The National Health Policy 2017: Through the Accountability Lens (Part 1)

Background

The health policy broadly defines the key strategies of the government contouring its role and the proposition of engagement with the principal stakeholders towards achieving health goals. There are two reasons why the government’s role is pivotal in the health sector. One is because of severe market failure, which among other things include problems of imperfect and asymmetric information, and failure of markets because of significant externalities. The health policy must ensure that government strategies are aimed at correcting or compensating for these failures. Second is the doctrine of beneficence suggesting moral obligation of the government to act for the benefit of its citizens, often by preventing or removing possible harms. Within the backdrop of SDGs, the NHP 2017 approved by the Government recently sets its goal as:

Attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.

I. Collectivists View of Health Financing and Delivery

Nearly seven decades ago in 1946 Bhore Committee had put forth the collectivist view arguing that health services would be available to all citizens, irrespective of their ability to pay. This view was construed at a time when globally there was the belief that willingness to pay and ability to pay can guide the allocation of health care resources in any country and the development of the strategies can be designed based on these two principles. A few decades later this collectivist view was rearticulated in Thatcherism era in the UK in the eighties as follows:

Adequate health care should be provided for all, regardless of their ability to pay, must be the foundation of any arrangement for financing the health services.

The NHP 2017 reiterates this view of the provision of universal access to good quality health care services without anyone having to face financial hardship as a consequence. The NHP 2017 echo’s the Bhore Committee view, which among other things had suggested that:

There should be provision for every patient, if his condition requires it, to secure the consultant, laboratory and other special services, which may be necessary for diagnosis and treatment. There should also be provision for the periodical medical examination of every person, sick or healthy, so as to ensure that his physical condition is appraised from time to time and that suitable advice and medical aid, wherever necessary, are given in order to enable him to maintain his health at the highest possible level.

The Committee at that time had laid down the basic foundation for the health delivery system in India suggesting that the most satisfactory method of solving this problem would be to provide a whole-time salaried service which will enable governments to ensure that doctors will be made available where their services are needed. Based on this strategy and following Alma Ata declaration India developed and implemented a comprehensive structure of primary, secondary and territory care system to ensure health for all. However, due to health transition and various emerging challenges, the performance of health system particularly in recent times has not met the expectations. India could not achieve all the MDGs. Today the health system is not in shape to address the NCDs, which now account for 60% of country’s illness burden. We are deficient on most critical health system parameters.

The significant reliance on the private sector has resulted in high OOP expenditures on health, and over 63 million persons are pushed into poverty every year due to this. The policy recognizes that public health delivery system is not responsive and fails to provide healthcare to all. The consequences of OPP expenditures on health care are serious affecting lives of a large section of the population. These and other challenges arose because of the public health sector, which assumed responsibility for producing and distributing the services, and it was not able to cope up with the demand or also turned out to be inefficient. The collectivist promise of previous policies, starting from Bhore and then in 1983 and last health policy of 2002 could not be delivered. The fact remains that the health system is not able to cover the entire spectrum of health care needs.

To meet these challenges, the NHP 2017 puts the fulcrum on the public health system in following words:

Reinforcing trust in public health care system by making it predictable, efficient, patient centric, affordable and effective with comprehensive package of services and products that meet immediate health care needs of most people.

Towards this the policy has set a target of increasing utilization of public health facilities by 50% from the current levels by 2025. However, the key strategy and the details of institutional reforms as a step towards the government plans to strengthen the public systems remain to be seen. The NHP 2017 falls short on this dimension of outlining the process of reforms except stating that the strategy of having periodic measurement and certification of the level of quality as a strategy to reform the public systems. One doubts whether these measures outlined in policy are going to deliver the results without considering and attending to the institutional, structural and incentive reforms and examining the responsibility structure in the health system. During this transition, the policy states that there would be many challenges and as an intermediate step the policy suggests:

Purchasing care after due diligence from non-Government hospitals as a short-term strategy till public systems are strengthened.

It remains to be discerned how states are going to participate in the reform process and initiating change process to strengthen and create trust in pubic facilities as most of them are within the state level jurisdictions.