DRAFT NATIONAL HEALTH POLICY - 2001
1. INTRODUCTORY :-
1.1 A National Health Policy was last formulated in 1983 and since then, there have been very marked changes in the determinant factors relating to the health sector. Some of the policy initiatives outlined in the NHP-1983 have yielded results, while in several other areas, the outcome has not been as expected.
1.2 The NHP-1983 gave a general exposition of the recommended policies required in the circumstances then prevailing in the health sector. The noteworthy initiatives under that policy were :-
(i). A phased, time-bound programme for setting up a well-dispersed network of comprehensive primary health care services, linked with extension and health education, designed in the context of the ground reality that elementary health problems can be resolved by the people themselves;
(ii). Intermediation through ‘Health volunteers’ having appropriate knowledge, simple skills and requisite technologies;
(iii). Establishment of a well-worked out referral system to ensure that patient load at the higher levels of the hierarchy is not needlessly burdened by those who can be treated at the decentralized level;
(iv). An integrated net-work of evenly spread speciality and super-speciality services; encouragement of such facilities through private investments for patients who can pay, so that the draw on the Government’s facilities is limited to those entitled to free use.
1.3 Government initiatives in the pubic health sector have recorded some noteworthy successes over time. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been a substantial drop in the Total Fertility Rate and Infant Mortality Rate. The success of the initiatives taken in the public health field are reflected in the progressive improvement of many demographic / epidemiological / infrastructural indicators over time – (Box-I).
Box-1 : Through The Years - 1951-2000Achievements
|Crude Birth Rate
|Crude Death Rate
|70 (99 SRS)
|Malaria (cases in million)
|Leprosy cases per 10,000 population
|Small Pox (no of cases)
|Guineaworm ( no. of cases)
|Dispensaries &Hospitals( all)
|Beds (Pvt & Public)
1.4 While noting that the public health initiatives over the years have contributed significantly to the improvement of these health indicators, it is to be acknowledged that public health indicators / disease-burden statistics are the outcome of several complementary initiatives under the wider umbrella of the developmental sector, covering Rural Development, Agriculture, Food Production, Sanitation, Drinking Water Supply, Education, etc. Despite the impressive public health gains as revealed in the statistics in Box-I, there is no gainsaying the fact that the morbidity and mortality levels in the country are still unacceptably high. These unsatisfactory health indices are, in turn, an indication of the limited success of the public health system to meet the preventive and curative requirements of the general population.
1.5 Out of the communicable diseases, which have persisted over history, incidence of Malaria has staged a resurgence in the1980s before stabilising at a fairly high prevalence level during the 1990s. Over the years, an increasing level of insecticide-resistance has developed in the malarial vectors in many parts of the country, while the incidence of the more deadly P-Falciparum Malaria has risen to about 50 percent in the country as a whole. In respect of TB, the public health scenario has not shown any significant decline in the pool of infection amongst the community, and, there has been a distressing trend in increase of drug resistance in the type of infection prevailing in the country. A new and extremely virulent communicable disease – HIV/AIDS - has emerged on the health scene since the declaration of the NHP-1983. As there is no existing therapeutic cure or vaccine for this infection, the disease constitutes a serious threat, not merely to public health but to economic development in the country. The common water-borne infections – Gastroenteritis, Cholera, and some forms of Hepatitis – continue to contribute to a high level of morbidity in the population, even though the mortality rate may have been somewhat moderated. The period after the announcement of NHP-83 has also seen an increase in mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular diseases. The increase in life expectancy has increased the requirement for geriatric care. Similarly, the increasing burden of trauma cases is also a significant public health problem. The changed circumstances relating to the health sector of the country since 1983 have generated a situation in which it is now necessary to review the field, and to formulate a new policy framework as the National Health Policy-2001.
1.6 NHP-2001 will attempt to set out a new policy framework for the accelerated achievement of Public health goals in the socio-economic circumstances currently prevailing in the country.
2. CURRENT SCENARIO
2.1. FINANCIAL RESOURCES
The public health investment in the country over the years has been comparatively low, and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9 percent in 1999. The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 20 percent of the aggregate expenditure is public health spending, the balance being out-of-pocket expenditure. The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent. The current annual per capita public health expenditure in the country is no more than Rs.160. Given these statistics, it is no surprise that the reach and quality of public health services has been below the desirable standard. Under the constitutional structure, public health is the responsibility of the States. In this framework, it has been the expectation that the principal contribution for the funding of public health services will be from States’ resources, with some supplementary input from Central resources. In this backdrop, the contribution of Central resources to the overall public health funding has been limited to about 15 percent. The fiscal resources of the State Governments are known to be very inelastic. This itself is reflected in the declining percentage of State resources allocated to the health sector out of the State Budget. If the decentralized pubic health services in the country are to improve significantly, there is a need for injection of substantial resources into the health sector from the Central Government Budget. This approach, despite the formal Constitutional provision in regard to public health, is a necessity if the State public health services - a major component of the initiatives in the social sector - are not to become entirely moribund. The NHP-2001 has been formulated taking into consideration these ground realities in regard to the availability of resources.
2.2.1 In the period when centralized planning was accepted as a key instrument of development in the country, the attainment of an equitable regional distribution was considered one of its major objectives. Despite this conscious focus in the development process, the statistics given in Box-II clearly indicate that attainment of health indices have been very uneven across the rural – urban divide.
Box II : Differentials in Health Status Among States
|Population BPL (%)
|IMR/Per 1000 Live Births (1999-SRS)
|<5Mort-ality per 1000 (NFHS II)
|Weight For Age- % of Children Under 3 years (<-2SD)
|MMR/ Lakh (Annual Report 2000)
|Leprosy cases per 10000 popula-tion
|Malaria +ve Cases in year 2000 (in thousands)
|Better Performing States
|Low Performing States
Also, the statistics bring out the wide differences between the attainments of health goals in the better- performing States as compared to the low-performing States. It is clear that national averages of health indices hide wide disparities in public health facilities and health standards in different parts of the country. Given a situation in which national averages in respect of most indices are themselves at unacceptably low levels, the wide inter-State disparity implies that, for vulnerable sections of society in several States, access to public health services is nominal and health standards are grossly inadequate. Despite a thrust in the NHP-1983 for making good the unmet needs of public health services by establishing more public health institutions at a decentralized level, a large gap in facilities still persists. Applying current norms to the population projected for the year 2000, it is estimated that the shortfall in the number of SCs/PHCs/CHCs is of the order of 16 percent. However, this shortage is as high as 58 percent when disaggregated for CHCs only. The NHP-2001 will need to address itself to making good these deficiencies so as to narrow the gap between the various States, as also the gap across the rural-urban divide.
2.2.2 Access to, and benefits from, the public health system have been very uneven between the better-endowed and the more vulnerable sections of society. This is particularly true for women, children and the socially disadvantaged sections of society. The statistics given in Box-III highlight the handicap suffered in the health sector on account of socio-economic inequity.
Box-III : Differentials in Health status Among Socio-Economic Groups
|Under 5 Mortality/1000
|% Children Underweight
2.2.3 It is a principal objective of NHP-2001 to evolve a policy structure which reduces these inequities and allows the disadvantaged sections of society a fairer access to public health services.
2.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
2.3.1 It is self-evident that in a country as large as India, which has a wide variety of socio-economic settings, national health programmes have to be designed with enough flexibility to permit the State public health administrations to craft their own programme package according to their needs. Also, the implementation of the national health programme can only be carried out through the State Governments’ decentralized public health machinery. Since, for various considerations, the responsibility of the Central Government in funding additional public health services will continue over a period of time, the role of the Central Government in designing broad-based public health initiatives will inevitably continue. Moreover, it has been observed that the technical and managerial expertise for designing large-span public health programmes exists with the Central Government in a considerable degree; this expertise can be gainfully utilized in designing national health programmes for implementation in varying socio-economic settings in the states.
2.3.2 Over the last decade or so, the Government has relied upon a ‘vertical’ implementational structure for the major disease control programmes. Through this, the system has been able to make a substantial dent in reducing the burden of specific diseases. However, such an organizational structure, which requires independent manpower for each disease programme, is extremely expensive and difficult to sustain. Over a long time-range, ‘vertical’ structures may only be affordable for diseases, which offer a reasonable possibility of elimination or eradication in a foreseeable time-span. In this background, the NHP-2001 attempts to define the role of the Central Government and the State Governments in the public health sector of the country.
2.4 THE STATE OF PUBLIC HEALTH INFRA-STRUCTURE
2.4.1 The delineation of NHP-2001 would be required to be based on an objective assessment of the quality and efficiency of the existing public health machinery in the field. It would detract from the quality of the exercise if, while framing a new policy, it is not acknowledged that the existing public health infrastructure is far from satisfactory. For the out-door medical facilities in existence, funding is generally insufficient; the presence of medical and para-medical personnel is often much less than required by the prescribed norms; the availability of consumables is frequently negligible; the equipment in many public hospitals is often obsolescent and unusable; and the buildings are in a dilapidated state. In the in-door treatment facilities, again, the equipment is often obsolescent; the availability of essential drugs is minimal; the capacity of the facilities is grossly inadequate, which leads to over-crowding, and consequentially to a steep deterioration in the quality of the services. As a result of such inadequate public health facilities, it has been estimated that less than 20 percent of the population seeks the OPD services and less than 45 percent avails of the facilities for in-door treatment in public hospitals. This is despite the fact that most of these patients do not have the means to make out-of-pocket payments for private health services except at the cost of other essential expenditure for items such as basic nutrition.
2.5 EXTENDING PUBLIC HEALTH SERVICES
2.5.1 While in the country generally there is a shortage of medical manpower, this shortfall is disproportionately impacted on the less-developed and rural areas. No incentive system attempted so far, has induced private medical manpower to go to such areas; and, even in the public health sector it has usually been a losing battle to deploy medical manpower in such under-served areas. In such a situation, the possibility needs to be examined for entrusting some limited public health functions to nurses, paramedics and other personnel from the extended health sector after imparting adequate training to them.
2.5.2 India has a vast reservoir of practitioners in the Indian Systems of Medicine and Homoeopathy, who have undergone formal training in their own disciplines. The possibility of using such practitioners in the implementation of State/Central Government public health Programmes, in order to increase the reach of basic health care in the country, is addressed in the NHP-2001.
2.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
2.6.1 Some States have adopted a policy of devolving programmes and funds in the health sector through different levels of the Panchayati Raj Institutions. Generally, the experience has been a favourable one. The adoption of such an organisational structure has enabled need-based allocation of resources and closer supervision through the elected representatives. NHP- 2001 examines the need for a wider adoption of this mode of delivery of health services, in rural as well as urban areas, in other parts of the country.
2.7 MEDICAL EDUCATION
2.7.1 Medical Colleges are not evenly spread across various parts of the country. Apart from the uneven geographical distribution of medical institutions, ,the quality of education is highly uneven and in several instances even sub-standard. It is a common perception that the syllabus is excessively theoritical, making it difficult for the fresh graduate to effectively meet even the primary health care needs of the population. There is an understandable reluctance on the part of graduate doctors to serve in areas distant from their native place. NHP-2001 will suggest policy initiatives to rectify these disparities.
2.7.2 Certain medical discipline, such as, molecular biology and gene-manipulation, have become relevant in the period after the formulation of the previous National Health Policy. Also, certain speciality disciplines – Anesthesiology, Radiology and Forensic Medicines – are currently very scarce, resulting in critical deficiencies in the package of available public health services. The components of medical research in the recent years have changed radically. In the foreseeable future such research will rely increasingly on such new disciplines. It is observed that the current under-graduate medical syllabus does not cover such emerging subjects. NHP-2001 will make appropriate recommendations in this regard.
2.8 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH’ AND ‘FAMILY MEDICINE’
2.8.1 In any developing country with inadequate availability of health services, the requirement of expertise in the areas of ‘public health’ and ‘family medicine’ is very much more than the expertise required for other specialized clinical disciplines. In India, the situation is that public health expertise is non-existent in the private health sector, and far short of requirement in the public health sector. Also, the current curriculum in the graduate / post-graduate courses is outdated and unrelated to contemporary community needs. In respect of ‘family medicine’, it needs to be noted that the more talented medical graduates generally seek specialization in clinical disciplines, while the remaining go into general practice. While the availability of postgraduate educational facilities is 50 percent of the total number of the qualifying graduates each year, and can be considered adequate, the distribution of the disciplines in the postgraduate training facilities is overwhelmingly in favour of clinical specializations. NHP-2001 examines the need for ensuring adequate availability of personnel with specialization in the ‘public health’ and ‘family medicine’ disciplines, to discharge the public health responsibilities in the country.
2.9 URBAN HEALTH
2.9.1 In most urban areas, public health services are very meagre. To the extent that such services exist, there is no uniform organisational structure. The urban population in the country is presently as high as 30 percent and is likely to go up to around 33 percent by 2010. The bulk of the increase is likely to take place through migration, resulting in slums without any infrastructure support. Even the meagre public health services available do not percolate to such unplanned habitations, forcing people to avail of private health care through out-of-pocket expenditure. The rising vehicle density in large urban agglomerations has also led to an increased number of serious accidents requiring treatment in well-equipped trauma centres. NHP-2001 will address itself to the need for providing this unserved population a minimum standard of health care facilities.
2.10 MENTAL HEALTH
2.10.1 Mental health disorders are actually much more prevalent than are visible on the surface. While such disorders do not contribute significantly to mortality, they have a serious bearing on the quality of life of the affected persons and their families. Serious cases of mental disorder require hospitalization and treatment under trained supervision. Mental health institutions are perceived to be woefully deficient in physical infrastructure and trained manpower. NHP-2001 will address itself to these deficiencies in the public health sector.
2.11 INFORMATION, EDUCATION AND COMMUNICATION
2.11.1 A substantial component of primary health care consists of initiatives for disseminating, to the citizenry, public health-related information. Public health programmes, particularly, need high visibility at the decentralized level in order to have any impact. This task is particularly difficult as 35 percent of our country’s population is illiterate. The present IEC strategy is too fragmented, relies heavily on mass media and does not address the needs of this segment of the population. It is often felt that the effectiveness of IEC programmes is difficult to judge; and consequently, it is often asserted that accountability, in regard to the productive use of such funds, is doubtful. NHP-2001, while projecting an IEC strategy, will fully address the inherent problems encountered in any IEC programme designed for improving awareness in order to bring about behavioural change in the general population.
2.11.2 It is widely accepted that school and college students are the most receptive targets for imparting information relating to basic principles of preventive health care. NHP-2001 will attempt to target this group to improve the general level of health awareness.
2.12 MEDICAL RESEARCH
2.12.1 Over the years, medical research activity in the country has been very limited. In the Government, such research has been confined to the research institutions under the Indian Council of Medical Research, and other institutions funded by the States/Central Government. Research in the private sector has assumed some significance only in the last decade. In our country, where the aggregate annual health expenditure is of the order of Rs. 80,000 crores, the expenditure in 1998-99 on research, both public and private sectors, was only of the order of Rs. 1150 crores. It would be reasonable to infer that with such low research expenditure, it would be virtually impossible to make any dramatic break-through within the country, by way of new molecules and vaccines; also, without a minimal back-up of applied and operational research, it would be difficult to assess whether the health expenditure in the country is being incurred through optimal applications and appropriate public health strategies. Medical Research in the country needs to be focused on therapeutic drugs/vaccines for tropical diseases, which are normally neglected by international pharmaceutical companies on account of limited profitability potential. The thrust will need to be in the newly-emerging frontier areas of research based on genetics, genome-based drug and vaccine development, molecular biology, etc. NHP-2001 will address these inadequacies and spell out a minimal quantum of expenditure for the coming decade, looking to the national needs and the capacity of the research institutions to absorb the funds.
2.13 ROLE OF THE PRIVATE SECTOR
2.13.1 Considering the economic restructuring underway in the country, and over the globe, since the last decade, the changing role of the private sector in providing health care will also have to be addressed in NHP 2001. Currently, the contribution of private health care is principally through independent practitioners. Also, the private sector contributes significantly to secondary-level care and some tertiary care. With the increasing role of private health care, the need for statutory licensing and monitoring of minimum standards of diagnostic centres / medical institutions becomes imperative. NHP-2001 will address the issues regarding the establishment of a regulatory mechanism to ensure adequate standards of diagnostic centres / medical institutions, conduct of clinical practice and delivery of medical services.
2.13.2 Currently, non-Governmental service providers are treating a large number of patients at the primary level for major diseases. However, the treatment regimens followed are diverse and not scientifically optimal, leading to an increase in the incidence of drug resistance. NHP-2001 will address itself to recommending arrangements, which will eliminate the risks arising from inappropriate treatment.
2.13.3 The increasing spread of information technologt raises the possibility of its adoption in the health sector. NHP-2001 will examine this possibility.
2.14 ROLE OF THE CIVIL SOCIETY
2.14.1 Historically, the practice has been to implement major national disease control programmes through the public health machinery of the State/Central Governments. It has become increasingly apparent that certain components of such programmes cannot be efficiently implemented merely through government functionaries. A considerable change in the mode of implementation has come about in the last two decades, with an increasing involvement of NGOs and other institutions of civil society. It is to be recognized that widespread debate on various public health issues have, in fact, been initiated and sustained by NGOs and other members of the civil society. Also, an increasing contribution is being made by such institutions, in the delivery of different components of public health services. Certain disease control programmes require close inter-action with the beneficiaries for regular administration of drugs; periodic carrying out of the pathological tests; dissemination of information regarding disease control and other general health information. NHP-2001 will address such issues and suggest policy instruments for implementation of public health programmes through individuals and institutions of civil society.
2.15 NATIONAL DISEASE SURVEILLANCE NETWORK
2.15.1 The technical network available in the country for disease surveillance is extremely rudimentary and to the extent that the system exists, it extends only up to the district level. Disease statistics are not flowing through an integrated network from the decentralized public health facilities to the State/Central Government health administration. Such an arrangement only provides belated information, which, at best, serves a limited statistical purpose. The absence of an efficient disease surveillance network is a major handicap in providing a prompt and cost effective health care system. The efficient disease surveillance network set up for Polio and HIV/AIDS has demonstrated the enormous value of such a public health instrument. Real-time information of focal outbreaks of common communicable diseases – Malaria, GE, Cholera and JE – and other seasonal trends of diseases, would enable timely intervention, resulting in the containment of any possible epidemic. In order to be able to use an integrated disease surveillance network, for operational purposes, real-time information is necessary at all levels of the health administration. NHP-2001 would address itself to this major systemic shortcoming in the administration.
2.16 HEALTH STATISTICS
2.16.1 The absence of a systematic and scientific health statistics data-base is a major deficiency in the current scenario. The health statistics collected are not the product of a rigorous methodology. Statistics available from different parts of the country, in respect of major diseases, are often not obtained in a manner which make aggregation possible, or meaningful.
2.16.2 Further, absence of proper and systematic documentation of the various financial resources used in the health sector is another lacunae witnessed in the existing scenario. This makes it difficult to understand trends and levels of health spending by private and public providers of health care in the country, and to address related policy issues and formulate future investment policies.
2.16.3 NHP-2001 will address itself to the programme for putting in place a modern and scientific health statistics database as well as a system of national health accounts.
2.17 WOMEN’S HEALTH
2.17.1 Social, cultural and economic factors continue to inhibit women from gaining adequate access to even the existing public health facilities. This handicap does not just affect women as individuals; it also has an adverse impact on the health, general well-being and development of the entire family, particularly children. NHP 2001 recognises the catalytic role of empowered women in improving the overall health standards of the community.
2.18 MEDICAL ETHICS
2.18.1 Professional medical ethics in the health sector is an area, which has not received much attention in the past. Also, the new frontier areas of research – involving gene manipulation, organ/human cloning and stem cell research _ impinge on visceral issues relating to the sanctity of human life and the moral dilemma of human intervention in the designing of life forms. Besides these, in the emerging areas of research, there is an un-charted risk of creating new life forms, which may irreversibly damage the environment, as it exists today. NHP – 2001 recognises that moral and religious dilemma of this nature, which was not relevant even two years ago, now pervades mainstream health sector issues.
2.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
2.19.1 There is an increasing expectation and need of the citizenry for efficient enforcement of reasonable quality standards for food and drugs. Recognizing this need, NHP – 2001 makes an appropriate policy recommendation.
2.20 REGULATION OF STANDARDS IN PARA MEDICAL DISCIPLINES
2.20.1 It has been observed that a large number of training institutions have mushroomed particularly in the private sector, for several para medical disciplines – Lab Technicians, Radio Diagnosis Technicians, Physiotherapists, etc. Currently, there is no regulation/monitoring of the curriculum, or the performance of the practitioners in these disciplines. NHP-2001 will make recommendations to ensure standardization of training and monitoring of performance.
2.21 OCCUPATIONAL HEALTH
2.21.1 Work conditions in several sectors of employment in the country are sub-standard. As a result of this, workers engaged in such activities become particularly prone to occupation-linked ailments. The long-term risk of chronic morbidity is particularly marked in the case of child labour. NHP-2001 will address the risk faced by this particularly vulnerable section of the society.
2.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
2.22.1 The secondary and tertiary facilities available in the country are of good quality and cost-effective compared to international medical facilities. This is true not only of facilities in the allopathic disciplines, but also to those belonging to the alternative systems of medicine, particularly Ayurveda. NHP-2001 will assess the possibilities of encouraging commercial medical services for patients from overseas.
2.23 IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR
2.23.1 There are some apprehensions about the possible adverse impact of economic globalisation on the health sector. Pharmaceutical drugs and other health services have always been available in the country at extremely inexpensive prices. India has established a reputation for itself around the globe for innovative development of original process patents for the manufacture of a wide-range of drugs and vaccines within the ambit of the existing patent laws. With the adoption of Trade Related Intellectual Property (TRIPS), and the subsequent alignment of domestic patent laws consistent with the commitments under TRIPS, there will be a significant shift in the scope of the parameters regulating the manufacture of new drugs/vaccines. Global experience has shown that the introduction of a TRIPS-consistent patent regime for drugs in a developing country, would result in an increase in the cost of drugs and medical services. NHP-2001 will address itself to the future imperatives of health security in the country, in the post-TRIPS era.
2.24 NON – HEALTH DETERMINANTS
2.24.1 Improved health standards are closely dependent on major non-health determinants such as safe drinking water supply, basic sanitation, adequate nutrition, clean environment and primary education, especially of the girl child. NHP-2001 will not explicitly address itself to the initiatives in these areas, which although crucial, fall outside the domain of the health sector. However, the attainment of the various targets set in NHP 2001 assumes a reasonable performance in these allied sectors.
2.25 POPULATION GROWTH AND HEALTH STANDARDS
2.25.1 Efforts made over the years for improving health standards have been neutralized by the rapid growth of the population. Unless the Population stabilization goals are achieved, no amount of effort in the other components of the public health sector can bring about significantly better national health standards. Government has separately announced the `National Population Policy – 2000’. The principal common features covered under the National Population Policy-2000 and NHP-2001, relate to the prevention and control of communicable diseases; priority to containment of HIV/AIDS infection; universal immunization of children against all major preventable diseases; addressing the unmet needs for basic and reproductive health services; and supplementation of infrastructure. The synchronized implementation of these two Policies – National Population Policy – 2000 and National Health Policy-2001 – will be the very cornerstone of any national structural plan to improve the health standards in the country.
2.26 ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine – Ayurveda, Unani, Sidha and Homoeopathy – provide a significant supplemental contribution to the health care services in the country, particularly in the underserved, remote and tribal areeas. The main components of NHP-2001 apply equally to the alternative systems of medicine. However, the policy features specific to the alternative systems of medicine will be presented as a separate document.
3.1 The main objective of NHP-2001 is to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions. Overriding importance would be given to ensuring a more equitable access to health services across the social and geographical expanse of the country. Emphasis will be given to increasing the aggregate public health investment through a substantially increased contribution by the Central Government. It is expected that this initiative will strengthen the capacity of the public health administration at the State level to render effective service delivery. The contribution of the private sector in providing health services would be much enhanced, particularly for the population group, which can afford to pay for services. Primacy will be given to preventive and first-line curative initiatives at the primary health level through increased sectoral share of allocation. Emphasis will be laid on rational use of drugs within the allopathic system. Increased access to tried and tested systems of traditional medicine will be ensured. Within these broad objectives, NHP-2001 will endeavour to achieve the time-bound goals mentioned in Box-IV.
Box-IV: Goals to be achieved by 2000-2015
|Eradicate Polio and Yaws
|Eliminate Kala Azar
|Eliminate Lymphatic Filariasis
|Achieve Zero level growth of HIV/AIDS
|Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases
|Reduce Prevalence of Blindness to 0.5%
|Reduce IMR to 30/1000 And MMR to 100/Lakh
|Improve nutrition and reduce proportion of LBW Babies from 30% to 10%
|Increase utilisation of public health facilities from current Level of <20 to >75%
|Establish an integrated system of surveillance, National Health Accounts and Health Statistics.
|Increase health expenditure by Government as a % of GDP from the existing 0.9 % to 2.0%
|Increase share of Central grants to Constitute at least 25% of total health spending
|Increase State Sector Health spending from 5.5% to 7% of the budget
Further increase to 8%"
4 NHP-2001 - POLICY PRESCRIPTIONS
4.1 FINANCIAL RESOURCES
The paucity of public health investment is a stark reality. Given the extremely difficult fiscal position of the State Governments, the Central Government will have to play a key role in augmenting public health investments. Taking into account the gap in health care facilities under NHP-2001 it is planned to increase health sector expenditure to 6 percent of GDP, with 2 percent of GDP being contributed as public health investment, by the year 2010. The State Governments would also need to increase the commitment to the health sector. In the first phase, by 2005, they would be expected to increase the commitment of their resources to 7 percent of the Budget; and, in the second phase, by 2010, to increase it to 8 percent of the Budget. With the stepping up of the public health investment, the Central Government’s contribution would rise to 25 percent from the existing 15 percent, by 2010. The provisioning of higher public health investments will also be contingent upon the increase in absorptive capacity of the public health administration so as to gainfully utilize the funds.
4.2.1 To meet the objective of reducing various types of inequities and imbalances – inter-regional; across the rural – urban divide; and between economic classes – the most cost effective method would be to increase the sectoral outlay in the primary health sector. Such outlets give access to a vast number of individuals, and also facilitate preventive and early stage curative initiative, which are cost effective. In recognition of this public health principle, NHP-2001 envisages an increased allocation of 55 percent of the total public health investment for the primary health sector; the secondary and tertiary health sectors being targetted for 35 percent and 10 percent respectively. NHP-2001 projects that the increased aggregate outlays for the primary health sector will be utilized for strengthening existing facilities and opening additional public health service outlets, consistent with the norms for such facilities.
4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
4.3.1 NHP-2001, envisages a key role for the Central Government in designing national programmes with the active participation of the State Governments. Also, the Policy ensures the provisioning of financial resources, in addition to technical support, monitoring and evaluation at the national level by the Centre. However, to optimize the utilization of the public health infrastructure at the primary level, NHP-2001 envisages the gradual convergence of all health programmes under a single field administration. Vertical programmes for control of major diseases like TB, Malaria and HIV/AIDS would need to be continued till moderate levels of prevalence are reached. The integration of the programmes will bring about a desirable optimisation of outcomes through a convergence of all public health inputs. The policy also envisages that programme implementation be effected through autonomous bodies at State and district levels. State Health Departments’ interventions may be limited to the overall monitoring of the achievement of programme targets and other technical aspects. The relative distancing of the programme implementation from the State Health Departments will give the project team greater operational flexibility. Also, the presence of State Government officials, social activists, private health professionals and MLAs/MPs on the management boards of the autonomous bodies will facilitate well-informed decision-making.
4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE
4.4.1 As has been highlighted in the earlier part of the Policy, the decentralized Public health service outlets have become practically dysfunctional over large parts of the country. On account of resource constraint, the supply of drugs by the State Governments is grossly inadequate. The patients at the decentralized level have little use for diagnostic services, which in any case would still require them to purchase therapeutic drugs privately. In a situation in which the patient is not getting any therapeutic drugs, there is little incentive for the potential beneficiaries to seek the advice of the medical professionals in the public health system. This results in there being no demand for medical services, and medical professionals, and paramedics often absent themselves from their place of duty. It is also observed that the functioning of the public health service outlets in the four Southern States – Kerala, Andhra Pradesh, Tamil Nadu and Karnataka – is relatively better, because some quantum of drugs is distributed through the primary health system network, and the patients have a stake in approaching the Public health facilities. In this backdrop, NHP-2001 envisages the kick-starting of the revival of the Primary Health System by providing some essential drugs under Central Government funding through the decentralized health system. It is expected that the provisioning of essential drugs at the public health service centres will create a demand for other professional services from the local population, which, in turn, will boost the general revival of activities in these service centres. In sum, this initiative under NHP-2001 is launched in the belief that the creation of a beneficiary interest in the public health system, will ensure a more effective supervision of the public health personnel, through community monitoring, than has been achieved through the regular administrative line of control.
4.4.2 Global experience has shown that the quality of public health services, as reflected in the attainment of improved public health indices, is closely linked to the quantum and quality of investment through public funding in the primary health sector. Box-V gives statistics which show clearly that the standards of health are more a function of accurate targeting of expenditure on the decentralised primary sector (as observed in China and Sri Lanka), than a function of the aggregate health expenditure.
Box-V: Public Health Spending in select Countries
|%Population with income of <$1 day
|Infant Mortality Rate/1000
|%Health Expenditure to GDP
|%Public Expenditure on Health to Total Health Expenditure
Therefore, NHP-2001, while committing additional aggregate financial resources, places strong reliance on the strengthening of the primary health structure, with which to attain improved public health outcomes on an equitable basis. Further, it also recognizes the practical need for levying reasonable user-charges for certain secondary and tertiary public health care services, for those who can afford to pay.
4.5 EXTENDING PUBLIC HEALTH SERVICES
4.5.1 NHP-2001 envisages that, in the context of the availability and spread of allopathic graduates in their jurisdiction, State Governments would consider the need for expanding the pool of medical practitioners to include a cadre of licentiates of medical practice, as also practitioners of Indian Systems of Medicine and Homoeopathy. Simple services/procedures can be provided by such practitioners even outside their disciplines, as part of the basic primary health services in under-served areas. Also, NHP-2001 envisages that the scope of use of paramedical manpower of allopathic disciplines, in a prescribed functional area adjunct to their current functions, would also be examined for meeting simple public health requirements. These extended areas of functioning of different categories of medical manpower can be permitted, after adequate training and subject to the monitoring of their performance through professional councils.
4.5.2 NHP-2001 also recognizes the need for States to simplify the recruitment procedures and rules for contract employment in order to provide trained medical manpower in under-served areas.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
4.6.1 NHP-2001 lays great emphasis upon the implementation of public health programmes through local self Government institutions. The structure of the national disease control programmes will have specific components for implementation through such entities. The Policy urges all State Governments to consider decentralizing implementation of the programmes to such Institutions by 2005. In order to achieve this, financial incentives, over and above the resources allocated for disease control programmes, will be provided by the Central Government.
4.7 MEDICAL EDUCATION
4.7.1 In order to ameliorate the problems being faced on account of the uneven spread of medical colleges in various parts of the country, NHP-2001, envisages the setting up of a Medical Grants Commission for funding new Government Medical Colleges in different parts of the country. Also, the Medical Grants Commission is envisaged to fund the upgradation of the existing Government Medical Colleges of the country, so as to ensure an improved standard of medical education in the country.
4.7.2 To enable fresh graduates to effectively contribute to the providing of primary health services, NHP-2001 identifies a significant need to modify the existing curriculum. A need based, skill-oriented syllabus, with a more significant component of practical training, would make fresh doctors useful immediately after graduation.
4.7.3 The policy emphasises the need to expose medical students, through the undergraduate syllabus, to the emerging concerns for geriatric disorders, as also to the cutting edge disciplines of contemporary medical research. The policy also envisages that the creation of additional seats for post-graduate courses should reflect the need for more manpower in the deficient specialities.
4.8 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH’ AND ‘FAMILY MEDICINE’
4.8.1 In order to alleviate the acute shortage of medical personnel with specialization in ‘public health’ and ‘family medicine’ disciplines, NHP-2001 envisages the progressive implementation of mandatory norms to raise the proportion of postgraduate seats in these discipline in medical training institutions, to reach a stage wherein ¼ th of the seats are earmarked for these disciplines. It is envisaged that in the sanctioning of post-graduate seats in future, it shall be insisted upon that a certain reasonable number of seats be allocated to `public health’ and `family medicine’ disciplines. Since, the `public health’ discipline has an interface with many other developmental sectors, specialization in Public health may be encouraged not only for medical doctors but also for non-medical graduates from the allied fields of public health engineering, microbiology and other natural sciences.
4.9 URBAN HEALTH
4.9.1 NHP-2001, envisages the setting up of an organised urban primary health care structure. Since the physical features of an urban setting are different from those in the rural areas, the policy envisages the adoption of appropriate population norms for the urban public health infrastructure. The structure conceived under NHP-2001 is a two-tiered one: the primary centre is seen as the first-tier, covering a population of one lakh, with a dispensary providing OPD facility and essential drugs to enable access to all the national health programmes; and a second-tier of the urban health organisation at the level of the Government general Hospital, where reference is made from the primary centre. The Policy envisages that the funding for the urban primary health system will be jointly borne by the local self-Government institutions and State and Central Governments.
4.9.2 The National Health Policy also envisages the establishment of fully-equipped ‘hub-spoke’ trauma care networks in large urban agglomerations to reduce accident mortality.
4.10 MENTAL HEALTH
4.10.1 NHP – 2001 envisages a network of decentralised mental health services for ameliorating the more common categories of disorders. The programme outline for such a disease would envisage diagnosis of common disorders by general duty medical staff and prescription of common therapeutic drugs.
4.10.2 In regard to mental health institutions for in-door treatment of patients, the policy envisages the upgrading of the physical infrastructure of such institutions at Central Government expense so as to secure the human rights of this vulnerable segment of society.
4.11 INFORMATION, EDUCATION AND COMMUNICATION
4.11.1 NHP-2001 envisages an IEC policy, which maximizes the dissemination of information to those population groups, which cannot be effectively approached through the mass media only. The focus would therefore, be on inter-personal communication of information and reliance on folk and other traditional media. The IEC programme would set specific targets for the association of PRIs/NGOs/Trusts in such activities. The programme will also have the component of an annual evaluation of the performance of the non-Governmental agencies to monitor the impact of the programmes on the targeted groups. The Central/State Government initiative will also focus on the development of modules for information dissemination in such population groups who normally, do not benefit from the more common media forms.
4.11.2 NHP-2001 envisages priority to school health programmes aiming at preventive health education, regular health check-ups and promotion of health seeking behaviour among children. The school health programmes can gainfully adopt specially designed modules in order to disseminate information relating to ‘health’ and ‘family life’. This is expected to be the most cost-effective intervention as it improves the level of awareness, not only of the extended family, but the future generation as well.
4.12 MEDICAL RESEARCH
4.12.1 NHP-2001 envisages the increase in Government-funded medical research to a level of 1 percent of total health spending by 2005; and thereafter, up to 2 percent by 2010. Domestic medical research would be focused on new therapeutic drugs and vaccines for tropical diseases, such as TB and Malaria, as also the Sub-types of HIV/AIDS prevalent in the country. Research programmes taken up by the Government in these priority areas would be conducted in a mission mode. Emphasis would also be paid to time-bound applied research for developing operational applications. This would ensure cost effective dissemination of existing / future therapeutic drugs/vaccines in the general population. Private entrepreneurship will be encouraged in the field of medical research for new molecules / vaccines.
4.13 ROLE OF THE PRIVATE SECTOR
4.13.1 NHP-2001 envisages the enactment of suitable legislations for regulating minimum infrastructure and quality standards by 2003, in clinical establishments/medical institutions; also, statutory guidelines for the conduct of clinical practice and delivery of medical services are to be developed over the same period. The policy also encourages the setting up of private insurance instruments for increasing the scope of the coverage of the secondary and tertiary sector under private health insurance packages.
4.13.2 To capitalize on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings.
4.13.3 NHP-2001 envisages the co-option of the non-governmental practitioners in the national disease control programmes so as to ensure that standard treatment protocols are followed in their day-to-day practice.
4.13.4 NHP-2001 recognizes the immense potential of use of information technology applications in the area of tele-medicine in the tertiary health care sector. The use of this technical aid will greatly enhance the capacity for the professionals to pool their clinical experience.
4.14 ROLE OF THE CIVIL SOCIETY
4.14.1 NHP-2001 recognizes the significant contribution made by NGOs and other institutions of the civil society in making available health services to the community. In order to utilize on an increasing scale, their high motivational skills, NHP-2001 envisages that the disease control programmes should earmark a definite portion of the budget in respect of identified programme components, to be exclusively implemented through these institutions.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
4.15.1 NHP-2001 envisages the full operationalization of an integrated disease control network from the lowest rung of public health administration to the Central Government, by 2005. The programme for setting up this network will include components relating to installation of data-base handling hardware; IT inter-connectivity between different tiers of the network; and, in-house training for data collection and interpretation for undertaking timely and effective response.
4.16 HEALTH STATISTICS
4.16.1 NHP-2001 envisages the completion of baseline estimates for the incidence of the common diseases – TB, Malaria, Blindness – by 2005. The Policy proposes that statistical methods be put in place to enable the periodic updating of these baseline estimates through representative sampling, under an appropriate statistical methodology. The policy also recognizes the need to establish in a longer time frame, baseline estimates for : the non-communicable diseases, like CVD, Cancer, Diabetes; accidental injuries; and other communicable diseases, like Hepatitis and JE. NHP-2001 envisages that, with access to such reliable data on the incidence of various diseases, the public health system would move closer to the objective of evidence-based policy making.
4.16.2 In an attempt at consolidating the data base and graduating from a mere estimation of annual health expenditure, NHP-2001 emphasis on the needs to establish national health accounts, conforming to the `source-to-users’ matrix structure. Improved and comprehensive information through national health accounts and accounting systems would pave the way for decision makers to focus on relative priorities, keeping in view the limited financial resources in the health sector.
4.17 WOMEN’S HEALTH
4.17.1 NHP-2001 envisages the identification of specific programmes targeted at women’s health. The policy notes that women, along with other under privileged groups are significantly handicapped due to a disproportionately low access to health care. The various Policy recommendations of NHP-2001, in regard to the expansion of primary health sector infrastructure, will facilitate the increased access of women to basic health care. NHP-2001 commits the highest priority of the Central Government to the funding of the identified programmes relating to woman’s health. Also, the policy recognizes the need to review the staffing norms of the public health administration to more comprehensively meet the specific requirements of women.
4.18 MEDICAL ETHICS
4.18.1 NHP – 2001 envisages that, in order to ensurethat the common patient is not subjected to irrational or profit-driven medical regimens, a contemporary code of ethics be notified and rigorously implemented by the Medical Council of India.
4.18.1 NHP – 2001 does not offer any policy prescription at this stage relating to ethics in the conduct of medical research. By and large medical research within the country is limited in these frontier disciplines of gene manipulation and stem cell research. However, the policy recognises that a vigilant watch will have to be kept so that appropriate guidelines and statutory provisions are put in place when medical research in the country reaches the stage to make such issues relevant.
4.19 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
4.19.1 NHP – 2001 envisages that the food and drug administration will be progressively strengthened, both in terms of laboratory facilities and technical expertise. Also, the policy envisages that the standards of food items will be progressively tightened at a pace which will permit domestic food handling / manufacturing facilities to undertake the necessary upgradation of technology so as not to be shut out of this production sector. The policy envisages that, ultimately food standards will be close, if not equivalent, to codex specifications; and drug standards will be at par with the most rigorous ones adopted elsewhere.
4.20 REGULATION OF STANDARDS IN PARAMEDICAL DISCIPLINES
4.20.1 NHP-2001 recognises the need for the establishment of statutory professional councils for paramedical disciplines to register practitioners, maintain standards of training, as well as to monitor their performance.
4.21 OCCUPATIONAL HEALTH
4.21.1 NHP-2001 envisages the periodic screening of the health conditions of the workers, particularly for high risk health disorders associated with their occupation.
4.22 PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
4.22.1 NHP-2001 strongly encourages the providing of health services on a commercial basis to service seekers from overseas. The providers of such services to patients from overseas will be encouraged by extending to their earnings in foreign exchange, all fiscal incentives available to other exporters of goods and services.
4.23 IMPACT OF GLOBALISATION ON THE HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious apprehension expressed by several health experts, of the possible threat to the health security, in the post TRIPS era, as a result of a sharp increase in the prices of drugs and vaccines. To protect the citizens of the country from such a threat, NHP-2001 envisages a national patent regime for the future which, while being consistent with TRIPS, avails of all opportunities to secure for the country, under its patent laws, affordable access to the latest medical and other therapeutic discoveries. The Policy also sets out that the Government will bring to bear its full influence in all international fora – UN, WHO, WTO, etc. – to secure commitments on the part of the Nations of the Globe, to lighten the restrictive features of TRIPS in its application to the health care sector.
5.1 The crafting of a National Health Policy is a rare occasion in public affairs when it would be legitimate, indeed valuable, to allow our dreams to mingle with our understanding of ground realities. Based purely on the clinical facts defining the current status of the health sector, we would have arrived at a certain policy formulation; but, buoyed by our dreams, we have ventured slightly beyond that in the shape of NHP-2001 which, in fact, defines a vision for the future.
5.2 The health needs of the country are enormous and the financial resources and managerial capacity available to meet it, even on the most optimistic projections, fall somewhat short. In this situation, NHP-2001 has had to make hard choices between various priorities and operational options. NHP-2001 does not claim to be a road-map for meeting all the health needs of the populace of the country. Further, it has to be recognized that such health needs are also dynamic as threats in the area of public health keep changing over time. The Policy, while being holistic, undertakes the necessary risk of recommending differing emphasis on different policy components. Broadly speaking, NHP – 2001 focuses on the need for enhanced funding and an organizational restructuring of the national public health initiatives in order to facilitate more equitable access to the health facilities. Also, the policy is focused on those diseases which are principally contributing to the disease burden – TB, Malaria and Blindness from the category of historical diseases; and HIV/AIDS from the category of ‘newly emerging diseases’. This is not to say that other items contributing to the disease burden of the country will be ignored; but only that, resources as also the principal focus of the public health administration, will recognize certain relative priorities.
5.3 One nagging imperative, which has influenced every aspect of NHP-2001, is the need to ensure that ‘equity’ in the health sector stands as an independent goal. In any future evaluation of its success or failure, NHP-2001 would like to be measured against this equity norm, rather than any other aggregated financial norm for the health sector. Consistent with the primacy given to ‘equity’, a marked emphasis has been provided in the policy for expanding and improving the primary health facilities, including the new concept of provisioning of essential drugs through Central funding. The Policy also commits the Central Government to increased under-writing of the resources for meeting the minimum health needs of the citizenry. Thus, the Policy attempts to provide guidance for prioritizing expenditure, thereby, facilitating rational resource allocation.
5.4 NHP-2001 highlights the expected roles of different participating group in the health sector. Further, it recognizes the fact that, despite all that may be guaranteed by the Central Government for assisting public health programmes, public health services would actually need to be delivered by the State administration, NGOs and other institutions of civil society. The attainment of improved health indices would be significantly dependent on population stabilisation, 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.