Journey of National Health Policy in India Presenter Dr. Mohan Lal Associate Professor, Dept. of Community Medicine GMC, Amritsar.

JOHN BRYANT Large numbers of the world’s people perhaps more than half , have no access to health care at all, and for many of the rest the care they receive does not answer the problems they have”………..

Contradictions India has the largest numbers of medical colleges in the world It produces the largest numbers of doctors among developing countries It gets “medical Tourists” from developed countries This country is fourth largest producer of drugs by volume in the world

But... the current situation…. Only 43.5% children are fully immunised. 79.1% of children from 6 months to 5 years of age are anaemic. 56.1% ever married women aged 15-49 are anemic. Infant Mortality Rate is 58/1000 live births for the country with a low of 12 for Kerala and a high of 79 for Madhya Pradesh. Maternal Mortality Rate is 301 for the country with a low of 110 for Kerala and a high of 517 for UP and Uttaranchal in the 2001-03 period. Two thirds of the population lack access to essential drugs. 80% health care expenditure born by patients and their families as out-of -pocket payment (fee for service and drugs) Health inequalities across states, between urban and rural areas, and across the economic and gender divides have become worse Health, far from being accepted as a basic right of the people, is now being shaped into a saleable commodity

Contd…. Poor are being excluded from health services Increased indebtedness among poor (Expenditure on health care is second major cause of Indebtedness among rural poor) Difference across the economic class spectrum and by gender in the untreated illness has significantly increased Cutbacks by poor on food and other consumptions resulting increased illnesses and increasing malnutrition

Health Inequities The infant mortality Rate in the poorest 20% of the population is 2.5 times higher than that in the richest 20% of the population A child in the ‘Low standard of living’ economic group is almost four times more likely to die in childhood than a child in a better of high standard living group A person from the poorest quintile of the population, despite more health problems, is six times less likely to access hospitlisation than a person from richest quintile.

Health Inequities A girl is 1.5 times more likely to die before reaching her fifth birthday The ratio of doctors to population in rural areas is almost six times lower than that for urban areas. Per person, government spending on public health is seven times lower in rural areas compared to government spending urban areas

National Health Policy 2002 National Population Policy 2000 National AIDS control and Prevention Policy National Blood Policy National Policy for empowerment of Women 2001 National Charter for Children National Youth Policy 2001998 National Nutrition Policy

Background India has the 2nd largest population in the World. The Growth rate has been 7.2 % in 2015-16. Economic development is not a necessary indicator of public health in a nation Human development index gives a quite different picture as India is placed at the 130 position in the HDI out of 188 countries. Life expectancy at birth: It increased to 68 years in 2014 from 67.6 in the previous year and 53.9 in 1980.

Judicial Intervention The India constitution provides for a frame work for welfare and socialist model of development. Health rights are social rights provided under the directive Principles and are not justciable. The right to life provided under Article 21 of the constitution of India various Directive Principles have been used time and again to demand access to health care. Article 21 imposes an obligation on the State to safeguard right to life of every person. Preservation of human life is thus of paramount Importance.

Health Policy Health policy of a Nation is its strategy for controlling and optimizing the social uses of its health knowledge & health resources. Alma-Ata Declaration called on all the governments to formulate national health policies according to their own circumstances to launch & sustain primary health care as a part of national health system.

The Ministry of Health and Family Welfare, Govt The Ministry of Health and Family Welfare, Govt. of India, evolved a National Health Policy in 1983 and 2002. The policy lays stress on preventive, promotive, public health and rehabilitation aspects of healthcare. The policy stresses the need of establishing comprehensive primary health care services to reach the population in the remote area of the country.

National Health Policy 1983 was in no way an original document. Inspire of the fact that India was working on its various health strategies /health committees implemented through the five year plans National Health Policy 1983 was in no way an original document. As a consequence of the global debate on alternative strategies during the seventies, haphazard way of the working of various committees, the signing of the Alma Ata Declaration on primary health care and the recommendations of the ICMR-ICSSR Joint Panel, Govt decided to implement the health policy in 1983 During Sixth Five Year Plan the need for a health Policy was first felt. It was no coincidence that India decided to have its first Policy only after Alma Ata Declaration

Policy and National Health Policy -1983 A policy document is essentially the expression of ideas of those governing to establish what they perceive is the will of the people A health policy is thus the expression of what the health care system should be so that it can meet the health care needs of the people. India had its first national health policy in 1983 i.e. 36 years after independence.

Salient features of the 1983 Health policy It was critical of the curative-oriented western model of health care Emphasized a preventive, promotive and rehabilitative primary health care approach Recommended a decentralized system of health care, the key features of which were low cost, deprofessionalisation (use of volunteers and paramedics), & community participation,

Salient features(Contd……) Called for an expansion of the private curative sector which would help reduce the government's burden It recommended the establishment of a nationwide network of epidemiological stations that would facilitate the integration of various health interventions It set up targets for achievement

DRAWBACKS OF NHP 1983 Despite the impressive public health gains the morbidity & mortality levels in the country were still unacceptably high. These unsatisfactory health indices are, in turn, an indication of the limited success of the public health system in meeting the preventive & curative requirements of the general population.

As regards the demographic & other targets set in the NHP, only crude death rate & life expectancy have been on schedule. The others, especially fertility & immunization related targets were much below expectation (despite special initiatives and resources for these programs over the last two decades), Those related to national disease programs were also much below the expected level of achievement

DRAWBACKS OF NHP 1983 Out of the communicable diseases which have persisted over time, the incidence of Malaria staged a resurgence in the1980s before stabilizing at a fairly high prevalence level during the 1990s. Incidence of the more deadly P-Falciparum Malaria rose to about 50 percent in the country as a whole.

DRAWBACKS OF NHP 1983 The period after the announcement of NHP-83 has also seen an increase in mortality through ‘life-style’ diseases diabetes, cancer and cardiovascular diseases. Occurrence of new communicable diseases like HIV/AIDS

DRAWBACKS OF NHP 1983 Another area of grave concern in the public health domain is the persistent incidence of macro & micro nutrient deficiencies, especially among women and children. The public health investment in the country over the years has been comparatively low, & as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9 percent in 1999. No difference in role of state govt. and central govt.

National Health Policy 2002 For the accelerated achievement of public health goals in the context of prevailing socio economic circumstance. Focuses on the need for the enhanced funding and organizational restructuring of the national public health initiatives in order to facilitate more equitable access to health facilities

Key Strategies Primary Health Care Approach Decentralized public health system Convergence of all health programme under single field umbrella Strengthening and extending public health services Enhanced contribution of private and NGO sector in health care delivery. Increase in public spending for health care.

Launch of NRHM in 2005 is a major step towards adoption of these strategies. The policy is focused on those diseases which are principally contributing to the disease burden –TB, Malaria and blindness from the category of ‘newly emerging diseases’. The governments and private sector programme planners will have to design separate schemes , tailor –made to health needs of women, children , geriatrics , tribals and other socio economic ally under served sections . An adequate robust disaster management plan has to be in place.

Consistent with primacy given to ‘equity ‘ marked emphasis has been provided for expanding & improving the primary health facilities, including the new concept of the provisioning of essential drugs through central funding. The policy also commits the central government to an increased under – writing of the resources for meeting the minimum health needs of the people. Thus the policy attempts to provide guidance for prioritizing expenditure , thereby facilitating rational resourcs allocation.

The policy broadly envisages a greater contribution from the central Budget for the delivery of Public health Services at the State level. However, it highlights the expected roles of the State administration, NGOs and other institutions of the civil society. The attainment of improved health levels would significantly dependent on population stabilization , as also on complementary efforts from other areas of the social sectors – like improved drinking water supply , basic sanitation , minimum nutrition , etc., - to ensure that the exposure of the populace to health risks is minimized.

In the ultimate analysis , the quality of health services , & the consequential improved health status of the citizenry , would depend not only on increased financial or material inputs, but also on a more emphatic & committed attitude in the service providers, whether in the private or public sectors . Any policy in the social sector is critically dependent on the service providers treating their responsibility not as a commercial activity, but as a service , albeit a paid one. In the area of public health , an improved standard of governance is a prerequisite for the success of any health policy.

Health Financing Mechanisms.. Revenue generation by tax Out of pocket payments or direct payments Private insurance Social insurance External Aid supported schemes

Spending on Health Annually over 150,000 crores or US$34 billion, which is 6% of GDP (Government spending on health Is only 0.9% of GDP) Out of this only 15 % is publicly financed 4% from social insurance, 1% by private insurance remaining 80% is out of pocket spending ( 85% of which goes in private sector) Only 15% of the population is in organised sector and has some sort of social security the rest is left to the mercy of the market

The Aspects of Neoliberal Economic Reforms Affecting Public Health Increasing unregulated privatisation of the health care sector with little accountability to patients Cutting down government Health care expenditure Systematic deregulation of drug prices resulting in skyrocketing prices of drugs and rising cost of health services Selective intervention approach instead comprehensive primary health care Measure diseases in terms of cost effectiveness Techno centric approach( emphasis on content instead processes)

Contradictions India has the largest numbers of medical colleges in the world It produces the largest numbers of doctors among developing countries It gets “medical Tourists” from developed countries This country is fourth largest producer of drugs by volume in the world