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HEALTH
POLICY MAKING IN
INDIA
The Union Government
released the Draft National Health Policy (NHP) which takes into account new
diseases and revolutionary changes in medical science since the last health
policy. It talks about reducing inequities and regional imbalances in the health
sector and strengthening the primary health care network all over the country.
By setting up a Medical Grants Commission to provide resources for upgradation
of the existing government medical colleges and ensuring an improved standard of
medical education, the policy envisages to improve the health care delivery
system.
Over the years, especially since independence there was a remarkable improvement
in life expectancy at birth, birth and death rate and infant mortality rate,
stated in the policy statement. Infrastructural improvement resulted in
epidemiological shifts. Incidences of communicable diseases declined whereas
sexual infections and emerging non-communicable diseases took its toll.
Achievement of an acceptable, affordable and sustainable standard of good health
and an appropriate health system to reduce disease burden is the main thrust of
the new policy.
The public health expenditure has been found to be low as compared to the total
health expenditure. Improving public health system through financial packages
and programme strategies to correct imbalances among states is of priority.
Public health system will be strengthened through addressing distortions and
shortcomings stated as the major focus of NHP.
Over the years, the private health care has enlarged in the country and
continues to be characterised by malpractices, substandard facilities and
unqualified staff. Absence of regulatory environment, uneven quality and narrow
range of service, and high propensity for over diagnosis and cost are
characteristics of the private sector, which constitute 80 percent of outpatient
treatment and 55 percent of inpatient care. The new policy encourages setting up
of private insurance instruments to bring secondary and tertiary sectors under
private health insurance coverage.
CEHAT, over the years, has been advocating for improving quality of health care
through research and action. The major areas in which CEHAT contributed are accreditation,
regulation, medical ethics, health care utilisation and health
expenditure studies and health sector reform and right to health care.
Research, action and advocacy on these and other related issues by CEHAT on its
own and in collaboration with other institutions, organisations and movements
has substantially impacted the agenda on health issues.
This panorama is an endeavour to put together policy documents, research papers
and articles that can facilitate understanding of various issues on health
policy. This panorama, with its two distinct sections, discusses the Draft
National Health Policy - 2001 and the National Health Policy 1982.
Followed by the Draft National Policy (NHP) are some of the comments and
criticisms raised by various advocacy groups and activists through media. In its
brief critique, the Jan Swasthya Abhiyan (JSA) points out the arbitrary nature
of finalisation of the policy. The draft is silent on village health worker -
the first contact in the primary health care system, population control
programme and the impact of pharmaceuticals on health care. It conflicts with
the increased drug prices and non-availability of essential drugs and its impact
on health sector. The ignored areas are women's health, child health, medical
education to the needs of primary care, ban of private medical colleges or their
regulation, necessity to initiate research on public health, regulation of
medical research and developing ethical criteria. The NHP, according to JSA,
constitutes abandonment of the Alma Ata declaration and legitimises further
privatisation of health sector.
The People's Health Charter adopted by participants of People's Health Assembly
(PHA) or JSA builds on perspectives of people and encourages people to develop
their own solutions and to hold accountable local authorities, national
governments, international organisations and corporations. "Governments
have a fundamental responsibility to ensure universal access to quality health
care, … according to people's needs, not according to their ability to
pay," states the charter.
In response to the NHP, Ravi Duggal points out the critical recommendations
viz., establishment of epidemiological stations, targets for demographic
achievement and establishment of private curative sector of NHP 1983 which NHP
2001 did not refer. He stresses the need for the NHP to regulate the private
health sector through statutory licensing and monitoring of minimum standards by
creating regulatory mechanisms. The prescriptions in the policy in favour of
strengthening of the private health sector must be removed. He suggests a
primary health care package comprising of general practitioners/family
physicians, referral care and basic speciality services, immunisation against
vaccine preventable diseases, maternity services and services like
pharmaceutical, epidemiological, ambulance and contraceptive and health
education.
Anant Phadke in his comparison of NHP with People's Health Charter raises a few
points. The policy does not state the essentials of good health.
Quoting from activists and academicians Davinder Kumar in his discussion
criticises the 'pay and be treated' policy in a country having a sizeable
population below poverty line. Prescriptions of policy fail to address collapse
of primary health care system, poor coverage of women's health and prevention of
infant mortality. Expenditure in public health system is low to make it the most
privatised health system in the world. Advantage of
India
having lowest prices of drugs in the world will be lost if a drug policy
favouring public health concerns is not put in place before 2005.
Sandhya Srinivasan explains yet another aspect, which requires immediate
attention in the NHP. It is the attention to declining sex ratio, which was
caused by prenatal sex detection tests promoted by medical profession. Sex
selective abortions followed by prenatal sex detection tests are of wide
practice all over the country. Doctors are even hawking these techniques with
mobile sonography units. Private health sector which has grown through subsidies
for medical education, soft loans to set up medical practice etc., are now
privileges of the rich but the only option of the poor as well.
Ravi Narayan discusses 'Health for All' in the context of People's Health
Assembly, where health and non-health networks came together to evolve global
and national solidarity in health. National Health Assembly delegates attended
the Global Health Assembly- the Global Charter - and unambiguously endorses a
call for action for health as a human right.
There are certain news clippings - comments of journalists on health policy,
which are reproduced in this section.
The second part of the panorama takes us through a historical over view of
health policy making in
India
culminating in the National Health Policy 1982 and its comments by activists
and researchers. The need for a National Health Policy has been evolved to serve
the need of an integrated, comprehensive approach towards development of medical
education, research and health services established to serve the health needs
and priorities of the country.
Ravi Duggal emphasises the relevance of Bhore Committee - Health Survey and
Development Committee, who assessed the health condition in
British
India
(in 1943) in comparison to developed countries. The present health condition of
India
is below that of developed countries of 1940s. The reasons attributed are
insanitary conditions, defective nutrition, inadequacy of the existing medical
and preventive health organisation and lack of health education. The major
stress in the report was on making health services available to all citizens,
irrespective of their ability to pay.
The Declaration of Alma Ata in 1978 stressed the need to achieve fullest
attainment of health and to reduce the gap between the health status of
developed and developing countries. Primary health care has been emphasised in
the declaration.
Prior to the formation of National Health Policy,
India
n Council of Social Science Research and
India
n Council of Medical Research organised a meeting, which gave rise to certain
recommendations for policy formulation. On health sector formation of a National
Population Commission, improvement of nutrition through adequate food
production, improvement of environment to reduce infection, health education, an
alternative model of health care services, expansion and improvement of MCH
services, eradication of communicable diseases, training of health manpower,
formation of a drug policy, priority areas of research viz., epidemiology,
communicable diseases, environmental research, drug research and problems of
rural water supply and sanitation, indigenous medicine etc., were recommended.
Recommendations were also made on forming an administrative machinery at central
and state governments and financial management.
The National Health Policy 1982 was initiated in this context of high population
growth having an adverse effect on health of people.
Ravi Duggal in his critical review of health policy issues pointed out the
recommendations made by Bhore Committee for a universal and comprehensive health
care system in comparison with existing growth of health care delivery system. A
lion share of public health facilities is concentrated in urban areas. Private
health facilities are largely uncontrolled and unregulated. The shortcomings of
the policy, pointed by Duggal, are its inability to define character of health
sector in
India
, rejection of the so called western model in favour of the low cost community
based model and finally the failure to comment on private health sector. Problem
areas identified are beyond the purview of the Ministry of Health, with
independent policies ministry can make useful contribution. He has identified
certain issues for a new health policy.
Padma Prakash in her paper on 'Women: Blind Spot in Health Policy' points out
the failure of Alma Ata Declaration to reflect women's health, neglect of
women's health in policy and programmes and the blinkered vision of women's
health. This invisibility of women in health policy has consequences for the
nature of information collected and the manner in which data are analysed.
It was the women's health issues that received attention during the period. An
initiative from VHAI and WAH! entitled 'Towards Comprehensive Women's Health
Policy and Programme' addressed issues of Ninth Five Year Plan and the National
Health Policy for the empowerment of women. They reviewed various committees,
historically, in relation to women's health. They pointed out the very fact of
low women's status despite government policies, programmes and efforts. And thus
recommended to formulate a health policy responsive to women's health needs.
Phadke has explained drug policy, an important recommendation of the ICSSR-ICMR
panel, in his overview. He states the increase in drug production with the
India
n Patent Act 1970. Even the recommendations given by Hathi Committee were not
used to prioritise drug production or procurement in
India
. Government's response to the Committee's recommendation to take prompt
measures to eliminate irrational drug combinations was not prompt. A rational
drug policy has been popularised by the Drug Action Groups.
The Draft National Policy on
India
n System of Medicine brought out by the Ministry of Health and Family Welfare is
also of importance in this context.
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