Healthy goals
Source: By Chandrakant Lahariya: The Telegraph
There is now wider acceptance that access, availability and affordability of health services in India remain sub- optimal for most of the population. People often have to delay seeking health services because of different reasons, including lack of finances to seek care. Alternatively, they go to unqualified providers which lead to unknown and undocumented impact on health outcomes. Furthermore, there are emerging challenges of non- communicable diseases, which require additional preventive and promotive health services — something that the Indian healthcare system is not designed or fully prepared for.
The health sector in India seems to have witnessed a lot of commotion in the last 15 years but the impact has not been commensurate. In the last decade, the outcome of government initiatives, be it the Rashtriya Swasthya Bima Yojana, the National Health Mission or a component of the NHM, such as the Janani Suraksha Yojana, has been less than desirable. The challenges in India's health sector are widely acknowledged.
They range from 'policy flip- flops' — the National Health Assurance Mission appeared an urgent and pressing priority in mid- 2014 but is not being referred to at all now — to 'long planning to implementation phase'. This is a common experience with many examples. It took nearly five years to launch the National Urban Health Mission since the draft framework document was first prepared in 2008. The National Health Protection Scheme was announced in February 2016, to be implemented from April 1, 2017. Eighteen months later, only a component of this scheme — on the elderly — has been launched, and there is limited clarity on the next step.
Similarly, the responsibility for poor health infrastructure, investment and outcomes is often shifted by Union and state governments on one another. There are a few feasible solutions, which have been agreed upon, over the years, by key stakeholders. However, their implementation till now has left much to be desired. Many of these are included in India's National Health Policy 2017 as well. Policy makers at both Union and state levels in India should consider facilitating the implementation of these solutions.
The weak primary healthcare system in both rural and urban India has long been recognized. The proposal in India's new National Health Policy 2017 to upgrade existing health sub centres to health and wellness centres is a practical solution. By the year 2022, establishing a network of fully functional 200,000 HWCs in rural areas and an agreed number of mohalla/wards clinics (call them by any other name, if that helps) in urban areas is a feasible solution.
It would require additional funding, a roadmap, and the desired political commitment at both national and state levels. It also means that every passing year 40,000 functioning HWCs would get added till the year 2022. The Swachh Bharat Mission has set an example of being a fast- paced and well- monitored government initiative in India, and there could be lessons and approaches which could be learnt for setting up HWCs.
Effective health service delivery would need addressing the shortage in the health workforce. Past attempts to address these shortages have met with partial success. The states have to rapidly adopt and expedite the process and make necessary legislative provisions for task shifting and engagement of AYUSH practitioners as well as the training of mid- level providers, such as community health officers, in service delivery.
The preventive and promotive health services are mostly provided by the government sector. The private sector has limited incentive in providing these services. The government needs to have specific and dedicated budgets for such services. Additionally, the providers should be given incentives if they devote more time to patients and deliver specific services. Health staff needs to be specifically equipped, trained, encouraged and facilitated to deliver such services. NHP 2017 recommends increasing total government spending in India for health to 2.5 per cent of the gross domestic product and to increase spending on health to 8 per cent of the state budget. These two proposals would be essential to make the provision of health services affordable to the people.
One approach to make progress is to expedite the implementation of these proposals. Ministers of health should work closely with ministers of finances to get a raise in health sector budget by 50 per cent over the previous year's budget in the first two years. This can make a good baseline for the health budget, which can be sustained with an annual increase rate by calculating economic growth rate plus 10- 20 per cent of the previous year's budget at both levels. Making health services affordable should not rely on increased funding only.
A few mechanisms have to be implemented alongside to ensure that the benefits reach the people to reduce out of- pocket expenditures. Two supplementary mechanisms are the removal of any type of user fee from government health facilities, especially for primary level of care, and Indian states adopting the policy of universal provision of free medicines and diagnostics for all, supported by legislation. The provision of free medicines should be for all patients, irrespective of whether they attend a private or public health facility/ provider. The free medicine scheme can also dramatically increase absorption capacity of the health sector in India.
India is known as an information, communication and technology hub and has achieved a number of enviable feats, including the provision of Aadhaar cards to nearly 90 per cent of citizens in less than a decade. Contrastingly, there is no reliable data on the availability and geographic distribution of approximately 800 thousand medical doctors and nearly 2 million other types of healthcare workers (excluding community health workers). The ICT mechanisms should be explored to develop a real- time database on health infrastructure, providers and the different types of health services in the public and the private sectors. In the health sector, the ICT appears to be underutilized and even the traditional focus on tele- medicine is mostly on paper. ICT and Aadhaar number information linkage have the potential to map all healthcare providers in the country.
There is need for a scale- up of select health interventions, which can deliver results within three to five years. This would contribute to the rapid increase in the availability of health services in India and achieve the goals of NHP 2017. It would be a fitting tribute to the people of India on the occasion of 75 years of Independence in 2022 and an important mid- term milestone for India's journey towards universal health coverage.
