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National Health Policy 2002: A brief critique

AMIT SEN GUPTA

INTRODUCTIONThe National Health Policy (NHP), released by the Ministry ofHealth and Family Welfare, marks the culmination of a rathertortuous process. It has reportedly been with the drafting board formany years. One would have assumed that such a process wouldinvolve wide ranging discussions at all levels. Unfortunately,besides a small group in the Central Health Ministry, almosteveryone appears to have been kept out ofthe process of draftingthe new policy. We are now presented with afait accompli. Whilethe policy itself repeatedly states that health is a state subject as perthe Indian constitution, from all accounts the state governmentshave not been involved in the process of drafting, nor has theCentral Council of Health and Family Welfare been consulted.

ELOQUENT SILENCEA critique of the policy is difficult as it is most eloquent where itis silent! It completely omits the concept of comprehensive anduniversal healthcare. In contrast, the NHP 1983 had said: 'Indiais committed to attaining the goal of "Health for All by the YearAD 2000", through the universal provision of comprehensiveprimary health care services.' The policy thus departs from thefundamental concept of the NHP 1983 and the Alma Ata Decla-ration. It is also conspicuously silent on the village health worker-the first contact in the primary healthcare system. By its silence,the NHP 2002 provides a framework for the dismantling of theentire concept of primary healthcare. Importantly, the section onpolicy prescriptions in the NHP 2002 is silent on the content of theprimary healthcare system.

The policy has nothing substantive to say of the populationcontrol programme, which the health movement has long held toconstitute amajor drain on primary healthcare. It repeats the usualexcuse that advances in public health have been nullified by anincrease in the population. This refrain contradicts all evidenceavailable across the globe, which show that population stabiliza-tion follows attainment of certain socioeconomic standards and donot precede them. The policy practically ignores pharmaceuticalsand their impact on healthcare, thereby accepting that it has no rolein the formulation of the drug policy. This is even more surprisinggiven the fact that a new drug policy has also been recentlyannounced. Are we to understand that the NHP 2002 believes thatincreased drug prices and non-availability of essential drugs haveno impact on the health sector?

IMPORTANT CONCERNS IGNOREDOther important concerns are either ignored or referred to only inpassing. The policy has a four-line section on women's health,without any specific proposals being spelt out. Child health is noteven given a separate section. It is silent on child nutrition despitethe fact that half the children below 5 years of age are malnour-ished in India-a dubious distinction that India shares with onlyone other country (Bangladesh) in the world.

In the area of medical education, the policy talks of the need tointroduce postgraduate courses in 'family medicine'. The long-

Delhi Science Forum and Peoples Health Assembly

The National Medical Journal of India 2002

standing position of the health movement has been to limitspecialization and reorient undergraduate education to equipdoctors in a manner that they are able to better address the healthneeds of the common people. Such a purpose cannot be served byjust introducing another specialty called family medicine. TheNHP 2002 betrays a lack of understanding regarding the need tocreate a system of medical education oriented to the needs ofprimary care, and instead is biased towards urban specialist -basedhealthcare. However, it is silent about the bane of private medicalcolleges and the need to stop setting up new ones and to regulatethese institutions.

The section on research harps on 'frontier areas' and medicalresearch. There is no understanding of the necessity to initiate andsustain research on public health. There is no mention of thenecessity to regulate medical research and to develop appropriateethical criteria. The impact of Trade- Related Intellectual PropertyRights (TRIPS) is discussed in terms of the possible impact ondrug prices, but there is no mention of the crippling effect of TRIPSon medical research.

COMPROMISE AND CONTRADICTIONSThe policy document appears to be a compromise effort thatmarries contradictory concerns. Section 2, titled 'Present Scenario'analyses many of the present initiatives and their deficiencies.Some of the conclusions drawn in this section are based on soundassumptions. However, many of these assumptions are ignored orcontradicted in the operative part of the document, Section 4, titled'Policy Prescriptions'. The document makes appropriate refer-ences to decentralization, inadequate funds, non-viability of verti-cal programmes, inadequate and dysfunctional infrastructure, etc.in Section 2.However, there are eitherno matching policy prescrip-tions in Section 4 or these prescriptions are expressed in vaguegeneralities. Out of the main policy prescriptions, most relate toencouragement of the private sector and legitimization ofprivatization of the healthcare delivery system.

INCREASED FUND ALLOCATION: TOO LITTLE ANDOVERDUEA further perusal of the policy document throws up many funda-mental concerns. The document admits that public health invest-ment has been 'comparatively low'. What it does not admit is thefact that such investment as a percentage of total health expendi-ture is possibly the lowest in the world; that India has the mostprivatized health system in the world! The document recommendsa welcome increase in public health expenditure from the present0.9% of GDP to 2% in 2010. However, the quantum suggested istoo little and comes very late. It falls far short of the 5% of GDP thathas been a long-standing demand of the health movement andrecommended by the World Health Organization long ago. More-over, the policy projects that the public expenditure in 2010 willbe 33% of the total health expenditure-up from the present 17%.However, even 33% is lower than that of the average of any regionin the globe today-India would continue to be one of the mostprivatized health systems in the world even in 2010! The policy iseloquent on the inability of states to increase expenditure on

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healthcare and laments that the allocation by states has in factdecreased in the past decade. There is a veiled attempt to castigatethe states for their inability to increase expenditure. Such insinu-ations are meaningless without a detailed analysis of the mannerin which the process of economic liberalization in India hasshattered the financial stability of states.

TOP-DOWN PRESCRIPTIONThe NHP 2002, for all the rhetoric on community participation, isreplete with 'top-down' prescriptions. While admitting the wast-age involved in running centrally sponsored and controlled verti-cal disease control programmes and envisaging their integrationin the decentralized primary healthcare system, it goes on torecommend that we would need to retain many of them! Allsubsequent formulations in the policy, especially in the section onpolicy formulations, assume the continuance of verticalprogrammes. Moreover, the policy repeatedly asserts that theCentre will continue to plan all public health programmes. Itcontinuously harps on the availability of expertise with the Centreto justify strong Central control. It is not clear where the basis ofsuch assertions lie. The document is vague about the actualdevolution of responsibility and financial powers to PanchayatRaj institutions (PRIs) and relocation of accountability to appro-priate levels of local self-governments. In the absence of suchclarity there is danger of the primary healthcare system becominga collector-driven exercise, which is controlled by the Centre,thereby defeating the entire effort at decentralization.

The policy talks about using Indian health facilities to attract

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 15, NO.4, 2002

patients from other countries. It also suggests that such incomescan be termed 'deemed export' and should be exempt from taxes.This formulation draws from recommendations that the industryhas been making and specifically from the 'Policy Framework forReforms in Health Care' drafted by the Prime Minister's AdvisoryCouncil on Trade and Industry, headed by Mukesh Ambani andKumaramangalam Birla. Such a proposal, termed by many as'health tourism' will divert our best resources within the country.The policy also talks of encouraging 'the setting up of privateinsurance instruments for increasing the scope of the coverage ofthe secondary and tertiary sector under private health insurancepackages'. Further, the document refers to the 'valuable' contribu-tions made by the private sector and the need to 'encourage' moresuch contributions. While it is often critical of the public healthsystem (justifiably so), there is no criticism of the ills of theunregulated private medical care system, though reference ismade to the need to develop regulatory norms.

In brief, the NHP 2002 identifies many of the gross deficienciesof the existing healthcare scenario, proposes a substantial rise inCentral Government expenditure on healthcare and has someother positive features such as the proposed regulation of theprivate sector. However, in operative terms, it constitutes anabandonment of the Alma Ata Declaration, and legitimizes fur-ther privatization of the health sector.

(Based on the critique to the Draft National Health Policy, 2001,formulated by the Jana Swasthya Abhiyan: A network of HealthMovements across the country.)

Draft National Health Policy 2001: A leap forward in assessment butlimping in strategies

V. MOHANANNAIR

SITUATIONAL ANALYSIS AND STATED OBJECTIVESThe 'Draft National Health Policy-2001' is a leap forward in thehistory of evolution of healthcare in India. The background againstwhich the draft was prepared is realistic because it was clear that thecountry could not make all the expected strides mentioned in theprevious National Health Policy (NHP) of 1983. The claims on theinitiatives in primary healthcare and control or eradication of com-municable diseases, and the quoted achievements in demographic,epidemiological and infrastructural indicators arewell founded. Theconcern shown regarding the alarmingly increasing trends of mor-

(A report of the workshop organized jointly by the Achutha Menon Centrefor Health Science Studies of Sree Chitra Tirunal Institute for MedicalSciences and Technology and the Department of Health and Family Welfare,Government of Kerala.)

Sree Chitra Tirunal Institute for Medical Sciences and Technology,Thiruvananthapuram, Kerala 695011, India

V. MOHANAN NAIRAchutha Menon Centre for Health Science Studies;vmnairtesctimst.kcr.nic.in

The National Medical Journal of India 2002

bidity, even in the wake of declining mortality and the relativeinability of the public healthcare system in the country to cope withthe mortality and morbidity burdens, is also apt. Thus the justifica-tions provided for the new health policy are convincing and theattempt to have a framework for accelerated achievement of the setpublic health goals optimistic.

The draft document realizes that the greatest impediment inachieving the set goals of NHP 1983 were factors outside theformal healthcare delivery system such as the fiscal crisis. Theequity considerations which the policy emphasizes are also rel-evant in the current context. Wide variations in health indicesacross regions is a matter of concern and even in 'better perform-ing states' the overall indicators mask the reality of differentialsacross regions. This amply justifies the concerns about 'access'.Inequitable distribution of services has worked to the disadvan-tage of the poor. Still worse is the case of women, children andmarginalized sections such as coastal, tribal and migrant popula-tions. Against such a background, the stated objectives of thepolicy appear realistic.