Approach to National Health Policy and Budget, 2014
Challenges in Health Care and the Decentralized Way Forward: Need for a Paradigm shift
Though there has been significant increase in investments in the Health sector after independence and
we have also expanded our infrastructure in a big way, there are major gaps in the desired Health
Indicators. Indian Health Care Infrastructure of the day and its approach has resulting in the present
scenario where:
• 13 of the 17 Goals of first National Health Policy have not been met (NSSO survey data, GoI)
• There had been a decline in public sector utilisation of OPDs from 26 to 19% between 1986-96,
which has increased to about the earlier level after NRHM implementation
• Access to free care during the same period reduced from 19 to 10%, and has improved
somewhat after NRHM.
It is due to this impasse that a large number of poor are not seeking formal health care due to financial
incapacity and that out of pocket health care expenditure is the cause of more than 30% cases of
indebtedness in the country.
Major Concerns of the present day Health Care infrastructure and approach are the following:
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Lack of access to health care, more so to rural areas, slums and vulnerable sections
Increasing Dual Burden of Disease (Both concerning Poverty and Life-style problems)
Poor Health Indicators in most States
Commercialization of Health Care (Medical care) leading to exorbitant Increase in expenditure
Focus on Management approach and vertical programs of Cure than Promotion & Preventive
health care or community involvement
Western Ethnocentric paradigm of ‘Medical care with Technological Subservience’ Although
there is a large body of knowledge and simple, effective and low-cost technologies exist to deal
with many diseases, Western Models are rampant and being further promoted in the country
Our chief constraints are in the social, educational, cultural, economic and political spheres;
ironically, these areas are largely ignored in health research
Dominant Budgetary Support to Allopathy
Continued neglect of inherent/indigenous knowledge systems of the community
Institutional Uprooting of folk practices and practitioners (including TBAs)
Any solution to overcome the above challenges would require a ‘Health Perspective’ shift from the
present focus of managing the sick, which has an undue emphasis on ‘Curative Medicine’. We have to,
ensure a ‘Paradigm Shift’ from Medical care Industry based approach to the basic philosophy of
‘Swasthya Swabalamban’ by providing quantum jump in our support to the all the systems under
AYUSH-- Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa Rigpa, Homeopathy where the emphasis
has to be on ‘Swasthasya Swasthya Rakshanam’ (Taking care of the health of the healthy).
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Overall Perspective
Health-care is an area which has wide potential and is a high priority need. It currently requires massive
expansion of the public sector for fulfillment of people's needs and optimising the potential of available
knowledge, practices and infrastructure. The approach for the same has to ensure people’s participation
with desired support from the public sector for ensuring primary to tertiary care with equitable access,
rationality, accountability and affordability.
The Prime Minister has placed health as one of the high priority areas for the present government.
Further, a message of strong political will needs to be sent out for public systems strengthening, which
can be articulated through the National Health Assurance Mission (NHAM) promised in the BJP election
manifesto. Besides increased budgetary allocations, it will be crucial to optimise utilisation of the funds
by appropriate design of service systems and programme.
The NHAM must be projected as a flagship programme that receives support from the highest levels of
government. The NHAM must be comprehensive and incorporate the other manifesto promise, that of
promoting other systems of medicine, by conceptualising an Integrated, Plural, Public Health-care
System for All. In addition, there are emerging challenges that the country needs to ready itself for,
such as diabetes, environmental toxicities, cancers, suicides, mental illness, increase in communicable
diseases due to the climate crisis and care of the elderly.
1. Financing
1.1. Increase budgetary allocation for Health by at least 5 times in this Five Year Plan. In the next plan
there should be further doubling of the allocation, thus by 2025, bringing us to the levels necessary for
optimal health services to all. Our public health budgetary allocations – center and state combined-and the component of expenditure by public health sector of the total health expenditure is presently
among the lowest in the world. The public funds should be utilised for strengthening public systems in
all states in the spirit of universal access to health care. [The argument given for not increasing the
health budget has been that the public services do not have the capacity to absorb funds. However, it
cannot be the reason to give it a low budget but to recognise that the system has not allowed speedy
fund flow and transparent expenditure. Where the NRHM plugged these gaps, expenditure was speedy
and appropriate, achievement of targets being in proportion to the expenditure. About one-third of the
required funds were allocated and a similar proportion of the targets were achieved.]
1.1a. Three units of the increase in budget must therefore go for the general health services
strengthening and expanding human resource capacities. One unit must go to strengthening AYUSH
services, i.e. of the seven systems, and developing integrated systems through collaboration across
pathies, with research and training as well as mainstreaming folk medicine as a part of the AYUSH Public
Health Strategy. One more unit will be required to build institutional capacity for research in public
health, environmental health and other emerging problems as well as ensuring inter-sectoral
coordination for health.
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I.2. Public funds should not be channeled to private services through social insurance schemes. Public
funds should be used exclusively to strengthen public services.
“the poorer sections of households in intervention districts of the Rashtriya Swasthya Bima Yojna , Rajiv
Aarogyasri of Andhra Pradesh, and Tamil Nadu Health Insurance schemes experienced a rise in real per
capita healthcare expenditure, particularly on hospitalisation, and an increase in catastrophic headcount conclusive proof that RSBY and other state government-based interventions failed to provide financial
risk protection.”
(Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing Financial Risk
Protection. EPW, Vol - XLVII No. 11, March 17, 2012 | Anup K Karan and Sakthivel Selvaraj)
I.2a. Insurance schemes have worked effectively for improving health status only where they have been
implemented through community collectives (CBOs) and workers' unions, whether it is in Germany
which is considered the originator of social insurance, or in the Indian social insurance schemes, such as
by Smt. Ela Bhatt's SEWA and Dr. Devi Shetty's Narayana Hrudayalaya. The problems being faced today
by RSBY, Rajiv Gandhi Arogyashree and other such recent social insurance schemes are due to this
component being missing. The USA experience shows that the individual insurance model of medical
care is counter- productive and unsustainable, with ever-escalating financial costs and negative health
effects. Therefore, social insurance should be supported only through associations of workers,
peasants, women and community cooperatives.
I.3. Create a special vehicle for pooling of philanthropic resources for health activities at local, state
and national levels. There could also be provision for CSR funds to be included in this special vehicle.
I.4. In addition to government services, missionary hospitals such as of the church, Rama Krishna
Mission, Waqf Board, Shiromani Gurudwara Prabandhak Committee and other trusts of religious or
secular inspirations, should also be supported so that they are able to continue providing free, good
and ethical care to the poor.
These institutions built with philanthropic and societal support are in recent years facing financial
constraints and falling prey to commercial interests. Such socially committed institutions need to be
supported through Public-Philanthropic Partnerships.
2. Strengthening Public System
The proposed measures apply to all public services, Allopathic and AYUSH, stand alone and co-located,
as appropriate to each of the eight systems.
2.1. Allocation for provision of free essential generic drugs and diagnostics to all patients in the public
services. The beginning of this process with 50 essential drugs, as announced by the Health Minister,
is a step in the right direction and we hope the measure will see rapid increments.
2.2. This should include allocation for states to set up transparent and efficient, need-based
procurement systems for drugs and diagnostics.
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2.3. Allocation for expanding the primary level services, increasing sub-centre density for adequate
population coverage with trained human resources.
2.4. Allocation for strengthening CHCs and District Hospitals to provide adequate secondary and
tertiary care.
2.5. Activation of the Village Health, Sanitation and Nutrition Samitis and strengthening the role of the
ASHA.
2.6. Strengthening of technical capacities in the Ministry of Health and Family Welfare so that we do
not have to rely on consultants paid by foreign funding agencies. At last count there were about 70 such
in the MOHFW. Such technical inputs only contribute to create programmes and systems that cater to
international interests and not necessarily plan as suited for national and local needs.
3. Strengthening Human Resources in the public health sector
The proposed measures apply to all public services, Allopathic and AYUSH, stand alone and co-located,
as appropriate to each to each of the eight systems.
3.1. Allocation for states to strengthen public health leadership, skills and capacities through (i)
creating a multi-capability Public Health Cadre similar to the IAS (see article in Indian Journal of Public
Health, Oct-Dec. 2013, 'Developing a Public Health Cadre in 21st Century India: Addressing Gaps in
Technical, Administrative and Social Dimensions of Public Health Services.), and (ii) modernising
education in community medicine/preventive and social medicine in medical and nursing colleges.
3.2. Allocation for expanding medical and public health education. Publically financed education must
be expanded at state and district levels so that doctors and public health professionals are encouraged
to join the public services.
3.3. Allocations for strengthening government medical colleges—by improving clinical facilities and
human resources, ensuring adequate hands on experience, as well as revising of curriculum according to
current needs.
3.4. Allocation for appointing point persons at all levels for implementing inter-sectoral coordination
with health-- at least in the areas of water, sanitation, nutrition, women and child development, social
welfare, tribal welfare, and care of the destitute.
3.5. Skill development among youth to include traditional knowledge based skills, such as of yoga and
herbal medicine. This will improve their practice and use benefitting the rural and urban communities,
as well as provide meaningful skill based employment opportunities to the youth.
3.6. Allocation for National Survey on Status and Potential for training and integrating folk healers as a
first level Primary Health Care providers, Accreditation and Certification of Folk Healers as community
supported Paramedical Health Workers and Establishment of Regional Centres of Folk Medicine,
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affiliated to the Institute of Folk Medicine, established in North Eastern region, at Pasighat, Arunachal
Pradesh.
4. Regulation
The proposed measures apply to all public services, Allopathic and AYUSH, stand alone and co-located,
as appropriate to each of the eight systems.
4.1. Allocation for consultative processes to develop regulatory systems for the private health sector
services. The private sector in health needs regulations to weed out the black sheep of the profession,
to get itself out of the current mire it is in.. Where 'Dharm, Arth, Kaam and Moksha' do not come
together in the right balance, it becomes unethical loot.
4.2. Allocation for Monitoring of implementation of the Clinical Establishments Act-- the Act is the first
step at developing any kind of oversight or regulatory mechanism for the private sector services. Even
this has been inadequately implemented in most states. While it's implementation is strenghtened, it
also needs to be the basis for incrementally evolving mechansisms for ensuring ethical health care.
4.3. Allocation for Revamping of Medical and Nursing professional regulatory bodies--professional
self-regulation by the existing MCI, CCIM and INC requires a review and evolving better mechanisms.
4.4. Allocation for strengthening the Drug Controller's office to ensure quality in production and
pricing regulation.
4.5. Allocation for Community Monitoring of Health Services to be institutionalised in all states-monitoring and feedback by the community of users of any service is one of the most effective
mechanisms for improving quality of services. It has been piloted in 9 states under NRHM and is in
practice in two states--Tamil Nadu and Maharashtra. It needs to be extended to all states in a systematic
manner.
5. Health Governance and the Community
5.1. While the broad policy contours and some issues need national attention, such as Professional
education and Health technology regulation mechanisms, Control of Communicable Diseases, Financing
o f health care, major planning and implementation has to be at state levels and below. Decentralised
governance is essential in the health sphere due to diverse ecological and morbidity profiles, social and
cultural contexts, health care systems and health related behaviours, as well as knowledge systems
such as Unani, Ayurveda, Siddha and Sowa Rigpa that may have similar principles but vary in
preventive, diagnostic and treatment regimens, and in their human resource base.
5.2. Decentralisation has to mean decision-making powers by elected representatives and other
community representatives at district level and below. There is a need to make the system more
appreciative of the role of these local representatives in existing structures and mechanisms such as
the Rogi Kalyan Samitis and District and Block Health Samitis.
5.3. The communities and households are the final implementers as well as beneficiaries and therefore
must have institutionalised space and mechanisms for planning of health care, monitoring of health
services and filling the knowledge gap of formal health care providers about the social context of health
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of the majority and their health perceptions and practices, Communities have diverse practices for
health protection and treatment, especially the adivasis and other marginalised groups, that may not
even be part of the codified system and need to be understood as forms of health care that is
accessible, effective, ecological and sustainable.
6. AYUSH and Folk Medicine
6.1. Department of AYUSH budget to be considerably increased with proviso for:
a) popularising the concepts of promotive and preventive health practices.
Besides universalisation of the existing National Programmes of AYUSH, namely Ksharsutra,
Geriatric Care and Mother & Child Health in a big way, promoting Ritucharya and Dincharya,
Prakriti Pareekshana at school level along with creating a self-awareness of health at indiviual
and collective levels, Garbhini charya (besides ANC), Yoga and Pranayam.
b) increasing its health systems planning capabilities as an integral part of the entire helath
planning and for the seven codified systems under AYUSH as wellas the folk practices and
practitioners.
c) developing and piloting optimal district level systems for universal access to healthcare with
integration of AYUSH and local folk medicine
d) developing mechanisms for separate record-keeping and monitoring of utilization of AYUSH
services
e) improving quality of stand-alone and co-located AYUSH services in the rural and urban health
facilities.
f) improving quality of AYUSH medical colleges with emphasis on the principles of the AYUSH
sciences including their public health component.
6.2. Promoting Folk Medicine
There are reportedly one million folk healers who serve their local community’s health needs, solely
based on community legitimacy and support. They do not receive any financial support from any
Government. This tradition is fast eroding and will be completely lost in the next 10 to 15 years, unless
Policy interventions are not immediately made. Since the number of folk healers has not yet been
authenticated, a National Survey is urgently required to assess their potential and scope to mainstream
their services as a part of the National Health Assurance Mission. The Governments at the centre and in
the states need to immediately recognize their services as community supported Paramedical
Community Health Workers. They need to be supported with legal, institutional mechanisms and
programmes of documentation, assessment, research and capacity building to strengthen and sustain
India’s unique community based health culture that has continued to serve the wider public despite lack
of any concerted policy devised and implemented by the national and state level health policy makers
and implementers.
a) Allocation for strengthening of the North East Institute of Folk Medicine (NEIFM) as a national
level institution for promotion of local traditional practices and practitioners (see Task Force on
Promotion of Local Traditional Health Practices and Practitioners, Dept of AYUSH, 2010). The
North Eastern Institute of Folk Medicine is the first institutional mechanism to strengthen folk
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medicine in the country. This institute may be upgraded as a National Institute of Folk Medicine,
and be extended in the form of a network of Regional and State Centres of Folk Medicine
(initially under the current 12th Five Year Plan and later under the 13th Five Year Plan) to
document, assess and promote folk medicine as a community driven strategy for self-reliance in
primary health care and also to strengthen the capacity of folk healers to enhance their quality
of services as a cost effective strategy to enhance universal health access, based on community
support.
b) Allocation for piloting District Health Swaraaj Knowledge Resource Centres with regional
centres under the oversight of the NEIFM.
Folk practitioners in all ecological-cultural zones have varied skills and specializations (such as dais,
bone-setters, herbalists). Studies have validated that 75% of knowledge of traditional home
remedies can be validated by the codified expert knowledge of Ayurveda, Siddha etc. There is a
need to recognize them and create a system of just and dignified integration with the formal
system. This will also provide recognition to the special knowledge held by various caste groups and
adivasis, thereby especially empowering the marginalised groups.
c) Promoting cultivation of medicinal plants and herbs in schools and all public spaces-- besides
strengthening the functioning of the national and state Medicinal Plant Boards, horticulture
departments, educational institutions etc. to give explicit space to cultivation of medicinal plants
and dissemination of knowledge about their use.
7. Health Research
7.1. Department of Health Research budget to be enhanced with proviso for:
a) research and setting up of surveillance systems for Non-communicable diseases including undernutrition, obesity, diabetes, mental health, cancers, environmental toxicities and occupational
hazards.
b) health systems research for better implementation and governance in the public services
c) review of all on-going programmes and schemes for fulfilling population health objectives—for
instance, the National TB Programme is failing to stem the deaths due to TB; dengue,
encephalitis, chikungunya and other vector borne diseases are increasing while malaria
continues to be a killer in some regions despite the National Vector Borne Disease Control
Programme.
d) Setting up of a Health Technology Assessment institution for (i) optimal use of health
technologies, (ii) ensuring their safety, (iii) developing low cost technologies, (iv) enhancing
indigenous production in the country, and (iv) developing 'Integrated Guidelines for Prevention
and Treatment' using strengths of all 'pathies' and folk practices for common public health
problems.
e) enhanced resources for the research institutions under ICMR, along with revamping their
procedures with the principle of 'less government and more governance'.
Among these, priority may be given to those with greater public health significance such as the National
Institute of Nutrition, which should have a unit in each state and develop community-based nutrition
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surveillance mechanisms for identifying under-nutrition stricken communities early so that immediate
administrative action can prevent starvation and severe malnutrition. The National Institute for
Environmental Health must study the health impacts of environmental toxicities and climate crisis, and
develop a regional network of institutions for this.
7.2. Review and strengthening of all public health research and training institutions to improve their
capacities for context specific work with national and local perspectives, such as the NIHFW and AIIHPH.
8. International Dimensions
8.1. The indigenous pharmaceutical and medical equipment industry should be supported to expand
and be protected from Free Trade Area agreements that are being negotiated and are likely to increase
drug prices in the country.
8.2. Indian industry should also be supported for exporting medicines at cheap prices relative to the
prices by other companies so that India contributes to improving access of poor all over the world.
Revival of the public sector pharmaceutical industry would also help in this direction.
8.3. State governments and private sector hospital chains should be encouraged to build facilities near
the borders with our neighbouring SAARC countries particularly Nepal, Bangladesh, Pakistan and
Myanmar, so as to provide services to their citizens as much as to Indians.
8.4. High end tertiary care hospitals in the private sector may be allowed to provide services for
international medical tourism as an isolated niche sector so that it cannot distort tertiary care services
for the general public in India.
Draft prepared on behalf of ‘Health Swaraaj’, a working group with SADED
[South Asian Dialogues on Ecological Democracy]
Health Swaraaj contacts:
Chairperson
Dr. Ritu Priya
Professor,
Centre of Social Medicine & Community Health
Jawaharlal Nehru University, New Delhi-110067
<ritu_priya_jnu@yahoo.com>
09313350186
Advisor
Dr. Narendra Mehrotra
Retd. Dy Director, CDRI,
Secretary,
Jeevaniya Society, Lucknow
<nnmehrotra@gmail.com>
09455388768
Coordinator
Dr. Ranvir Singh
Research Fellow
South Asian Dialogues on Ecological Democracy
BE 14A, DDA Flats Munirka, New Delhi
<ranvir4u@gmail.com>
Ph:09899754995
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Lucknow