National health policy: Need to innovate

FROM PLANNING TO TRANSFORMATION

Globally, health care systems are undergoing serious debate and introspection. The curative model of disease management as the focus of healthcare is being questioned on the grounds of affordability, accessibility, availability. Alternative models are being seriously explored where India with its rich medical heritage might assume a leadership role. India's Prime Minister has announced shift in focus from planning to transformation. New establishment known as “National Institution for Transforming India” (NITI Aayog) has replaced the Planning Commission. As a part of such reforms, the Ministry of Health and Family Welfare has published a draft National Health Policy (NHP) for improving performance of health systems.

The draft NHP document discusses how to improve health care delivery and align with technological advancements. J-AIM welcomes the idea of releasing draft for public debate. It is good to note that NHP has formally recognized potentials of AYUSH and integrative medicine. It is also good to note that India is moving toward one health policy for the country. While medicine can be modern or traditional, “health” cannot be divided into compartments. India with legacy of traditional health knowledge must have inclusive policy where modern and AYUSH systems are integrated to improve quality and delivery of public health. We are happy to note that many suggestions given through J-AIM do reflect in the draft NHP.[1] We find the draft policy well-intended, but it contains avoidable jargon and over-emphasis on health care as an industry and private service. In general, we feel that NHP needs more focus on “health” protection component of care than “medical” cure component with drugs, pharmaceuticals, and hospital services.

Thankfully, the NHP document recognizes the importance of health promotion. It also suggests more efforts for evidence-based AYUSH systems. This policy reiterates mainstreaming of AYUSH, introducing Yoga as a culture and integrative medicine as an approach. Rightly so, the NHP focuses on prevention of noncommunicable diseases in addition to the curative care. The NHP emphasizes need for adequate support for research and academic infrastructure to strengthen India's specialty of health care pluralism.

FROM FINANCING TO FACILITATION

The NHP admits that though about 5% public health expenditure is required, at present it is around 2%. The NHP targets to increase this by 0.5% so to increase existing health specific funding by 25%. The policy assumes per capita fund allocation at Rs. 3800, which is grossly inadequate considering the phenomenal rise in health care costs. This situation forces us to innovate and explore newer approaches for healthcare systems. Integration of AYUSH certainly has the potential to address this challenge.

Concerns over health care costs and expenditure are a growing globally. Most of the countries, rich and poor, experience shortage in health budgets. This is probably because present health care in reality is a medical care based on curative model. The industrialization of health care has led to the medicalization of society in many parts of the world[2]. Once health care becomes medical care and when well-being is looked as separate entity, the commerce takes over the public good. As a result, profit-making becomes primary motive and mission to keep people healthy becomes secondary. The profits come from pockets of ill, gullible, and poor people. Hospitals and doctors’ business “grow” at the cost of ill society. Sadly, many doctors feel happy when community is at health risk and epidemics as “opportunities” to make more money[3]. The American healthcare, which is described as world's fifth economy is a classic case in point. Despite the insurance linked substantial spending capacity, technological advances, cutting edge research, and academic leadership, country like America is still not in the list of top healthy countries in the world. This indicates that growth of the health industry is not linked to health indicators. Health indicators do not improve merely with economic growth but are more associated with facilitation of social determinants such as equality, education, and environment.

PUBLIC GOOD AS REWARD

Today, we need to find a model that strikes a balance between well-being of people and satisfaction of health care providers. The United States, after reaching the epitome of medicalization and curative care, now plans to pay incentives to doctors if they keep patients healthier. This new health policy known as “Obamacare 2.0” is aiming for a radical change through health-linked financing and by curbing unnecessary services. This may change the existing “fee-for-service” system to “health-linked incentives.” Thus, health protection and promotion will get priority over disease and cure. This might turn out to be a game-changer for health care services. Such model might not work in India, where medical insurance system is still in infancy. However, if we are able to go back to our roots, it is possible to regain focus on health care through the integration of modern medicine and AYUSH. For instance, Yoga has social acceptance as health promotive lifestyle. A decision to promote Yoga at the workplaces and proposed tax exemption for Yoga classes fees are representative examples of steps in the right direction. Historically, in Indian society, a Vaidya was responsible for health and well-being of the community through community awareness, healthy practices of diet, lifestyle advice, and medicines. A Vaidya used to receive satisfaction and more respect when people were healthy. In the same spirit, it might be prudent to recognize contributions to the public good for rewards and incentives.

DEMONSTRATING BENEFITS

In India, we will have to demonstrate benefits of AYUSH integration. This is a difficult task because we have many challenges both internal and external. Today, the limitations of modern medicine are being increasingly recognized especially in the management of lifestyle diseases. While the integrative medicine is being practiced at top medical centers such as Mayo, Harvard, and Yale; ironically, the medical associations India feels that integrated medicine concept is a misplaced thought process and prefer to call AYUSH as an alternate system. There is no denial that every medical intervention should be evidence-based, and every drug be it modern or AYUSH should be safe. However, the evidence and safety of modern medicine cannot be assumed through continuing education received from medical representatives.

Actually, doctors trained in modern medicine need not be the only choice for medical and health care. The health system needs to be properly segregated into primary, secondary, and tertiary levels with clear roles for medical and paramedical professionals. In fact, before accessing primary health care, people should be empowered to take care of minor illnesses through homecare. With the help of preprimary health care, many common illnesses may be easily treated with traditional medicine, home remedies, and by simple interventions of diet and lifestyle. Many countries like India have pluralistic systems of medicine as part of their culture, which need to be integrated and mainstreamed with public health system.[4] Countries like China have done such integration successfully.

True success of “integrative” approach will remain in the mutual trust and ability to recognize, respect and maintain identities, philosophies, foundations, methodologies, and strengths intact while building sufficient evidence base for integrating respective systems. This is not a turf war between allopathic doctors and AYUSH doctors. This is about providing best quality health care, which is affordable, available, and accessible to people. We need to be little humble before criticizing or praising any system or monopolizing the science or blindly accepting the evidence-based medicine approach. It is important to remember: “Absence of evidence is not evidence of absence.” In all fairness, it is crucial to ensure that the required rigor of the science is achieved by avoiding any hubris of technology power. It is necessary to ensure that the spirit of integration is achieved without compromising the foundations of the traditional practices and knowledge.

NATIONAL AYUSH MISSION

The draft NHP has rightly stated “A policy is only as good as its implementation.” Mainstreaming AYUSH has remained an operational failure for many years. We have started co-location of practitioners, but there are no guidelines for cross medical referrals and no orientation of doctors on principles, scope, advantages, and limitations of integrative health care. Unfortunately, nurses are not sufficiently empowered as primary health practitioners. AYUSH doctors are still looked as sources of cheap labor undermining strengths especially to manage chronic, difficult-to-treat diseases and lifestyle disorders, where modern medicine has limitations.

Now, the government has launched national AYUSH mission for strengthening network and providing cost effective services in the public sector. This mission aims at revitalization of AYUSH systems. This is a welcome step taken by the government. However, the actual implementation will remain very crucial. Any reforms in AYUSH sector require long-term planning and critical assessment of its implementation.

As this editorial is being written, a 12 member task force under the chairmanship of Dr. H. R. Nagendra has been constituted by the government to advice on practical strategies for integrative research, education, and practice. J-AIM welcomes this bold decision and hopes that the task force can provide definitive strategic directions to explore AYUSH potential to transform global health care. It is time to address a question “How can India provide global leadership for integrative health care?” The public good should supersede all egos of professionals, associations or governments. The NHP is expected to facilitate this long awaited process of mainstreaming and integrative health care beyond any boundaries.