The National Health Policy of 1983 was announced during the Sixth plan period. The National Health Policy (NHP) in light of the Directive Principles of the constitution of India recommends “universal, comprehensive primary health care services which are relevant to the actual needs and priorities of the community at a cost which people can afford” (MoHFW, 1983, 3-4).

It recommended the establishment of a nationwide network of epidemiological stations that would facilitate the integration of various health interventions.

It set up targets for achievement that were primarily demographic in nature.

The NHP 1983 stated that: ‘India is committed to attaining the goal of “Health for All by the Year AD 2000”, through the universal provision of comprehensive primary health care services.’ This goal was in line with the 1978 Alma-Ata conference of the WHO.

Some of the policy initiatives outlined in the NHP-1983 have yielded results, while, in several other areas, the outcome has not been as expected.

National Health Policy of India – 2002

The results of the 1983 policy have been mixed. The most noteworthy initiative under this policy was a phased, time-bound programme for setting up a well dispersed network of comprehensive primary healthcare services. However the financial resources and public health administrative capacity which it was possible to marshal, was far short of that necessary to achieve such an ambitious and holistic goal. The outcomes have been far less than targets as NHP 1983 was a set of broad-based macro-level recommendations spanning not only the health sector, but also sectors associated with other contributors such as water supply, sanitation, environment, nutrition, etc. to the health status of the population.

Thus against the above backdrop the existing health policy was modified in 2002 and the National health policy – 2002 was formulated. The National Health Policy 2002 renews its commitment to expeditiously control communicable diseases, eliminate a few and contain the rest in a time-bound manner. Some of the time bound goal this policy expects to achieve are shown in the table below:

Goal

Target Dates

Eradicate polio and yaws

2005

Eliminate leprosy

2005

Eliminate kala-azar

2010

Eliminate lymphatic filariasis

2015

Achieve zero level growth of HIV/AIDS

2007

Reduce mortality by 50% on account of tuberculosis, malaria and other vector and water-borne diseases

2010

Reduce prevalence of blindness to 0.5% 2010

2010

Reduce infant mortality rate to 30/1000 and maternal mortality rate to 100/100000

2010

Increase utilization of public health facilities from current level of <20% to >75%

2010

Establish an integrated system of surveillance, national health accounts and health statistics

2005

Increase health expenditure by government as a % of GDP from the existing 0.9% to 2%

2010

Increase share of Central grants to constitute at least 25% of total health spending

2010

Increase state sector health spending (from 5.5% to 7% of budget)

2005

Further increase state sector health spending to 8% of budget

2010

In this essay we analyse the national health policy by addressing the following questions:

Have the tasks enlisted in the 2002 NHP been fulfilled as desired?

Did the 2002 NHP sufficiently reflect the ground realities in health care provision?

And lastly, what are the gaps in national health policy formulation and what is the road ahead for the health policy of the country?

Achievements of the NHP – 2002:

India achieved the lowest ever polio transmission levels in 2010, especially during the high transmission season. Also a sharp decline was seen in number of polio cases reported with only 633 polio cases reported in November 2010 compared to 633 cases in 2009

Adult HIV prevalence at national level has declined from 0.41% in 2000 to 0.31% in 2009. The estimated number of new annual HIV infections has declined by more than 50% over the past decade. According to data from National AIDS Control Organization, there has been an overall reduction in adult HIV prevalence and HIV incidence (new infections) in India.

Leprosy Prevalence Rate has been further reduced to 0.71/10,000 2010. 32 State/UTs (except Bihar, Chhattisgarh and Dadra & Nagar Haveli) have achieved elimination by March 2010. Similar progress of elimination has also been in 81% of districts and 77% of Block PHC in the country.

TB mortality in the country has reduced from over 42/lakh population in 1990 to 23/lakh population in 2009 as per the WHO global report 2010. As per the WHO global TB report, 2010 the prevalence of TB in the country has reduced from 338/lakh population in 1990 to 249/lakh population by the year 2009.

Problems not addressed by NHP – 2002

NHP – 2002 completely omits the concept of comprehensive and universal healthcare. The policy thus departs from the fundamental concept of the NHP 1983 and the Alma Ata Declaration. By its silence, the NHP 2002 provides a framework for the dismantling of the entire concept of primary healthcare. Importantly, the section on policy prescriptions in the NHP 2002 is silent on the content of the primary healthcare system.

Despite the increase financial resources dedicated to health care the country continues to struggle in creating sufficient healthcare infrastructure. The government estimated there was a shortage of 4,803 primary health centres and 2,653 community health centres in 2006. According to a study conducted by the Confederation of Indian Industry, the formal healthcare system reaches only about 50% of the total population. India is also desperately short of doctors, with only 645,825, or 0.6 per 1,000 people, in 2004, according to the World Health Organisation (WHO).

Even though the NHP – 2002 plans to raise public health investment to 2% of GDP, the target is far less than the WHO recommended target of 5%.

The policy does admit grave deficiencies in the health sector and notes how only 20 per cent of the population seeks OPD services and is forced to turn to private clinics. It also admits the collapse of the primary healthcare system and acknowledges the poor coverage of women’s health and prevention of infant mortality. Ironically, its prescriptions fail to address the problems or offer solutions.

The policy calls for providing incentives to the private sector to move to the primary healthcare system. However, the experience in urban centres has been discouraging. The incentives in terms of subsidised land, water, electricity and duty-free import facility doled out to high-profile private medical centres and hospitals in the urban areas has seen little benefit for the poor. Very few of these hospitals conform to the mandatory provision of free medical care to the population below the poverty line or the reservation of a certain percentage of their beds for the poor.

Recommendations and conclusion:

Although the Indian economy had high growth rates in recent years (9·4% in 2005-06 and 9·6% in 2006-07, with a consistent 7·0% growth rate even during the period of global economic slowdown), according to the Human Development Index India is ranked 134 among 182 countries. India’s economic transformation does not seem to have produced tangible improvements in the health of the nation, and the recognition that improvement in health contributes to accelerated economic growth has not led to adequate investment in or improved the efficiency of health care.

The NHP – 2002 fails to check the growing influence of the private sector in the health care system. The private sector grew in an uncoordinated manner, to become the default option for healthcare in many cases. In an unregulated environment, neither the private sector nor the public sector provided an assurance of quality or access. The increasing dependence on the private sector, in addition to very weak regulation and corruption, has led to a huge increase in health-care costs in the country.

Considering the above scenario the new healthcare policy or any other healthcare plan of the government should focus mainly on achieving the following objectives in the period of next 10 years:

Ensure the reach and quality of health services to all in India;

Reduce the financial burden of health care on individuals;

Empower people to take care of their health and hold the health-care system accountable.

Thus the new policy should again focus on the goal of universal health care which was mentioned in the NHP – 1983, but was sidelined in the NHP – 2002.

Strategic plan to achieve healthcare goals:

In this section we briefly discuss the goals that are desired to be achieved by the new healthcare policy framework and proposed strategies to achieve these goals.

Goal: Integrate private and public health-care delivery systems

Strategies:

All health-care institutions and practitioners should be required to register with a national health regulatory agency and make this information available on the internet.

Define a rational mix of public and private health-care services to enhance complementarities, and invest in further development of public health-care services including health promotion and prevention services.

Goal: Create a universal health-care fund and reduce the cost of health care

Strategies:

Increase the proportion of gross domestic product as public health expenditure

Merge all existing health insurance funds (eg, Rashtriya Swasthya Bima Yojna, Arogyasri) with this fund

Apply heavy taxes on harmful products such as tobacco products, alcohol, and foods of low nutritional value, and allocate most revenue to health care

Define the costs of all essential and emergency health-care interventions, and finance a package of care that is based on diseases that should be prioritised and cost-effective interventions

Negotiate prices with providers, including caps, for different services on the basis of the cost of the care packages

Invest in health promotion and early recognition of disease

Goal: Increase the numbers, diversity, and distribution of human health resources

Strategies:

Establish an autonomous organisation to govern the supply of a full range of health workers, from accredited social health activists to doctors to health administrators

Strengthen the role of community health workers with clearly defi ned skills, adequate remuneration, and career paths

Encourage postings in rural or other underserved areas through increased salaries and other incentives such as provision of education to children

Establish the Indian Health Service for careers in government health care

All senior personnel in the Ministry of Health should be required to have public health training

Promote the creation of medical and nursing colleges in underserved districts

Goal: Promote evidence-based health-care practices

Strategies:

Establish an autonomous organisation to set guidelines for care practices in the Integrated National Health System

Monitor and regulate the use of practices that are not based on evidence

Strengthen capacities of health and non-health policy makers to recognise the importance of this approach

Increase resources for priority health research

Implement and act on the findings of district and national health surveillance and information systems, and encourage assessments

Goal: Promote rational use of drugs and technology

Strategies:

Promote use of generic drugs through a wide network of pharmacies for generic drugs, with at least one in each block

Ban incentives by pharmaceutical and medical technology companies to practitioners or consumer groups

Negotiate bulk purchasing for patented drugs

Make the best use of information technology that is being developed for the health system

Goal: Create a decentralised governance structure that responds to local needs and is accountable

Strategies:

Create systems for accountability of local health-care services to fully empowered civil society groups

Provide flexibility and expertise in districts and subdistricts to plan local health-care management plans

Monitor and promote equity, efficiency, effectiveness, and accountability in the health-care system