I believe this policy is a well-crafted effort to transform our health system towards greater levels of outreach, effectiveness and equity. The policy is looking in the right direction even if some of the proposed measures fall short. The success will depend upon how the states adopt and implement NHP and the levels of commitment in governance they will bring forth during implementation. Unless the states act in coordination, we will see a huge disconnect and the intention of the policy may not be translated on the ground. That is the concern.

If the centre says that two-third of the funding should go to primary healthcare and that there should be a strategic purchasing mechanism for secondary and tertiary care, are the states ready to accept that? Are all states willing to accept that free diagnostic care should be available in hospitals? Right now, primary healthcare is funded through central schemes. But for the policy to succeed, states have to increase the budgetary allocation for health above 8 percent. They too have to put a lot of money in primary healthcare. There are a number of directions that the new policy is providing including strengthening of district hospitals. The states have to act on that.

Is the target of spending 2.5 percent of GDP on public health very ambitious? Is our system ready to absorb the amount effectively?

I believe 2.5 percent is the absolute minimum needed. We need more than that. Second, it should have been spent by 2020 rather than 2025. For the last three-four decades we have been stuck at around one percent. If they achieve the spending by 2025 it is not bad. 

One of the reasons for the system to absorb all money allocated and to utilise it appropriately, even at the current low level, is because the health system has been a very feeble, with very limited human resources, sub-optimal infrastructure and poorly functioning supply chains for drugs, vaccines and technology. We need front-end spending to strengthen the system so that it can absorb better. [For instance] if you have a sub-centre with only one ANM [auxiliary nurse midwife] you will not be able to spend all the money and provide all the services. Absorption capacity depends upon how much you are ready to spend to change the health system so that it is better equipped. 

NHP lacks in clarity – in terms of objectivity, implementation and financial assistance. Your comments.

One must recognise that the policy is not a strategic action plan. A policy sets out to coordinate the direction in which the system must move; how policy in the health sector and other areas align the health goals. It picks out the key areas of action. Detailing out these areas is part of a later strategic action plan that will get into the National Health Mission or the National Disease Control programme documents or others. So, to expect a health policy to provide all details of action is incorrect. Second, some part of the design elements of the programme will lie with the states. In a sense, NHP is creating space for the states to act while providing the building blocks of a new health system.

We are trying to fill gaps in the health sector with the help of private players. How would it work?

Ideally, the public sector should be capable of delivering all the services. We would wish for that. Since it is not going to happen in a short time frame, we have mixed the health system. It has evolved not by design but by default; we have to live with that reality. Some gap-filling has to be done by the private sector but it has to be done in a planned and regulated manner so that it becomes an extension of the public sector in universal health coverage [UHC] framework.

NHP speaks of ‘strategic purchasing of services’ from the private sector. What would it entail?

Strategic purchasing means services have to come by clearly defined deliverables and accountability mechanisms – the quality of that service delivery has to be clearly defined. All states and districts may not have the necessary level of strength of public services and one may need to pull in players from not-for-profit or private sector to deliver some of the services. But you have to pay for it. The government says that it will purchase services from the public sector too. There is, however, still not much clarity.
 

They [government] have said that they will emphasise on primary healthcare, and finance secondary and tertiary healthcare. They will try to move primary healthcare through a ‘capitation fee system’. It is bundled payment [annually] for looking after a person. The provider will look after the health and will be paid a fixed amount in a year. There is an actual incentive for the provider to emphasise on effective early care. For secondary and tertiary care it will be still fee for the services. For each visit and procedure, you will have to pay. This somehow doesn’t gel well together because you have to decide on creating a system integrating all of this.

They are talking about setting different agencies looking at the different aspects of regulation. In the 2016 budget, a pronouncement was made regarding the National Health Protection Scheme, coming up from April 2017, which is going to be a modified version of the Rashtriya Swasthya Bima Yojana [RSBY]. It was also proposed that a National Health Agency will be set up along with state health agencies. Surprisingly, the NHP 2017 and the budget [2017-18] have been very quiet on that. But I believe it may still come through. But the idea of having a well-coordinated system of regulation both for provision as well as for purchase is absolutely critical. These aspects need to be elaborated in any future document or plan of implementation.

Are we looking at health insurance to become the backbone of our healthcare system?

I hope not. Some of the insurance schemes that have sprung up after 2002 like RSBY and Aarogyasri Scheme [in Telangana], have served some purpose in increasing access to hospital care including private hospitals to the poor and the vulnerable sections. However, an analysis by Brookings India shows that these schemes have not eased any of the financial burdens, which was the original intent. They have not reduced out-of-pocket expenditure. In fact, it has increased. Second, they have not reduced any catastrophic expenditure and third, no reduction in the healthcare related impoverishment. While all these insurance schemes had good intentions, because of the add-on hospital costs as well as inability to provide aftercare through diagnostics, the actual financial burden has increased. Unless you have a financing scheme that link primary care as a gatekeeper, all this disjointed schemes will not serve the purpose. That still remains as a bit of disconnect in the NHP 2017.
 

Second, the success of any insurance scheme depends upon risk pooling. The rich must subsidise the poor and the young must subsidise the old. In a progressive tax system, where rich people pay more than poor people and the state is providing most services in taxes, the rich are subsidising the poor.

Equity dimension goes out of the window. In social insurance schemes, like in the Scandinavian countries, money is mandatorily deducted from the salary for health purposes. In our country, a close to 93 percent is in the informal sector, so how do you collect their salary contribution? The classical insurance system won’t work here. You do need a single payer system in which the government’s tax revenue would flow in for purchasing of services. 

The policy does not include the right to health. Is it retrograde or the government is being practical?

In other countries, right to health is either incorporated in their constitution or has been interpreted in the judicial pronouncement. From our point of view it is important to have right to health. This is what we said in our recommendations for the high-level expert group, submitted to the NITI Aayog in 2011-12.

It is disappointing to see that the mention of the right to health in the earlier draft has been deleted. What matters is the implementation of the effective measure which advances the ‘right’ in real terms. You have a right enshrined in the constitution but are falling short of UHC. All countries who have put right to health in their constitution have not achieved UHC and the right has not been fully realised in those countries. You have to be serious of multi-sectoral actions to influence policies and programmes in other sectors impacting health, like water, sanitation, agriculture [seven priority areas] and see whether you are able to align all of that. 

Is the idea of integrating Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) with allopathy feasible in the long run? 

The question is, why are we integrating AYUSH? Is it to extend the range of services by bringing in expertise of AYUSH? They have their own strengths and advantages; there is a certain degree of complementarity as well. We ought to bring that in. For that you need to provide them the facilities to practise their craft for which they have been trained. If you don’t provide ayurvedic medicines in primary health centres (PHCs), then what are AYUSH doctors going to do? The other alternative being talked about is the placement of AYUSH doctors to man the PHCs by giving them training in allopathy for six months. You are asking them to do something for which they are not trained and even if you give them bridge training it’s a half-hearted measure. Don’t use AYUSH as a cheap substitute. I would rather go in for nurse practitioners or bachelors in community health.

What can we make of the idea of ‘public health management cadres’ in all states – a proposal in the policy?

Public health requires expertise at multiple levels. Right from policy to economic evaluation, you require health economists to find out whether an intervention is cost-effective or not. Similarly, you require a good epidemiologist to determine the cause of a particular problem like infections or why diabetes levels are rising in India. You also need a social scientist to understand the behaviour of individuals and communities. So, public health is a multi-disciplinary learning for multi-sectoral applications. One of the systems where we are deficient is public health management. It requires an understanding of public health dimensions, determinants and pathways of prevention and control of all health problems at population level. There have been failures at the district and state programme level management due to this. Even in terms of designing programmes and policies. Cadres will focus particularly at the district level, as stated in the NHP because that is where the implementation will take place. Tamil Nadu has introduced health cadres but they have taken only medically trained professionals and put them in charge of primary health services. There is no reason why nurses can’t be trained in public health or why an ANM cannot have a career progression in public health. But you need health economists, social scientists and communication specialists to come in. They may not come in as a part of the cadre since day one but at least they should be given contractual appointments in national programmes so that they can support the system to the broader public health dimension. Over a period a much more inclusive public health cadre will turn up. 

Delhi’s AAP government has consistently hiked the health allocation in the budget dramatically and launched mohalla clinics. Should the centre not borrow this idea?

As far as governments are concerned, Kerala and Tamil Nadu have done well not just in social determinants but also in terms of percentage of budgetary spending on health. Bringing health as an important political issue in the policy arena, I think the government of Delhi has done well by projecting it. Mohalla clinic is a very clear signal of why primary healthcare must be delivered as close to home [as possible]. In urban primary healthcare, we have not set up community health centres while some municipalities have dispensaries but they do not function at the same level. 

What are India’s challenges in healthcare in the coming years? Does the policy account for it?

NCDs will be a major challenge including mental illnesses. Meanwhile, injuries and avoidable road traffic deaths and disabilities due to it, problems of air pollution, climate change, zoonotic diseases and antimicrobial resistance will emerge as major challenges. The policy does acknowledge these challenges and we have to prepare our system for it. Many of these challenges call for multi-sectoral actions. The system should be capable of providing persuasive factors to act in a direction. That is where you need a health impact assessment. If the health ministry sees their role as only running hospitals, then they would fail in providing healthcare.