Frontline Gist: Issue
April 14, 2017
How the poor die
The national health policy’s professed commitment to strengthening the public health system are providing equitable, affordable and quality care to all is hollow as it relies heavily on private and voluntary sectors to fulfill it.
Features of National Health Policy:
(Related Articles: A policy let down, by T.K. Rajalakshmi, page no. 4; Public policy, Private care, by Imrana Qadeer & Arathi PM, page no. 9; Interview with Sujatha Rao, by Kunal Shankar, page no. 21)
•National Health policy (NHP) 2017, unveiled on March 16, was much awaited policy document and long due as last policy was released in 2002 and previously in 1983.
•The policy informs and prioritizes the role of the Government in shaping health systems in all its dimensions- investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross-sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and progressive assurance for health.
•The policy is aimed at reaching healthcare in an assured manner to all, particularly the underserved and underprivileged.
•The policy seeks to move away from Sick- Care to Wellness, with thrust on prevention and health promotion.
•The Policy proposes raising public health expenditure to 2.5% of the GDP in a time bound manner.
•It envisages providing larger package of assured comprehensive primary health care through the ‘Health and Wellness Centers’ and denotes important change from very selective to comprehensive primary health care package which includes care for major NCDs, mental health, geriatric health care, palliative care and rehabilitative care services.
• It advocates allocating major proportion (two-thirds or more) of resources to primary care.
•It aims to ensure availability of 2 beds per 1000 population distributed in a manner to enable access within golden hour
•The Policy has also assigned specific quantitative targets aimed at reduction of disease prevalence/incidence under 3 broad components viz.
(a) Health status and programme impact
(b) Health system performance
(c) Health systems strengthening aligned to the policy objectives.
•Some key targets that the policy seeks to achieve are –
a)Life Expectancy and healthy life
a.Increase Life Expectancy at birth from 67.5 to 70 by 2025.
b.Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022.
c.Reduction of TFR to 2.1 at national and sub-national level by 2025.
b)Mortality by Age and/ or cause
a.Reduce U5MR to 23 by 2025 and MMR from current levels to 100 by 2020.
b.Reduce infant mortality rate to 28 by 2019.
c.Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025
c)Reduction of disease prevalence/ incidence
a.Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i. e,- 90% of all people living with HIV know their HIV status, - 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
b.Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
c.To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
d.To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels.
e.To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.
•This policy focuses on tackling the emerging challenge of non-communicable diseases. It supports an integrated approach where screening for the most prevalent NCDs with secondary prevention would make a significant impact on reduction of morbidity and preventable mortality.
•The policy envisages a three dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines. This has a huge potential for effective prevention and therapy, that is safe and cost-effective
Criticism of NHP(2017):
(Related Articles: A policy let down, by T.K. Rajalakshmi, page no. 4; Public policy, Private care, by Imrana Qadeer & Arathi PM, page no. 9; In poor health, by Akshay Deshmane, page no. 15; Poverty amidst plenty, by R.K. Radhakrishnan, page no. 19; Interview with Sujatha Rao, by Kunal Shankar, page no. 21)
•NHP 2017 does not underpin the government’s centrality in providing health care to all.
•The policy does not acknowledge reducing high out of pocket expenditure which constitutes 64% of total health expenditure. India ranked 183 among 192 countries in high out of pocket expenditure as a percentage of total health expenditure.
•The policy talks about eliminating corruption on healthcare systems but falls short of suggesting a framework for regulation of those systems but falls short of suggesting framework for regulation of those systems in a highly privatized medical education system as well as health care scenario
•The commitment to universal coverage does not accompany guaranteed increase in health care at all levels
•According to policy, the private sector is to be enabled to meet public health goals and make health care systems more effective, rational, safe, affordable and ethical. But is silent about tightening the regulatory framework relating to private health care sector, in all its dimensions
•India ranks high on Global Hunger Index but there does not seem to be any section on hunger and nutritional challenges
•There is no mention of strengthening the PDS, which indicates lack of all crucial determinants of health affecting all ages of population
•The policy says that while ASHAs would be “mainly voluntary and remunerated for the time spent” those who obtain qualifications could be given more regular terms of engagement. The approach towards those who are backbone of health delivery system in rural India is an indication of ad hoc approach
•Policy does not offer guaranteed free and affordable health care
•There is a cursory mention of inadequate calorie intake and nutrition status in the context of reproductive and sexual health in subsection on child and adolescent health
•The policy does not see overall morbidity and mortality as a function of either disparities in purchasing power or declining the ability of majority of population to have access to a diversified diet
•The policy emphasis was on promoting the private sector
•NHP 2017 considers medical industry as “robust” as the revenue it generates adds to the GDP, but shift of state subsidies and negative impact on public sector infrastructure and distributive justice in health care is not considered as contextual shift
•The link between medical industry and rising expenditure is completely missing from policy
•Policy perspective on organization of primary health care throws light on certain questions
a)State led health care or universal health coverage as defined by WHO is not framework of NHP
b)Role of government is visualized as one that shapes, finances, assures, strengthens, and regulates rather as a primary provider
c)An unrealistic divide is created between universal health coverage and public health care system
•Strategic purchase from non-governmental institutions, which logically should be based on an assessment of gaps, weaknesses or absence of public facilities in timelines laid out for strengthening them
•Even the paramedical workers are seen as the technical support staff for tertiary and secondary care but little attention is paid to auxiliary mid wives and multipurpose workers
•No as such focus on upgrading the basic infrastructure of public health care centres
•Huge void left in rural health care as primary health care centres have not been focused on
•The policy should have been more forceful and should have taken the integration of water, sanitation, environmental hygiene, nutrition, education and basic health committee
•Given the lax regulatory mechanism for the private health care system, the policy should have emphasized regulation in areas involving private partners
National Family Health Survey 4:
(Related Articles: Falling short, by T.K. Rajalakshmi, page no. 26; Cause for concern, by Ramesh Chakrapani, page no. 30)
•There has been marginal improvement in the child sex ratio at birth from 914 in NFHS3 to 919 in NFHS 4
•Improvement in households using improved facility of sanitation
•Decline in TFR
•Improvement in IMR from 57 to 41 per 1000 live births and U5MR from 74 to 50
•Only 21% of mothers receive full antenatal care
•Drop in number of children in 0-6 age group who receive semi solid or breast feeding
•Some 43% SC children, 44% ST children and 39% OBC children are stunted
•39% of SC children and 45% of ST children are underweight
•High rate of female sterilization
•Households with any member covered by a health scheme or health insurance
a)Top States: Andhra Pradesh, Chhattisgarh, Telangana, TN, Kerala, Odisha
b)Bottom states: J&K, UP, Haryana, Bihar, Jharkhand, Maharashtra, Goa
•Mortality rate data (per 1000 live births)
a)States with highest IMR: UP, Chhattisgarh, MP, Bihar, Jharkhand
b)States with lowest IMR: Kerala, Goa, TN, Maharashtra, WB
•Alcohol consumption among men:
a)Highest percentage: Telangana, Chhattisgarh, TN, Goa, HP, Odisha, Jharkhand
b)Lowest percentage: J&K, Gujarat, Rajasthan, Maharashtra, UP, Haryana, Delhi
•Women experienced spousal violence:
a)Worst states: Telangana, AP, Bihar, TN, UP, Chhattisgarh, Odisha, Jharkhand, WB, Haryana
b)Least Incidents: HP, J&K, Uttarakhand, Goa, Kerala