Recognising the urgent need to improve the performance of health care system in the country the Central government recently released the Draft National Health Policy 2015 document. It is now in the public domain seeking comments from various stakeholders. The document starts with the acceptance of the fact that though India has achieved remarkable strides in economic development the progress in the health sector is not satisfactory.
The existing health system is dysfunctional in many respects. Quality health care is available only to the elitist class. Widespread inequities in access is a problem haunting us since long. Sustainability, efficiency and affordability are also the challenges being faced by the health system. It is in this context that the government proposes to make health a fundamental right.
The focus of the government will be to leverage economic growth to achieve health outcomes. Better health contributes to improving productivity. The health and wellness of a population influences the quality of life and people’s capability to productively contribute as efficient labour force. The proposal to raise public health expenditure to 2.5 per cent from the current 1.04 percent of GDP is a welcome step especially in the context of the government slashing 20 per cent of the 2014-15 health care budget.
This temporary cut to help government to achieve its 2014-15 fiscal deficit target of 4.1 percent of GDP has attracted nationwide criticism. The government plans to raise percapita health expenditure from the current `957 to `3,800. General taxation and a health cess are among the sources for financing the increase in health care expenditure.
Like the earlier health policies the 2015 policy too fails to recognise that health care has very little to do with improvements in the health status of a population. Past evidence shows that improvements in agricultural productivity which reduced near starving conditions, improvements in public health facilities like water supply, sanitation which checked great epidemics and immunisation against small pox, antrax, tetanus, polio, etc., have greatly contributed in better health outcome and reduction in mortality rates. The new policy should place more emphasis on strengthening basic amenities and ensuring proper nutrition and sanitation. In the contemporary scenario since lifestyle diseases account for 60 per cent of all deaths in the country emphasis should have been given for strategies for lifestyle modifications of the population that is exposed to the risk of diseases like diabetes, coronary artery diseases and obesity.
According to the World Health Organisation (WHO), “Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity and good health is the state of being vigorous and free from bodily or mental disease”. The health status of a person is determined by his income and social status, education, physical environment in which he lives, social support network, genetics, his individual characteristics and behaviour.
The new health policy seems to be too restrictive in its scope since it is placing too much emphasis on the access and use of health care services. In measuring the health status of an individual, in addition to the absence of physical pain, physical disability or a condition that is likely to cause death, his emotional wellbeing and satisfactory social functioning should be considered. In the Indian context, an ideal health policy should focus on minimising the imperfections on the supply side of health care services.
On the supply side the physicians involved in providing information and advice and the actual delivery of services like surgery and drugs prescriptions, nurses, paramedics, general staff, medical suppliers like drugs and instrument suppliers are all important in determining the optimum delivery of health care services. But very often unaccounted ‘incentives’ may induce these ‘agents’ on the supply side to produce too much or too little health care of a particular kind. Also there is the risk of a given level of care being produced inefficiently with a wrong input mix.
In India health care practitioners are under- regulated and under-legislated. Many doctors are involved in private practice in a competitive market characterised by a lot of market imperfections. Many of them rely on commissions from laboratories and specialists for referrals. Doctors, pharmaceutical cartels and drug inspectors are all partners in a crime endangering the safety of patients. There should be a strategy to eliminate corrupt medical practices, arbitrary pricing and administration of unwanted tests and medical procedures. The emphasis should be on transparency and cost-effective dispensation of medical services. Best practices in advanced countries like ensuring safer surgery, reducing hospital acquired infections and minimising readmissions could be emulated.
The immense possibilities of Information and Communication Technologies (ICT) to augment affordability and accessibility of health care should be explored. According to a recent World Bank report, “Reliable information and effective communication are crucial elements in public health practices. They help in enabling people to produce their own health.”
E-health, the organisation and delivery of health services and information using mainly the Internet, has immense possibilities in treating chronic diseases and it is a key in reducing costs. The possibilities of pharmacogenomics, the science of prescribing drugs according to an individual’s bio markers, have to be explored for cost effective drug administration.
The new policy acknowledges the role of private sector in the delivery of health services in the country. There is now a consensus that public sector should focus on preventive and secondary care services while services like ambulatory care, imaging and diagnostic services , tertiary care services and many non-medical services such as catering and laundry should be in the domain of private sector. The private sector already provides nearly 80 per cent of outpatient care and about 60 per cent of inpatient care in India. The possibilities of public- private partnerships could also be explored.
Though the NABH (National Accreditation Board for Hospitals & Healthcare Providers) and other accrediting agencies are involved in assessing and accrediting hospitals on quality parameters a more coordinated and integrated approach in the measurement of quality of health care in hospitals is required.
The author is a Bangalore-based professor of health economics.