – Bhore Committee, 1946, p. 410) . India has had only two National Health Policies till date; i.e. the National Health Policy 1983 and the National Health Policy 2002 – the first healthcare policy came after a gap of 37 years from Bhore committee recommendation.

Also, there are some learning from the past National Health Policies. The ‘National Health Policy’ did not adequately reflect ground realities. Despite the fact that the National Population Policy (NPP) 2000, the National Health Policy 2002, the Eleventh Five Year plan (2007-12 ) and the National Rural Health Mision (2007-12)- having laid down the goals for child health, the number of children dying < 5 years in 2000 was 2294000 and had reduced to 1696000 in 2010. But still, it is way too high.

‘Universal comprehensive primary healthcare services which was the goal of the National Health policy is far from being realised’……..NHP recommended the formulation of the medical education and a population policy , but this has not been done till today . (Voluntary Health Association of India, 1997, pp. 39,40)

Also, the earlier National Health Policies did not even have the word ‘chronic diseases’, and so clearly, the older policy documents are not relevant today.

The National Health Policy document of 1983 aimed at achieving ‘Health for all by the year 2000’ and emphasised universal provision of comprehensive primary care, community participation, decentralisation, increase in outreach services through domiciliary care and field camps, seek involvement of voluntary organisations, according priority to tribal, hilly and backward areas, promotion of family planning, supply of drinking water and sanitation, over hauling health manpower development, phasing out private practice amongst government doctors , integration of indigenous system of medicine in healthcare delivery, besides other issues.

NHP 2002 came out after 19 years of the first National Health Policy in 1983. The policy document accepted that some areas of NHP 1983 have yielded results, but in several other areas, the outcome has not been as expected!

NHP 2002 accepted that the mortality and morbidity were unacceptability high and such indices are an indication of the limited success of the public health system in meeting the preventive and curative needs of the general population.

The document dwells on problems like stagnancy of the public health funding, inequity in healthcare, health being the responsibility of states, shortfall in health infrastructure (as high as 58 per cent when disaggregated for CHCs) and accepted that the public health infrastructure was far from satisfactory.

NHP 2002 looked into the deficiency of health personnel, healthcare education, specialists in public health and family welfare, shortage of nursing personnel, use of generics, urban health, mental health, IEC, health research, enhancing the role of private sector, role of civil society, national disease surveillance network, scientific health statistics database, women’s health, medical ethics, quality standards for health foods, standards for paramedics, medical tourism, inter sectoral issues in health, population growth, increase in use of traditional/alternative systems of medicine, controlling the irrational use of drugs etc.

NHP 2002 recommended the increase in allocations for healthcare, reversed the 1983 policy of decentralisation in a sense by recommending key role of central government in designing national programmes and technical support, monitoring and evaluation at the national level by the centre. NHP 2002 recommended the gradual convergence of all health programmes under a single field administration, vertical programmes for major diseases like TB, malaria, HIV/AIDS, RCH and Universal Immunisation programmes.

The NHP 2002 did not talk about child health, chronic disease, the role of technology besides a host of other important issues.

In the summary section, NHP 2002 stated ‘NHP 2002 does not claim to be a road map for meeting all the health needs of the populace of the country’.

Clearly, if one reads any of the NHP documents, it looks like more money in the kitty and more doctors and allied health professionals are the only solution to the healthcare problems of this country. But the experience in the US and UK have not been able to demonstrate the positive impacts of reckless increase in health budgets or professionals. Policy makers have to go beyond the confines of Nirman Bhawan (HQs of Ministry of Health & Family Welfare) and Yojna Bhawan (Planning Commission). Earlier approaches have led to over dozen committees in health since 1947 and all have failed time and again. If we continue with the same approach, we are bound to fail in our goal of Universal Health Coverage. It is time we rethink our entire approach. One also needs to look at the Public Accounts Committee report on NRHM and its recommendations

Also, it is important to note that the last National Health Policy was drafted more than 10 years ago in 2002, since then a lot of things have changed, like;

• NRHM was launched in 2005 as a flagship programme focused on rural health
• Rashtriya Swasthya Bima Yojna (RSBY) was launched for BPL families, and as of October 31, 2013, it had 37,506,938 active smart cards and 6,215, 293 registered hospitalisation cases
• Rise in use of broadband and mobile phones. As on date, the number of internet users in the country are more than 200 million, and the number of mobile phones far exceed the land lines and India has more than 900 million users according to the Press Information Bureau (PIB, Govt. of India, 2013)
• Pandemic outbreaks like H1N1 (swine flu) have been a surprise and have shaken the world
• Rise of MDR – TB
• Increase in the incidence of chronic diseases and the issues related to child health
• Occupational hazards
• High IMR/MMR and MDGs deadline approaching in 2015
• Besides, a lot of other developments have taken place, like;
• UID –Aadhaar number for the entire population have been initiated . UIDAI plans to issue 60 crore Aadhaar cards till 2014 .
• Emergence of mHealth and telemedicine
• Newer technological interventions for diagnostics and treatment
• Emergence of Big Data Analytics
• Also that, India is focusing on transitioning the healthcare system to Universal Coverage
• Emergence of innovative concepts, like Disease Management, Accountable Care Organisations (ACOs), Health Management Organisations (HMOs) and meaningful use.
• Emergence of the prominent role of civil society organisations in healthcare delivery
• Role of social media

To me, the most important aspect to look at, is the increased sectoral allocations. The health sector allocations have increased from Rs 65.3 crores in the first plan to Rs 3.84 lakh crores in the 12th Plan. If we compare this to the 11th five year plan , this is a jump of 174 per cent. I some times shudder to think how can the ministry spend so much money without a policy in place? Even the Ministry of IT has a National Policy for IT ( NPIT), for the country.

Health has been getting the focus at the highest levels and the Prime Minister in his independence day speech (2011), highlighted that health would be accorded the highest priority. Also that, the 12th Five Year Plan has often been referred to as the ‘plan for health’, and it is the right time to set up a committee to draft the new National Health Policy for 2015-2025.

We should not lose any time in doing so, as drafting the policy is a time consuming process and it involves a lot of research and consultation. Even if the committee is set up in early 2014, it will take at least a year to do the survey and complete the policy and so, most likely, the NHP would be tabled by 2015 and would cover a period of next 10 years (2015-2025).

Key areas to consider in the National Health Policy

• Rural Urban Divide – despite decades of planning, we are failing
• Social Media Policy – This is a new development and India can leverage this, considering that 65 per cent of the population is less than 35 years in age
• Affordable and accessible medicines – Despite referring to the use of generics in Hathi Committee report in 1975 and in NHP 1983, we have not succeeded
• Nutrition policy – 50 per cent of Indian children are malnourished, according to the CRY report
• NCD policy – NHP 2002 made a passing reference to diabetes, CVD and cancer and now, we have a full blown problem of chronic diseases.
• Communicable disease/epidemic outbreak policy – Dengue, malaria are still around, and 100s of people die.
• Health Technology Policy – It is time we leveraged technology for providing some form of healthcare information and advice through technology driven care and also for surveillance and reporting
• Medical Devices policy – A lot needs to be done besides the MDRA
• Epidemiology policy – We are making ad hoc policies if we do not have an annual epidemiological survey. In fact, with the right usage of IT, we can have live data that can be used for effective and relevant policies
• Medical education and CME policy – Big gaps remain
• School health policy – school health programmes started in Baroda in 1909. We still could not make it a universal programme despite the idea being over 100 years old
• Innovations in health –This needs to be the focus area.
• Occupational health – Another big challenge that India has to be prepared for
• MCH – We continuously face flak for missing out of MDGs
• PPP – Time to clear our thoughts on how and what we wish to do with the private sector
• Sanitation and hygiene – Too much to do
• Implementation plan – All the NHP documents have been high level policy papers which never touched the implementation part and the new NHP must go in detail to ‘professionalise’ the public healthcare delivery system

It is time we started work on the NHP 2015-2025, before parliament questions the ministry on how they can use Rs 3.84 lakh crores without even having a policy in place! As we say prepare and prevent is better than repair and repent!