India's draft National Health Policy, 2015: Improving policy to implementation effectiveness

Abstract

As the Government of India is working on drafting a new National Health Policy, developing national health accounts, and planning for a “health assurance mission,” this opportunity has the potential to transform health status of millions of Indians and achieve universal health coverage. The draft of new National Health Policy of India was put in public domain for comments in early 2015. This editorial reviews the draft National Health Policy 2015 and proposes a few steps to improve implementation effectiveness.

The health situation in India has improved significantly in the last few decades. The policy and programmatic interventions have succeeded in reducing the burden of communicable diseases and achieved big successes like elimination of polio from India. However, there are many persisting challenges such as, health services are quantitatively inadequate and quality often not known, low public expenditure on health and people often have to pay out of their pockets to avail health services at risk of falling into poverty, and the emerging burden of noncommunicable diseases (NCDs), etc.[1] Fortunately, these challenges are being recognized and there are incremental steps and clearly articulated intentions to improve access to quality health services at cost affordable to the people, as a part of ongoing discourses on universal health coverage (UHC) in India.

On policy level, the newly elected Union Government of India has prepared a draft of the next National Health Policy (NHP) for India.[2] The draft policy has a number of necessary ingredients, specifically focusing on tackling the known health challenges in the country. The process of drafting of the new NHP for India has advantage of the wisdom of hindsight and the opportunity to learn from the implementation (what “did” and “did not” work and why?) of the previous two health policies of the country -First national Health Policy released in 1983 and the second and current national Health Policy of 2002.[3,4]

On financing and expenditure in the health sector, work is in progress to develop new “National Health Accounts” (NHA) for India, as well. The most recent NHA provides information for the year 2004–2005 published in the year 2009.[5]

On operationalization and implementation level, at the union level, there are ongoing activities and discussions to design a “health assurance mission” for the country. In parallel, a number of states in India are taking initiatives such as expanding health assurance/insurance coverage to additional population, making provision of free medicines and diagnostics through public health facilities, re-organizing service delivery for emerging challenges of NCDs, and strengthening primary health care and referral linkage, amongst others.

The situation is that the key policy strategies and operational plans – drafting NHP and designing a new health assurance mission with better understanding of health financing and spending (through NHA) are being prepared in parallel. It is a unique historical opportunity to harmonize policy intentions with programmatic interventions. This editorial aims to provide a few suggestions which might strengthen the process and ensure implementation effectiveness of policy prescriptions to achieve better health outcomes in India.

First, utilize the opportunity to harmonize multiple health initiatives and programs being run by different Departments of Ministry of Health and Family Welfare and those by other ministries (i.e., Ministry of Women and Child Development, Ministry of Labor and Employment, and Ministry of Water Supply and Sanitation, etc.), often with overlapping objectives and limited interactions with each other. The opportunity could also be used for synchronising the initiatives and proposals made in different policies that is, National Nutrition Policy 1993 and National Population Policy 2000, etc., as well.

Second, establish institutional mechanism like “health policy and implementation unit” in the ministry of health (at both union and state levels). This unit can work to coordinate with various departments and program units within Ministry of Health and Family Welfare and between Ministries, may focus upon tracking and monitoring the implementation of policy proposals and can have a sustained engagement with academia and other stakeholders on evidence generation and collation for informed policy decision making.

Third, move from largely “inputs based approach” (adding more human resources, equipment and infrastructure to health system) to bring focus on “output (number of services delivered) and outcome (morbidity and mortality reduction) based approach”.

Fourth, expand mechanisms to ensure that people have cashless (at delivery point) access to quality health services. Making health services affordable to the people is one of the key expectations from the health systems. The initiatives such as Rashtriya Swasthya BimaYojana and other state-specific health insurance/assurance initiatives need to be optimally harmonized and expanded to cover additional populations.[6]

Fifth, while the NHP should be supplemented by a national level implementation plan, there is a definite need for states to develop mid-term (5–10 years) health sector operational plans. The state plans would be essential to address the wide inter- and intra-state variations in the health status of populations and in the availability of health services. The state operational plan should capture both union level initiatives and state specific activities in the health sector.

Sixth, encourage state-level innovations specifically in areas such as engagement with private sector in service delivery, reaching the unreached or inaccessible populations by health services, regulation of all healthcare providers, use of information and communication technology for healthcare, and increased allocation to primary health care by the state governments, etc.

Seventh, focus on efficiencies in the health sector through re-organization of health services as people-centered and integrated. The re-organization of services needs to have more attention on primary healthcare with strong referral linkages with secondary and tertiary acre. The cost and complexities in health service organization often deter or delay poor people from accessing public health services. The health service organization which was originally designed to address the high burden of communicable diseases has to be re-organized to address the changing pattern of diseases in India.

Finally, as the global experience indicates that a reasonable progress toward UHC is possible over a period of approximately 10–15 years, the policy and plans have to be sufficiently detailed and futuristic to fulfill the needs arising and should not work as limiting factors. The Health policy has to be considered as live documents with possibilities and mechanisms for mid-course modification. This requires institutional mechanisms, independent, and accountable institution to track and accelerate the progress and strong stewardship at both union and state levels.

To conclude, a study on “good health at low cost,” conducted in four low and middle income countries and in one state of India, hypothesized that one of the commonalities in these settings was their ability to make use of “window of opportunities” for improved health.[7] India has seen many incremental changes in the health sector over last few decades. It is worth observing whether the historical “window of opportunity” presented now is used for bringing the transformational changes in the health sector in India to progress toward UHC. If it does and it should, healthcare in India is likely to change for better, forever.