Ills of a draft Health Policy

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HEALTH POLICY

" The current annual per capita public health expenditure in the

country is no more than Rs. 160. "

- from Draft National Health Policy-2001.

THE Draft National Health Policy, which was released in August, has

come under fire from several quarters. The first salvo came from the

Jana Swasthya Abhiyan (JSA), an organisation dealing with public

health issues. It has been close to 18 years since the last health

policy was framed in 1983. Therefore the decision of the Union

Ministry for Health and Family Welfare to frame a health policy

document went largely unopposed though there were complaints of lack

of consultation prior to the drafting stage.

Overall the draft policy, while emphasising federal principles and

decentralisation in terms of public health and the role of State

governments, is silent on how to remedy the ills of the public health

care system. The blueprint for the system lacks the kind of vision

that would ensure that marginalised populations have access to health

care in the future. An assessment of the public health infrastructure

has to be more than just platitudes and should take forward the

objective of making equitable health for all a reality. The draft

policy acknowledges some of the possible ills in the health care

system. However, it fails in its basic function of including the

fiscally starved State governments as well as people working in the

area of community health in the task of addressing issues of public

health.

The Ministry put the draft proposal on its Website and invited

comments from the various forums concerned with health-related

issues. The JSA, an umbrella organisation of 18 national networks

dealing with community health and people's science, responded with a

comprehensive critique of the draft policy. While welcoming the

government's initiative, the JSA has drafted an alternative policy

document which incorporates some valuable suggestions but excludes

aspects that, in the JSA's opinion, misrepresent the situation.

Members of the JSA met recently to review the policy document within

the framework of the people's health charter evolved at a " national

people's health assembly " held in Kolkata in December 2000. The

health assembly was essentially a reiteration of the commitment

of " Health for all - Now " . The people's health charter included,

among other things, a 'basic needs' approach and the need to confront

the commercialisation of medical education and health care, issues

that the people's health assembly expected the national health policy

to address.

While the draft makes several candid admissions - for instance, it

acknowledges the high levels of morbidity and mortality and the poor

functioning and severe underfunding of health services - it is silent

about a strategy to make comprehensive health care available to all.

It expresses concern about the impact of Trade-Related aspects of

Intellectual Property Rights (TRIPS) and globalisation policies on

health and recommends a higher level of expenditure on primary health

care; however, it lacks a comprehensive analysis of why National

Health Policy-1983 failed. One of the primary premises of the 1983

policy was that India is committed to attaining the goal of " Health

for All by the Year 2000 A.D. " through the universal provision of

comprehensive primary health care services. The words 'comprehensive'

and 'universal' are missing in the Draft Health Policy of 2001.

The historic Alma Ata declaration, in which many governments have

committed themselves to a " Health for All " strategy, is not even

mentioned in the 2001 document. Government representatives from over

100 countries attended the World Health Assembly at Alma Ata,

Kazakhstan, in 1978 and committed themselves to making comprehensive

health care available to everybody, highlighted primary health care

as a priority area, and acknowledged that in the matter of health

care there were certain socio-economic determinants too that had to

be dealt with. It was for the first time that health was not treated

as a biomedical issue, said Amit Sen Gupta of the All India People's

Science Network, one of the groups in the JSA. The 1983 policy had

initiated a phased, time-bound programme to set up a well-dispersed

network of comprehensive primary health care services, among other

things.

Another area where the Union government has been criticised is its

inability to involve the State governments in the drafting of the

document. Even the Central Council of Health and Family Welfare, an

apex body of representatives from all State Health Departments, was

not consulted. Also, the one month that was given to elicit comments

and suggestions on the draft was deemed inadequate, especially in

view of the fact that the draft policy remained in the drafting stage

for three years. Public and community health organisations like the

JSA believe that the government acted in a hurry to secure approval

for the draft, even without going through a consultative process with

the State governments.

THE policy document brings to light several unpalatable features,

such as the unacceptably high morbidity and mortality levels, the

resurgence of malaria, especially of the deadly P-Falciparum type,

and the dominant presence of tuberculosis and the growing of drug

resistance in the types of infection prevalent in the country. In

addition, water-borne diseases such as gastroenteritis, cholera and

some forms of Hepatitis continue to contribute to the high levels of

morbidity among the population. While the concern and facts are

genuine enough, the remedies seem lopsided. For one, it blames the

failure of the public health system for the unsatisfactory health

indices. The draft policy admits that the investment in public health

over the years has been comparatively low and has declined as a

percentage of Gross Domestic Product to 0.9 per cent in 1999. The

linkages between policy and ground realities are missing. The Central

budgetary allocation as a percentage of the total Central Budget over

a 10-year period has been stagnant at 1.3 per cent while in the

States it declined from 7 to 5.5 per cent. Given these figures, the

current annual per capita health expenditure works out to a paltry

Rs.160.

The need for the universalisation of public health services has been

substituted by a new concern - decentralisation of public health

services. The intent, as is evident in the sub-section " Delivery of

national public health programmes " in the draft policy, is a

decentralised public health machinery. The obsession with vertically

structured programmes is evident in the draft, which states

categorically that the role of the Central government in designing

broad-based public health initiatives will continue especially as the

Central government will be responsible for funding additional public

health services over a period of time. Interestingly, the policy

arrogates to the Central government the areas of technical and

managerial expertise for designing large-span public health

programmes. The JSA has been especially critical of this overwhelming

role of the government as it believes that designing programmes

should be the primary responsibility of the State governments.

The Centre, if anything, should play a coordinating role and provide

technical and financial support wherever necessary. The JSA, in its

alternative draft policy, a copy of which has been submitted to Union

Minister for Health and Family Welfare C.P. Thakur, suggests that in

the long run it is a more sustainable option to integrate disease

control strategies within the decentralised primary health care

network, which should be linked to adequate secondary and tertiary

support services.

On the section dealing with the public health infrastructure, JSA

draft suggests that the primary health centres (PHCs) have been

reduced to centres for family planning aid and immunisation. It is

this situation, coupled with inadequate facilities, that has resulted

in less than 20 per cent of the population seeking out-patient

department services and less than 45 per cent availing itself of

treatment as in-patients in public hospitals. The draft policy, while

outlining the poor infrastructure facilities in public hospitals,

including the shortage of medical and paramedical personnel, glosses

over the relentless pursuit of " family planning and immunisation "

goals by the PHCs. This aspect is mentioned in the alternative draft.

The draft policy suggests the need for specialists in " public health "

and " family medicine " and agrees that the current curricula for

graduate/post-graduate medical degrees are outdated and unrelated to

contemporary community needs. " Contemporary needs " should be spelt

out, given the ambiguity of the phrase. The JSA draft contends that

the long-standing objective of the health movement has been to limit

specialisation and re-orient undergraduate education to equip doctors

to address the health needs of the common people. However, by

suggesting the introduction of another course in family medicine and

even specialisation in public health, the draft policy inadvertently

encourages the craze for specialisation.

The draft policy is silent on the issue of private medical colleges

and the need to regulate them. Similarly, on the question of medical

research, it focusses more attention on frontier areas of research,

calling them the thrust areas. This, the JSA draft observes, does not

take into account the need to initiate and sustain research in public

health. There is also no mention of the need to regulate medical

research and develop ethical criteria.

The effect of TRIPS is discussed in the context of a possible impact

on drug prices but there is no mention of any such impact on medical

research. While lamenting that investment in public health has been

comparatively low, the draft policy fails even to record that such

investment as a percentage of health expenditure was perhaps the

lowest in the world and that the country has the world's most

privatised health system. The policy's prescription to raise the

current health expenditure from 0.9 per cent of GDP to 2 per cent in

2010 fell drastically short of the health movement's demand that the

expenditure should be nothing less than 5 per cent of GDP.

The JSA has objected to what it calls " prescriptions for further

privatisation " of an already highly privatised health care system.

The proposal in the draft policy to levy " user fees " at public

hospitals, so that those who can afford to should be made to pay,

would only serve to drive out the poorer sections. The government

wants to shift the burden on the secondary and tertiary sectors while

strengthening the primary health care sector by increased resource

allocation.

The cursory mention of mental health given the tragic events at

Erwadi in Tamil Nadu involving the death of 28 mental patients

(Frontline, August 31, 2001), the casual treatment of women's health

and the total absence of any mention of children's health have

surprised activists in the health movement. The socio-cultural and

economic factors that determine access to health care, particularly

by women, are glossed over in the draft policy. The JSA's draft,

however, contends that women's health issues go way beyond problems

related to " child bearing " and the " reproductive tract " and that the

entire gamut of problems faced in a patriarchal society has to be

considered. Given the fact that more than half the children under

five in India are malnourished, it is surprising that questions of

their nutrition and subsequent well-being do not find even a fleeting

mention in the draft. On the other hand, the policy draft does re-

emphasise the connection between population stabilisation and

improved health indices. It states: " The synchronised implementation

of these two policies - National Population Policy-2000 and National

Health Policy - 2001 - will be the very cornerstone of any national

structural plan to improve the health standards in the country. "

What is required is a paradigm shift, a shift away from the apparent

panaceas of population stabilisation and private sector participation

in the health sector. But the language continues to be the same. It

is couched in platitudes with little or minimal emphasis on

rejuvenating, strengthening and making effective the primary health

care sector. This, according to the draft policy, is closely linked

with the quality of public health services, which is in turn

reflected in improved public health indices.

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Source-FRONTLINE 8-21 Dec 2001

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