August 19, 2016

A Brief Introduction to Health Care of India

The author of the article had served as a Myanmar diplomat in the Republic of India for a number of years and had travelled to some states. With the backdrop of 1.252 billion (2013)  population in that nation, the planning and implementation of health care programs are quite interesting.
India is a federal union of states comprising twenty-nine states and seven union territories. The states and union territories are further subdivided into districts and more into smaller administrative divisions.
The Ministry of Health and Family Welfare is an Indian government ministry charged with health policy in India. It is also responsible for all government programs relating to family planning in India.
The Minister of Health and Family Welfare holds cabinet rank as a member of the Council of Ministers. The Ministry regularly publishes the Indian Pharmacopoeia since 1955 through Indian Pharmacopoeia Commission (IPC) an autonomous body under the ministry for setting of standards for drugs, pharmaceuticals and healthcare devices and technologies in India.
The ministry is composed of four departments: (1) Health & Family Welfare; (2) Health Research; (3) AIDS Control; and (4) Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH).
Department of Health
The Department of Health deals with health care, including awareness campaigns, immunization campaigns, preventive medicine, and public health. Bodies under the administrative control of this department are:
•    National AIDS Control Organization (NACO)
•    13 National Health Programmes
•    Medical Council of India
•    Dental Council of India
•    Pharmacy Council of India
•    Indian Nursing Council
•    All India Institute of Speech and Hearing (AIISH), Mysore
•    All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai
•    Hospital Services Consultancy Corporation Limited (HSCC)
•    Food Safety and Standards Authority of India
•    Central Drugs Standard Control Organization
Department of Family Welfare
The Department of Family Welfare (DFW) is responsible for aspects relating to family welfare, especially in reproductive health, maternal health, pediatrics, information, education and communications; cooperation with NGOs and international aid groups; and rural health services. The Department of Family Welfare is responsible for:
•    18 Population Research Centers (PRCs) at six universities and six other institutions across 17 states
•    National Institute of Health and Family Welfare (NIHFW), South Delhi
•    International Institute for Population Sciences (IIPS), Mumbai
•    Central Drug Research Institute (CDRI), Lucknow
•    Indian Council of Medical Research (ICMR), New Delhi; (founded in 1911, it is one of the oldest medical research bodies in the world).
Department of AYUSH
The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) deals with ayurveda (Indian traditional medicine), yoga, naturopathy, unani, siddha, and homoeopathy, and other alternative medicine systems.
The department was established in March 1995 as the Department of Indian Systems of Medicines and Homoeopathy (ISM&H). The department is charged with upholding education standards in the Indian Systems of Medicines and Homoeopathy colleges, strengthening research, promoting the cultivation of medicinal plants used, and working on Pharmacopoeia standards. Bodies under the control of the Department of AYUSH are:
•    Research councils
•    Educational institutions
•    Indian Medicine Pharmaceutical Corporation Limited (IMPCL), Mohan, Uttaranchal (a public sector undertaking)
•    Professional councils
Health care is a state subject as per “The Constitution of India” within the federal set up of the nation, consisting of a central government and individual state governments. It makes every state responsible for “raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”.
The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. The National Health Policy is being worked upon further in 2015 and a draft for public consultation has been subsequently released.
The private health sector is the dominant health care provider in both urban and rural Indian households as per nationwide surveys.
Provisions of Draft National Health Policy 2015
•    The draft National Health Policy 2015 has proposed a target of raising public health expenditure to 2.5 % from the present 1.2% of GDP. It also notes that 40 % of this would need to come from central expenditure.
•    The draft policy suggests in making health a fundamental right similar to education and that the denial of the same could be punishable. The Centre shall enact, after due discussion and on the request of three or more states a National Health Rights Act, which will ensure health as a fundamental right, whose denial will be justifiable.
•    The draft policy has been placed in the public domain until 28 February 2015 for public consultation. The new health policy is being introduced almost 13 years after the last health policy was drafted.
International covenants
The proposal for a National Health Rights Act comes after a debate on whether India should pass a Bill to make health a fundamental right as was done for education. “Many industrialized nations have laws that do so. Many of the developing nations that have made significant progress towards universal health coverage, such as Brazil and Thailand, have done so and therefore such a law is a major contributory factor for health care in India. A number of international covenants to which India is joint signatories give such a mandate, and this could be used to make a national law. Courts have also rulings that, in effect, see health care as a fundamental right, and a constitutional obligation flowing out of the right to life,” the draft policy says.
Pointing out that there has been a 10-year discussion on this issue but “without a resolution,” the draft popped up questions whether India has reached the level of development in economic and health systems to make this a justiciable right on health care, implying that its denial is an offence.
The draft National Health Policy 2015 proposes that “the Center shall enact, after due discussion and on the request of three or more States using the same legal clause as used for the Clinical Establishments Bill, a National Health Rights Act, which will make in ensuring health as a fundamental right.”
“The States would voluntarily opt to adopt this by a resolution of their Legislative Assembly. The States which have achieved a per capita public health expenditure rate of over Rs. 3,800 (59 US$) per capita should be in a position to deliver on this. Although many States are some distance away, there are States which are approaching or have even reached this target.”
On the issue of increasing health spending, the draft says it accepts and endorses the understanding that a full achievement of the Millennium Development Goals (MDG) will require an increase in public health expenditure from 4 to 5 per cent of the GDP.
Potentially achievable
However, given that the previous National Health Policy 2002, the target of 2 per cent of the GDP was not met. In recent time, taking into account the financial capacity of the country to provide this amount and the institutional capacity to utilize the increased funding in an effective manner, this new policy proposes a potentially achievable target of raising public health expenditure to 2.5 per cent of the GDP.
“It also notes that 40 per cent of this health expenditure would need to come from Central expenditures. At current prices, a target of 2.5 per cent of the GDP translates to Rs. 3,800 per capita, representing an almost four-fold increase in five years. Thus, a longer time frame may be appropriate to even reach this modest target,” the policy notes. The Indian government’s draft National Health Policy 2015 clearly articulates its goals and principles going forward, which is a laudable departure from previous policy pronouncements. It is very candid in its acceptance of the failures of past health initiatives, but does not identify the reasons for such failure. By failing to do so, the solutions offered for existing problems seem to be an effort to patch up over the past oversights, rather than straight forward policy actions that can achieve future progress.
The policy explicitly talks of the difficulties in enhancing public expenditure on healthcare, and prefers to limit its expectations to a modest 2.5% of the GDP. But no country in the world has achieved universal health coverage with such low levels of investment in health care and the policy overlooks that sphere. No policy actions can work and go ahead without appropriate fiscal allocation and this is where the policy does not meet the identified gaps in healthcare provision.
Moreover, the policy seeks to garner additional resources for health through a health “cess” (assessment or tax being collected and exclusively earmarked for health care) and “sin” taxes on tobacco, alcohol, and other products—and this is regressive. The universal health “cess” will not be equitable and reasonable, as those at the lower ends of the income quintiles (one of five equal groups at the lowest) will pay a higher proportion of their incomes when compared to those at higher income levels, which is morally unacceptable.
The policy looks towards market driven expansion to meet the workforce needs for providing comprehensive primary health care. Yet, unfortunately, the very same market forces have failed so far to provide even rudimentary primary health care.
The draft policy has recognized the relevance of medical technologies for a strong and robust health care delivery system, but it has placed medical devices within the legal framework of the Drugs and Cosmetics Act, 1940, making conceptually different from drugs. This does a disfavor to the medical devices industry, and also to end users who will not have the protection of effective regulations for devices.
The policy proposes to make health care “affordable” instead of “universal”. It does not recognize or enact two essential principles necessary for universal health care access in a federal system: solidarity and portability. The principle of solidarity provides the moral basis for making care available for those who are not always able to pay. The principle of portability enables citizens to have the right to health care across all the states of the country, which is very important in a federal political system. By failing to make this policy jump from affordable to universal, the government abdicates on its responsibility towards securing equality of status and opportunity for its citizens.
Still heading for Universal Health Coverage
Aditya Kalra of New Delhi recently reports that Prime Minister Narendra Modi has asked for a drastic cutback of an ambitious health care plan after cost estimates came in at $18.5 billion over five years, delaying a promise made in his election manifesto, several government sources have commented.
Modi has had to make difficult choices to boost economic growth, his government’s first full annual budget, announced in last week of February 2015, ramped up infrastructure spending, leaving less federal funding immediately available for social sectors.
In fact, the health ministry developed a draft policy on universal health care in coordination with the prime minister’s office in 2014. The National Health Assurance Mission aims to provide free drugs, diagnostic services and insurance for serious ailments for India’s 1.2 billion people.
Universal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, usually refers to a health care system which provides health care and financial protection to all citizens of a particular country.
PM Modi’s manifesto ahead of the election that brought him to power last year accorded “high priority” to the health care sector and promised a universal health assurance plan. The manifesto said previous public health schemes that have been mired in payment delays recently had failed to meet the growing medical needs of public.
The health plan was drafted in consultation with the PM office and an expert panel, including an expert from the World Bank. The proposal included insurance to cover more expensive and serious ailments such as heart surgeries or organ failure.
The health ministry has originally proposed for rolling out the system from April 2015 and in October 2014 projected its cost as $25.5 billion over four years. By the time the project was presented to Modi in January 2015 the costs had been pared away to 1.16 trillion rupees ($18.5 billion) over five years.
That was still too much. The programme was not approved; three health ministry officials and two other government sources told the media. Three officials said the health ministry has been asked to revamp the policy, but work is yet to start.
The PM has another four years left in his first term to fulfill the promise. India currently spends about 1 percent of its gross domestic product (GDP) on public health, but funds are not fully utilized. A health ministry vision document in December proposed to pull up for spending to 2.5 percent of GDP but did not specify a time period.
The Indian government in February 2015 kept its healthcare budget for 2015-16 on a tight leash and asked states to contribute more funds for running the country’s flagship health care programmes.
The government announced 297 billion rupees ($4.81 billion) for its main health department, roughly 2 percent higher than current year’s revised budget of 290 billion rupees.
The World Bank’s Global Monitoring Report for 2014-15 on the Millennium Development Goals says India has been the biggest contributor to poverty reduction between 2008 and 2011, with around 140 million or so lifted out of absolute poverty. Since the early 1950s, Indian government initiated various schemes to help the poor attain self-sufficiency in food production.
The author of this article is safe to draw a conclusion that Prime Minister Narendra Modi would ramp up central health spending in a bid to achieve his goal of Universal Health Coverage. Until now, the Prime Minister has already vowed to revamp the sector and make medical services more affordable for the poor.


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