Outsourcing public service

The new national health policy that allows the government to purchase healthcare services from private hospitals and non-profits could be a double-edged sword

THE GOVERNMENT has made up its mind to stop being the provider of healthcare services, or so it seems from the National Health Policy 2017 released on March 16 by the Union Ministry of Health and Family Welfare. The policy seeks universal health coverage and enhanced secondary and tertiary healthcare services. But instead of strengthening the public healthcare system to ensure this, it proposes purchasing healthcare services from private hospitals and non-profit healthcare facilities.

This is the third time a national health policy has been framed in the country. The first one was released in 1983 after India became a signatory to the Alma-Ata Declaration of 1978, which stated that governments were responsible for the health of their people. The second one was released in 2002. A new policy was needed because the “health priorities” of the country have changed, the healthcare industry is growing and healthcare costs are rising, making it inaccessible to the poor. But how will the new policy help in facing these challenges?

What's new

Under the new policy, “trusts or registered societies” will be created at the Cental and state levels. These agencies will have institutional autonomy and ensure that the “purchasing is strategic”. They can also authorise payments for the purchase made. Experts say this will limit the role of the government to a regulator of purchased services and deal a death blow to the public healthcare system, which is already weak.

T Sundararaman, Dean, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, says the term “strategic purchasing” is used in different contexts at different places in the policy and is, therefore, open to misinterpretation. “For secondary and tertiary levels, it refers to patients purchasing healthcare services using insurance schemes, while for primary it refers to the government operationalising Health and Wellness Centres with the help

of the private sector. The details of what shape this collaboration will take are not yet clear,” he says.

These Health and Wellness Centres mentioned in the policy are also a first for the country. These centres will be set up to provide comprehensive primary healthcare services, which include geriatric health care, palliative care and rehabilitative care. Every family would have a health card that links it to these wellness centres and the family will be eligible for a defined package of services anywhere in the country. Yogesh Jain, a doctor and secretary of non-profit Jan Swasthya Sahyog working in tribal areas of Chhattisgarh, welcomes this thrust on primary healthcare but adds a word of caution. “Primary healthcare should not be at the cost of secondary and tertiary healthcare. If funds are not sufficient, the state may disown its responsibility of providing secondary and tertiary care, and may even privatise these services,” he says.

This becomes significant, considering the budgetary increase for the health sector proposed in the policy is minuscule. The policy states that the government would increase its healthcare expenditure to 2.5 per cent of India’s gdp by 2025. Jain calls the allocation a pittance. “A 2.5 per cent rise spread over eight years would mean an annual increase of 0.2 per cent. This is very less,” says Sundararaman.

To overcome monetary shortage, the policy talks of imposing tax on tobacco and food items that have a negative impact on health and by channeling corporate social responsibility funds towards healthcare.

The big miss

One decision that could have helped improve health infrastructure in the country, and was part of the draft policy of 2015, was to make health a fundamental right. Since fundamental rights are justiciable, the government would have been forced to provide access to healthcare facilities to everyone. Unfortunately, the new health policy is silent on this matter.

Jain criticises this omission. “Without this right, the government is not guaranteeing access to healthcare facilities to the public.” Satish Kumar, Adviser, Public Health Planning, National Health Systems Resource Centre, Union Ministry of Health and Family Welfare, however, says that the right was removed because the state does not have enough resources to implement it. “It does not make sense to just include the right and not implement it. We would definitely aspire for such a right in future.” (See ‘No risks with strategic purchasing’)

Nutritional shift

A new focus area in the policy is with regard to micronutrition. India’s population is deficient in both macronutrients (foods required in large quantities, for example proteins and carbohydrates) and micronutrients (elements required in trace amounts, for instance iodine). Till now, the government focussed on both these deficiencies, but the new policy is focussed on micronutrients. “The focus is on food fortification. Addressing macronutrient deficiency takes time whereas micronutrient deficiencies can be addressed immediately and we can see short-term dividends. For instance the introduction of iodised salt was quite successful,” says Kumar (see ‘Staple solution’, Down To Earth, 1-15 April, 2017).

Jain, however, says, “This shift is worrisome. Macronutrient deficiency needs to be addressed first because stunting is a major problem in the country. Moreover, it is a

continuing anomaly that the nutrition of children is under the purview of the Ministry of Women and Child Welfare.”

The policy also lays emphasis on standardisation of treatment guidelines and banning the use of antibiotics as growth promoters for food animals to address the growing problem of antimicrobial resistance. There are some new ideas in the policy, says Jain, but implementation remains a concern.