The missing healing touch 

The missing healing touch 

Context

State has failed both in providing quality healthcare and regulating private players

Article 47: Part of Directive Principles of State Policy

Author starts the article by mentioning the contents of Article 47

Duty of the State to raise the level of nutrition and the standard of living and to improve public health: The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavor to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health

Current controversy

From Article 47 it is clear that public health is a major responsibility of the government. Yet from around the time when India opened up its economy, the government has increasingly ceded space to the private sector in matters related to health — that is the root cause of the current controversy over billing methods in private hospitals

• The controversy erupted after a seven-year-old girl, Aadya, lost her life due to dengue-related complications in Fortis Hospital Gurugram last month

Public health system: Only a poor man’s choice

The growth of the private sector — largely unregulated — is, in fact, less a statement of its efficiency than a result of the government’s failure to provide affordable, accessible and equitable healthcare. As the demand-supply gap widened and the government found itself incapable of providing quality healthcare, the private sector moved in swiftly, becoming the health set-up of choice for all except the poorest

• A 2007 paper in the Economic and Political Weekly notes, “high absenteeism, low quality in clinical care, low satisfaction levels with care (clinical and with regards to courtesy and amenities) and rampant corruption plague the [public health] system

Observations of HLEG

A High Level Expert Group was constituted by erstwhile Planning Commission to look into how India could move towards universal health coverage

• From 8 per cent in 1947, the private sector now accounts for 93 per cent of all hospitals, 64 per cent of all beds, 80 per cent to 85 per cent of all doctors, 80 per cent of out-patients, and 57 per cent of in-patients
• Of the 1.37 million functional hospital beds in India, 8,33,000 are in the private sector, according to the report

Best model

International experience and countless academic papers have suggested that tax-based public financing is the ideal health finance option along with social insurance — or private insurance for those who can afford it

Regulation efforts

There have been sporadic and half-hearted attempts at regulation

• CEA 2010: The Clinical Establishments (Registration and Regulation) Act, 2010, intended by the Centre as a model legislation for the regulation of hospitals by state governments — health is a state subject — has had a low uptake
• Standard Treatment Guidelines that were drawn up for specific conditions and diseases, to obviate over-prescription of drugs or additional costs of diagnostics, remain documents that nobody takes seriously — few doctors have perhaps even read them, given that there is neither monitoring nor an enforcement mechanism that can pick violators
• The West Bengal Clinical Establishments (Registration, Regulation and Transparency) Act, passed earlier this year, and the Karnataka Private Medical Establishments (Amendment) Bill, 2017 — that was recently tabled in the Karnataka Assembly — have been criticised as draconian. The two acts have penal provisions against doctors who overcharge

What can be done?

Promote Health insurance: Check on false billing

Author states that health insurance can act as a check on false billing as insurance companies would not want to pay for false bills but health insurance has penetrated only 3-4 per cent of the country’s population

National health Policy

The National Health Policy 2017 cleared by the Union cabinet lays out a roadmap for public-private partnerships in healthcare

Major features of the policy that aims to transform healthcare in India:

• The policy aims for attainment of highest possible level of health and well-being for every citizen through a preventive and promotive healthcare orientation.
• It seeks to provide and deliver healthcare services, particularly to underprivileged and socially vulnerable groups of people in the country.
• Under the policy, every family will have a health card for access to primary care facility as well as to defined package of services nationwide.
• Health and hygiene to become part of school curriculum – Yoga would be introduced much more widely in schools and work places as part of promotion of good health.
• The policy envisages a three dimensional integration of AYUSH systems by promoting cross referrals, co-location and integrative practices across systems of medicines.
• The policy also seeks to address health security and promotes Make in India for drugs and devices.
• It seeks to establish a Public Health Management Cadre (PHMC) in all states.
• It also proposes rising public health expenditure to 2.5% of the GDP in a time bound manner.

Targets set under the NHP 2017

1. Increasing life expectancy to 70 years from 67.5
2. Reduce fertility rate to 2.1 (Replacement levels) by 2025.
3. Reduce infant mortality rate to 28 by 2019.
4. Reduce Under Five Mortality to 23 by 2025.
5. Reducing premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025
6. The policy seeks to achieve ’90:90:90′ global target by 2020 – implying that 90% of all people living with HIV know their HIV status, 90% of those diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of those receiving antiretroviral therapy will have viral suppression.
7. Reducing the prevalence of blindness to 0.25 per 1000 persons by 2025 and
8. The disease burden to be reduced by one third from the current levels.
9. Elimination of leprosy by 2018, kala-azar by 2017 and lymphatic filariasis in endemic pockets by 2017.

Positives of the Policy

• The broad principles of the policy is centered on Professionalism, Integrity and Ethics, Equity, Affordability, Universality, Patient Centered & Quality of Care, Accountability and pluralism.
• This Policy looks at problems and solutions holistically with private sector as strategic partners
• The Policy advocates a progressively incremental assurance-based approach for GDP allocation increase to 2.5% instead of a hollow rhetoric.
• It envisages providing a larger package of assured comprehensive primary health care through the ‘Health and Wellness Centres’ and denotes an important change from very selective to comprehensive primary health care package which includes care for major NCDs [non-communicable diseases], mental health, geriatric health care, palliative care and rehabilitative care services.
• It aims to ensure availability of 2 beds per 1,000 population distributed in a manner to enable access within golden hour [the first hour after traumatic injury, when the victim is most likely to benefit from emergency treatment].
• In order to provide access and financial protection, it proposes free drugs, free diagnostics and free emergency and essential health care services in all public hospitals

Criticism of the Policy

• The policy duplicates portions of the Health section 2017 Budget speech.
• It reiterates health spend targets set by the High Level Expert Group (HLEG) set up by the erstwhile Planning Commission for the 12th Five Year Plan (which ends on March 31, 2017)
• It also fails to make health a justiciable right through National Health Rights Act like the Right to Education Act 2005 did for school education.
• A health cess was a path-breaking idea in the Health Ministry’s draft policy; it has now been dropped out of the final policy
• The government through 2002 policy promised it would increase health spending to 2 percent of GDP, which never happened either under the National Democratic Alliance (NDA-1) or during 10 years of the United Progressive Alliance (UPA) administration.
• Old Targets and New Deadlines: Look at the Graphic below.
  • The IMR in 2015-16 was 41.
  • The MMR in 2015-16 is 167.
  • The 2002 NHP had set the target of eliminating leprosy by 2005, kala azar by 2010 and lymphatic filariasis by 2015–none of which could be achieved yet.