Health needs a shot in the arm

The  NDA government had promised good governance and policy stability. Yet, in the last three years, we have a fourth in the Health Department, the seventh in the last seven years. Since both the outgoing  and incoming officers have sterling reputations, the reason for this  mid-course change is unclear.

Why it matters?

Health  is a complex sector and a highly contentious one with several  stakeholders working at cross purposes, requiring focused leadership,  undistracted by the noise — something similar to the journey of Odysseus  when he was tied to the ship’s mast to keep himself from being  distracted by the lovely music of the Sirens and, in the process, wreck  the ship on the rocks. But such focused leadership requires knowledge of the purpose of the journey, the direction to take, and the end to reach. Such clarity comes with years of engagement, absorbing the  nuances, developing an intuitive grasp of matters and, most importantly,  building a team and assessing the political environment within which to  steer policy. It is for this reason that the Second Administrative Commission suggested that the tenure of Secretaries should be three  years. Every change at the top then means a loss of a few months till  new equations are formed, trust developed and understanding gained.

Issues of importance

In  line with the predecessor governments, the NDA, too, accorded a lukewarm  priority to health. It sacked a knowledgeable minister, wound up the  National Aids Control Organization (NACO) that had a global reputation  of being a best practice, stopped the reform process of the Rashtriya  Swasthya Bima Yojna (RSBY), shifting it instead to the already  overburdened Ministry of Health, and reduced Central funding to states  in real terms. Instead of swift action to reform the Medical Council of India (MCI), in response to the scathing report of the Parliamentary Standing Committee on Health, a committee was constituted. Two years down, the draft bill is still waiting for action. 

On  the positive side, the NDA articulated a bold health policy framework  that is significant for adopting a more comprehensive health-system approach. Rather than being coy about the participation of the private  sector for achieving welfare goals, the policy makes its cooperation  vital to the achievement of the Universal Health Coverage through a National Health Assurance Programme. Undoubtedly, the NHP, 2017,  notwithstanding its several loopholes, flaws, and contradictions,  provided a way forward. But not without the risk of the health system  being hijacked by corporate sector lobbies to the detriment of the poor,  as seen in the cluttered policy framework that the NITI Aayog came up  with and met with nationwide criticism, including state governments.  Likewise, the NDA introduced the NEET that has some lessons to build upon. The government also sought to make drugs and diagnostics more  affordable by capping prices, which is likely to provoke a reaction from  vested interests.

The juncture

India  is clearly standing at the crossroads. Even as the agenda of unfinished  tasks is growing long, new challenges are emerging from the shadows.  Inadequate budgets and the non-availability of well-trained human  resources are two problems that need to be addressed without further  prevarication. Medical and paramedical education has been brazenly  commercialised. In the race for profits, quality has been severely  compromised with. This needs to be rectified. Solutions on how to do so are available. Likewise, through dialogue, reforms to remove bottlenecks and facilitate the partnering with the private sector for achieving  national goals need to be carefully put into place. As a process, this requires patience and negotiating skills, but is more sustainable than  the lazy option of selling off government assets. Finally, the scope for  exploring non-budgetary financing to meet the huge capex needs of the primary health system, requires being looked into for bringing about an  architectural correction. Conclusive evidence shows that a cost-effective and sustainable health system is possible only when built  upon the foundations of an accessible and free at the point of use,  primary care. India’s health system is based on the more expensive model of specialist-led hospital treatment. Even here, the various  government-sponsored health insurance schemes cover only surgeries. This  needs to be expanded to cover other services and with time the outpatient treatment as well. Finally, the government, like Odysseus,  needs to be tied to the mast for focusing, uncompromisingly, upon  eliminating and effectively containing the load of infectious diseases that still accounts for a third of the disease burden and hurts the poor  disproportionately. Universal access to nutrition, tap water, sanitation and clean air are the vital ingredients of such a strategy.  This basket of public goods then must be made universally available to  all without discrimination as the first charge on government finances. 

The  list of what needs to be done is endless posing a challenge to the most  well-meaning of governments. A beginning needs to be made by keeping the  Secretary unchanged for three years and making him/her accountable to  results — the precedent for the wisdom of such a policy being Tamil  Nadu. 

The writer is the author of Do We care? India’s Health System. Views expressed are personal.