The National Health Policy (NHP) 2017 has been remarkable for the time that was required for its finalisation. While the draft policy was displayed for comments on the health ministry website in December 2014, it took over 26 months for the final policy to see the light of the day. This should not be surprising to those aware of some of the debates that took place during the finalisation of this document, often beyond public gaze. The chief reason for the major delay was a lack of consensus between two key stakeholders – the health ministry and Niti Aayog – around certain key provisions in the policy. The former is the natural locus of health sector policymaking, the latter a recent political creation with limited official powers or proven expertise in the health sector.
A third player – the general public, represented through many civil society formations like Jan Swasthya Abhiyan, as well as thousands of groups and individuals who gave comments on the policy draft – has also played a role, not only through direct inputs but also as a referent stakeholder and putative ‘target’ of policy. The health ministry received an unprecedented 5,000 submissions related to the policy draft which were systematically analysed and certain suggestions have also been included in the final draft.
Given this background, rather than commenting on the important aspects of this policy like has been done here, here and here, the aim of this article is to rather take an institutional approach to analysing the policy.
Contentions in the broader context reflect in tensions in the policy document
The final policy document has certain core tensions that result from interplay between wider neoliberal logic and institutional public health logic. One is the tension between the aspiration to achieve public health goals in line with the needs of India’s people in early 21st century and the constraints imposed by neoliberal ‘fiscal conservatism’ and ‘minimum government’. The second is the tension between aspirations to achieve some form of health coverage for the entire population based on public health logic and the compulsions of involving a largely profit-driven private medical sector to achieve this goal.
These tensions have led to something of a compromise where each of the stakeholders has obtained something – a moderate plan for public health system development with a promise of modest increase in resources (for public health officials), promise of improved access to care and accountability oriented provisions (for people) and formulations of so-called ‘strategic purchasing’ of care, potentially opening the window for further expansion of outsourcing-type support to largely unregulated private providers (for privatisers).
Without going into all undeniably significant aspects of the policy, we examine four major health policy components that reflect the mentioned tensions and would together decide whether the current health system architecture, which is today heavily skewed towards the private sector, will be brought fully in line with public health goals or will undergo further distorted development in the coming period.
Public health system strengthening and expansion
Regarding public health system development, what is being proposed is rather modest, though not insignificant. Most of the public reform recommendations – increasing health sector financing to 2.5% of the GDP by 2025 (in the earlier draft this was to be achieved by 2020), developing comprehensive primary health care, providing free medicines and diagnostics, moves for better inter-sectoral action for health – have been already proposed in earlier policy documents in some form. There are some relatively new and significant formulations such as section 3.3 (seven key policy shifts in organising healthcare services), which are positive, yet need further elaboration and translation into sets of concrete actions.
However, we need to correlate the stated objectives of the policy with the possible plans and linked levels of expenditure that would be required for achievement of these goals. It is here that the tension between public health aspirations and neoliberal policy compulsions becomes evident. For example, let us take just one goal: increase utilisation of public health facilities by 50% from current levels by 2025.
For this admirable goal to be achieved, assuming current utilisation of inpatient care in the public health system is 38% of total (NSS 71st round). Increasing this by 50% would mean moving to levels of around 57% of all hospitalisation care being sought by people in the public health system in next eight years. Similar projections could be made for outpatient care. To achieve this laudable goal implies a concrete and time-defined plan for massive strengthening and expansion of public health services – including doctors and staff, infrastructure, equipment – so that during the coming decade, various forms of public provisioning would become the major player in hospitalisation care. Such plans would need to be developed keeping in view the growing population and existing gaps that need to be closed along with projecting the relevant financial implications for each action component.
Such a systematic exercise could provide both a concrete roadmap for public health system strengthening and evidence-based projection of resource needs, which might even necessitate upward revision of figures for desired levels of public financing. However, it is worth questioning whether this scale of expansion is compatible with the mentioned ceiling on health financing (2.5% of GDP), current policy blockade on regular appointments in the public system as well as constraints imposed by the existing private sector. Failing parallel major policy changes to address these wider issues, such key goals in the policy would remain unfulfilled.
Regulation of the private medical sector
The mentioned public health goals cannot be achieved while the dominant private medical sector remains unregulated. Nominal regulation (registration of hospitals) or regulation limited to peripheral aspects (like biomedical waste disposal), though important, are insufficient. We must move forward to regulation which tackles the manner in which medical care is organised and provided by private facilities. This needs to deal with quality, rationality and costs of care and observance of patients rights – all of which are interlinked and are areas of massive concern in context of India’s private hospitals today.
Reflecting the tensions between public health and private medicine, on most of these fronts the policy provisions are muted and focus mostly on promoting adoption of the Clinical Establishments Act, which has so far been at a snail’s pace. Some bright areas are clear exposition of standard treatment guidelines, the need to protect patients rights (rights to information, access to records and reports, second opinion), proposed empowered medical tribunal to address various disputes and regulatory body for medical devices. Standard regulatory framework for lab services, imaging centres, specialised services such as surrogacy and organ transplantation is also mentioned.
Significantly missing is regulation of rates charged by private medical establishments, which appears in the rules of the national Clinical Establishments Act, but seems to be officially disowned subsequently since even transparency of rates by private establishments is not mentioned in the NHP 2017. Given the pernicious influence of private medical colleges and the background drama regarding the Medical Council of India, the policy is inadequate in spelling out how the regulatory system related to medical education must be overhauled. Overall in this key area of policy, we can see that the ‘public’ oriented forces plan some inroads but the line seems to be drawn by ‘private’-oriented policy influencers.
Interface between public system and private providers
This is where the contention between ‘public’ oriented forces (public health officials and people) and ‘private’ oriented influencers (privatisers) has been the sharpest. To effectively achieve public health goals, one grand challenge is bringing the ‘wild elephant’ of private medical sector under public direction. Here a Jan Swasthya Abhiyan document notes:
For example, individual private doctors working in the NHS in UK function more like public actors than profit driven private entities. The latter approach would also require taking a differential strategy to the private medical sector in India since individual practitioners and smaller providers are more likely to work with publicly organised systems while corporate and large private multi-speciality hospitals will be least inclined to abandon their profit-driven mode of functioning. With this background, the final NHP 2017 again reflects an uneasy compromise between positions taken by public health officials and people versus prescriptions of privatisers.
Here we may note that certain pro-privatisation proposals keep asserting themselves like resistant bacteria that refuse to vanish despite treatment; like bacteria these also mutate over time, changing form but not essence. The Planning Commission’s draft chapter on health for the 12th Five Year Plan (July 2012) had recommended a ‘managed care’ type model, indicating that private networks could bid for providing multiple levels of care, and such networks could be handed over substantial responsibility for provisioning. The Niti Aayog has recently circulated an internal document with somewhat similar formulations exploring the formation and involvement of networks of public, private and not-for-profit providers for provision of care at primary, secondary and tertiary levels.
With this background in view, it should be acknowledged that NHP 2017 has avoided such extreme pro-privatisation formulations, though leaving critical areas unclear. The situational analysis of section 2.19 states that with projected level of public health expenditure increasing to 2.5% of GDP, “purchasing” would have to be mainly from public providers for efficient use of resources, with purchasing from private providers only for supplementation. This reasonable formulation seems to be the baseline position of public health officials. In sections 12 and 13 of the policy document, the so-called ‘strategic purchasing’ from the private sector is presented, the sequence of preference being from public providers followed by not-for-profit and then for-profit private providers. How this approach will roll out in practice in various areas remains to be seen. Yet this welcome differential approach would need to be followed by developing objective criteria to differentiate between not-for profit and for-profit facilities, defining ceilings on rates and examining demonstrated provision of free or highly subsidised care to people.
Insurance schemes appear relatively briefly in section 13.6.2, mentioned as option along with purchasing of care by trusts. Another expectation is that private providers would offer expanded free services for the poor (section 13.7), which appears either naïve or ill-informed given the experience of so-called charitable hospitals, which have systematically subverted even their legal obligations to provide such care.
Hence this policy creates a window for ‘strategic purchasing’, and the scale and forms it might take are undefined which can allow the ‘devil to enter in the details’. Most importantly, it is not clear what proportion of the projected increase in public finances (supposed to be increasing from 1.15% of GDP now to 2.5% of GDP by 2025) would flow towards expansion and strengthening of public health facilities, what proportion would be dedicated to care from demonstrated not-for profit entities and what proportion would flow to for-profit providers. If gap-filling is the sole criterion, then given the dominance of private provisioning especially at higher levels and in urban areas, the bulk might flow to private providers. However, if correcting public-private imbalance to achieve public goals and ‘socialising’ sections of the private sector are explicit strategies, then public-system strengthening options would emerge foremost.
Strengthening the ‘public’: rights, accountability and people’s participation
Reorientation of the health system to bring public health logic centre stage requires people’s voices to radiate through the entire health system. For this, governance must be transformed and the public needs to be systematically empowered. NHP 2017 takes a major step backward on the commitment to enacting a National Health Rights Act (mentioned in the 2015 draft), being replaced by the vague ‘incremental assurance based approach’, which is a major disappointment. The reasons cited are financial constraints, again reminding us of the larger neo-liberal framework. This is a circular argument. Without committing to fulfilling the right to healthcare, when will governments get around to allocating sufficient finances for the health sector? At least a start should have been made, as in the case of South Africa, of initiating a rights-based framework for health focussed on levels like primary care and then progressively expanding this over time.
Positively certain provisions for community accountability have been included, particularly in the section on governance (section 26). It is stated that community based monitoring and planning of health services should be made mandatory along with grievance redressal systems. Institutionalising patients rights in clinical establishments and medical tribunals to address patient complaints are steps in the right direction. Regarding protection of clinical trial participants, adoption of global good clinical practice guidelines and independent monitoring mechanisms to safeguard the health and rights of trial participants are positive inclusions.
Overall, due to external constraints and internal tensions, NHP 2017 falls somewhere between a comprehensive plan for major expansion of public health services and socialisation of the private sector and extreme privatisation and corporate sector oriented policy proposals. From the people’s perspective, a mixed bag has emerged through contention between key actors with promise of modest public health system reform, but with questions about levels of resources and how these resources will be allocated between public and private sectors combined with possibilities of further privatisation. Whatever is positive in this policy will need to be actively monitored for implementation along with campaigns for further expansion and accountability of the public health sector. Privatisation oriented measures will need to be challenged while presenting counter-proposals for effective regulation and socialisation of private providers towards public health goals. Developing the expected implementation framework would be a next crucial step, which would decide how some of the open-ended statements are actually interpreted and implemented (or not implemented).
Ultimately, we must view health policy making as one evolving terrain of struggle and popular intervention, among many others. Although one phase is completed, the story of health system changes linked with this policy is just beginning. All social actors concerned with public health will need to join hands and assert themselves to ensure that positive spaces opened up by the policy are actualised and enlarged while constraints imposed by the neoliberal framework are frontally challenged.
Abhay Shukla is a public health physician and health activist associated with Jan Swasthya Abhiyan and Alliance of Doctors for Ethical Healthcare.
A third player – the general public, represented through many civil society formations like Jan Swasthya Abhiyan, as well as thousands of groups and individuals who gave comments on the policy draft – has also played a role, not only through direct inputs but also as a referent stakeholder and putative ‘target’ of policy. The health ministry received an unprecedented 5,000 submissions related to the policy draft which were systematically analysed and certain suggestions have also been included in the final draft.
Given this background, rather than commenting on the important aspects of this policy like has been done here, here and here, the aim of this article is to rather take an institutional approach to analysing the policy.
Contentions in the broader context reflect in tensions in the policy document
The final policy document has certain core tensions that result from interplay between wider neoliberal logic and institutional public health logic. One is the tension between the aspiration to achieve public health goals in line with the needs of India’s people in early 21st century and the constraints imposed by neoliberal ‘fiscal conservatism’ and ‘minimum government’. The second is the tension between aspirations to achieve some form of health coverage for the entire population based on public health logic and the compulsions of involving a largely profit-driven private medical sector to achieve this goal.
These tensions have led to something of a compromise where each of the stakeholders has obtained something – a moderate plan for public health system development with a promise of modest increase in resources (for public health officials), promise of improved access to care and accountability oriented provisions (for people) and formulations of so-called ‘strategic purchasing’ of care, potentially opening the window for further expansion of outsourcing-type support to largely unregulated private providers (for privatisers).
Without going into all undeniably significant aspects of the policy, we examine four major health policy components that reflect the mentioned tensions and would together decide whether the current health system architecture, which is today heavily skewed towards the private sector, will be brought fully in line with public health goals or will undergo further distorted development in the coming period.
Public health system strengthening and expansion
Regarding public health system development, what is being proposed is rather modest, though not insignificant. Most of the public reform recommendations – increasing health sector financing to 2.5% of the GDP by 2025 (in the earlier draft this was to be achieved by 2020), developing comprehensive primary health care, providing free medicines and diagnostics, moves for better inter-sectoral action for health – have been already proposed in earlier policy documents in some form. There are some relatively new and significant formulations such as section 3.3 (seven key policy shifts in organising healthcare services), which are positive, yet need further elaboration and translation into sets of concrete actions.
However, we need to correlate the stated objectives of the policy with the possible plans and linked levels of expenditure that would be required for achievement of these goals. It is here that the tension between public health aspirations and neoliberal policy compulsions becomes evident. For example, let us take just one goal: increase utilisation of public health facilities by 50% from current levels by 2025.
For this admirable goal to be achieved, assuming current utilisation of inpatient care in the public health system is 38% of total (NSS 71st round). Increasing this by 50% would mean moving to levels of around 57% of all hospitalisation care being sought by people in the public health system in next eight years. Similar projections could be made for outpatient care. To achieve this laudable goal implies a concrete and time-defined plan for massive strengthening and expansion of public health services – including doctors and staff, infrastructure, equipment – so that during the coming decade, various forms of public provisioning would become the major player in hospitalisation care. Such plans would need to be developed keeping in view the growing population and existing gaps that need to be closed along with projecting the relevant financial implications for each action component.
Such a systematic exercise could provide both a concrete roadmap for public health system strengthening and evidence-based projection of resource needs, which might even necessitate upward revision of figures for desired levels of public financing. However, it is worth questioning whether this scale of expansion is compatible with the mentioned ceiling on health financing (2.5% of GDP), current policy blockade on regular appointments in the public system as well as constraints imposed by the existing private sector. Failing parallel major policy changes to address these wider issues, such key goals in the policy would remain unfulfilled.
Regulation of the private medical sector
The mentioned public health goals cannot be achieved while the dominant private medical sector remains unregulated. Nominal regulation (registration of hospitals) or regulation limited to peripheral aspects (like biomedical waste disposal), though important, are insufficient. We must move forward to regulation which tackles the manner in which medical care is organised and provided by private facilities. This needs to deal with quality, rationality and costs of care and observance of patients rights – all of which are interlinked and are areas of massive concern in context of India’s private hospitals today.
Reflecting the tensions between public health and private medicine, on most of these fronts the policy provisions are muted and focus mostly on promoting adoption of the Clinical Establishments Act, which has so far been at a snail’s pace. Some bright areas are clear exposition of standard treatment guidelines, the need to protect patients rights (rights to information, access to records and reports, second opinion), proposed empowered medical tribunal to address various disputes and regulatory body for medical devices. Standard regulatory framework for lab services, imaging centres, specialised services such as surrogacy and organ transplantation is also mentioned.
Significantly missing is regulation of rates charged by private medical establishments, which appears in the rules of the national Clinical Establishments Act, but seems to be officially disowned subsequently since even transparency of rates by private establishments is not mentioned in the NHP 2017. Given the pernicious influence of private medical colleges and the background drama regarding the Medical Council of India, the policy is inadequate in spelling out how the regulatory system related to medical education must be overhauled. Overall in this key area of policy, we can see that the ‘public’ oriented forces plan some inroads but the line seems to be drawn by ‘private’-oriented policy influencers.
Interface between public system and private providers
This is where the contention between ‘public’ oriented forces (public health officials and people) and ‘private’ oriented influencers (privatisers) has been the sharpest. To effectively achieve public health goals, one grand challenge is bringing the ‘wild elephant’ of private medical sector under public direction. Here a Jan Swasthya Abhiyan document notes:
“… we need to decide how to deal with the existing private medical sector while moving towards health care for all. In this context, two diametrically opposing approaches are available to us today. Either public resources would be made to serve private benefit, or private resources would be made to serve public benefit.”The currently dominant option, observed in most current public-private partnerships and health insurance schemes, is handing over major public resources to weakly regulated private providers without rationalising their practices, making them systematically accountable to public or scrutinising their impact on existing public provisioning. The counter-trend proposes making sections of private providers work as extension of public health services and rationalising their functioning while ensuring their public accountability.
For example, individual private doctors working in the NHS in UK function more like public actors than profit driven private entities. The latter approach would also require taking a differential strategy to the private medical sector in India since individual practitioners and smaller providers are more likely to work with publicly organised systems while corporate and large private multi-speciality hospitals will be least inclined to abandon their profit-driven mode of functioning. With this background, the final NHP 2017 again reflects an uneasy compromise between positions taken by public health officials and people versus prescriptions of privatisers.
Here we may note that certain pro-privatisation proposals keep asserting themselves like resistant bacteria that refuse to vanish despite treatment; like bacteria these also mutate over time, changing form but not essence. The Planning Commission’s draft chapter on health for the 12th Five Year Plan (July 2012) had recommended a ‘managed care’ type model, indicating that private networks could bid for providing multiple levels of care, and such networks could be handed over substantial responsibility for provisioning. The Niti Aayog has recently circulated an internal document with somewhat similar formulations exploring the formation and involvement of networks of public, private and not-for-profit providers for provision of care at primary, secondary and tertiary levels.
With this background in view, it should be acknowledged that NHP 2017 has avoided such extreme pro-privatisation formulations, though leaving critical areas unclear. The situational analysis of section 2.19 states that with projected level of public health expenditure increasing to 2.5% of GDP, “purchasing” would have to be mainly from public providers for efficient use of resources, with purchasing from private providers only for supplementation. This reasonable formulation seems to be the baseline position of public health officials. In sections 12 and 13 of the policy document, the so-called ‘strategic purchasing’ from the private sector is presented, the sequence of preference being from public providers followed by not-for-profit and then for-profit private providers. How this approach will roll out in practice in various areas remains to be seen. Yet this welcome differential approach would need to be followed by developing objective criteria to differentiate between not-for profit and for-profit facilities, defining ceilings on rates and examining demonstrated provision of free or highly subsidised care to people.
Insurance schemes appear relatively briefly in section 13.6.2, mentioned as option along with purchasing of care by trusts. Another expectation is that private providers would offer expanded free services for the poor (section 13.7), which appears either naïve or ill-informed given the experience of so-called charitable hospitals, which have systematically subverted even their legal obligations to provide such care.
Hence this policy creates a window for ‘strategic purchasing’, and the scale and forms it might take are undefined which can allow the ‘devil to enter in the details’. Most importantly, it is not clear what proportion of the projected increase in public finances (supposed to be increasing from 1.15% of GDP now to 2.5% of GDP by 2025) would flow towards expansion and strengthening of public health facilities, what proportion would be dedicated to care from demonstrated not-for profit entities and what proportion would flow to for-profit providers. If gap-filling is the sole criterion, then given the dominance of private provisioning especially at higher levels and in urban areas, the bulk might flow to private providers. However, if correcting public-private imbalance to achieve public goals and ‘socialising’ sections of the private sector are explicit strategies, then public-system strengthening options would emerge foremost.
Strengthening the ‘public’: rights, accountability and people’s participation
Reorientation of the health system to bring public health logic centre stage requires people’s voices to radiate through the entire health system. For this, governance must be transformed and the public needs to be systematically empowered. NHP 2017 takes a major step backward on the commitment to enacting a National Health Rights Act (mentioned in the 2015 draft), being replaced by the vague ‘incremental assurance based approach’, which is a major disappointment. The reasons cited are financial constraints, again reminding us of the larger neo-liberal framework. This is a circular argument. Without committing to fulfilling the right to healthcare, when will governments get around to allocating sufficient finances for the health sector? At least a start should have been made, as in the case of South Africa, of initiating a rights-based framework for health focussed on levels like primary care and then progressively expanding this over time.
Positively certain provisions for community accountability have been included, particularly in the section on governance (section 26). It is stated that community based monitoring and planning of health services should be made mandatory along with grievance redressal systems. Institutionalising patients rights in clinical establishments and medical tribunals to address patient complaints are steps in the right direction. Regarding protection of clinical trial participants, adoption of global good clinical practice guidelines and independent monitoring mechanisms to safeguard the health and rights of trial participants are positive inclusions.
Overall, due to external constraints and internal tensions, NHP 2017 falls somewhere between a comprehensive plan for major expansion of public health services and socialisation of the private sector and extreme privatisation and corporate sector oriented policy proposals. From the people’s perspective, a mixed bag has emerged through contention between key actors with promise of modest public health system reform, but with questions about levels of resources and how these resources will be allocated between public and private sectors combined with possibilities of further privatisation. Whatever is positive in this policy will need to be actively monitored for implementation along with campaigns for further expansion and accountability of the public health sector. Privatisation oriented measures will need to be challenged while presenting counter-proposals for effective regulation and socialisation of private providers towards public health goals. Developing the expected implementation framework would be a next crucial step, which would decide how some of the open-ended statements are actually interpreted and implemented (or not implemented).
Ultimately, we must view health policy making as one evolving terrain of struggle and popular intervention, among many others. Although one phase is completed, the story of health system changes linked with this policy is just beginning. All social actors concerned with public health will need to join hands and assert themselves to ensure that positive spaces opened up by the policy are actualised and enlarged while constraints imposed by the neoliberal framework are frontally challenged.
Abhay Shukla is a public health physician and health activist associated with Jan Swasthya Abhiyan and Alliance of Doctors for Ethical Healthcare.
Source The wire
