HEALTH POLICY MAKING IN INDIA

The Union Government released the Draft National Health Policy (NHP)
which takes into account new diseases and revolutionary changes in
medical science since the last health policy. It talks about reducing
inequities and regional imbalances in the health sector and strengthening
the primary health care network all over the country. By setting up a
Medical Grants Commission to provide resources for upgradation of the
existing government medical colleges and ensuring an improved standard
of medical education, the policy envisages to improve the health care
delivery system.

Over the years, especially since independence there was a remarkable

improvement in life expectancy at birth, birth and death rate and infant
mortality rate, stated in the policy statement. Infrastructural improvement
resulted in epidemiological shifts. Incidences of communicable diseases
declined whereas sexual infections and emerging non-communicable
diseases took its toll. Achievement of an acceptable, affordable and
sustainable standard of good health and an appropriate health system to
reduce disease burden is the main thrust of the new policy.
The public health expenditure has been found to be low as compared to the
total health expenditure. Improving public health system through financial
packages and programme strategies to correct imbalances among states is
of priority. Public health system will be strengthened through addressing
distortions and shortcomings stated as the major focus of NHP.
Over the years, the private health care has enlarged in the country and
continues to be characterised by malpractices, substandard facilities and
unqualified staff. Absence of regulatory environment, uneven quality and
narrow range of service, and high propensity for over diagnosis and cost
are characteristics of the private sector, which constitute 80 percent of
outpatient treatment and 55 percent of inpatient care. The new policy
encourages setting up of private insurance instruments to bring secondary
and tertiary sectors under private health insurance coverage.

CEHAT, over the years, has been advocating for improving quality of
health care through research and action. The major areas in which CEHAT
contributed are accreditation, regulation, medical ethics, health care
utilisation and health expenditure studies and health sector reform and
right to health care. Research, action and advocacy on these and other
related issues by CEHAT on its own and in collaboration with other
institutions, organisations and movements has substantially impacted the
agenda on health issues.
This panorama is an endeavour to put together policy documents, research
papers and articles that can facilitate understanding of various issues on
health policy. This panorama, with its two distinct sections, discusses the
Draft National Health Policy - 2001 and the National Health Policy 1982.

Followed by the Draft National Policy (NHP) are some of the comments
and criticisms raised by various advocacy groups and activists through
media. In its brief critique, the Jan Swasthya Abhiyan (JSA) points out the
arbitrary nature of finalisation of the policy. The draft is silent on village
health worker - the first contact in the primary health care system,
population control programme and the impact of pharmaceuticals on health
care. It conflicts with the increased drug prices and non-availability of
essential drugs and its impact on health sector. The ignored areas are
women's health, child health, medical education to the needs of primary
care, ban of private medical colleges or their regulation, necessity to
initiate research on public health, regulation of medical research and
developing ethical criteria. The NHP, according to JSA, constitutes
abandonment of the Alma Ata declaration and legitimises further
privatisation of health sector.
The People's Health Charter adopted by participants of People's Health
Assembly (PHA) or JSA builds on perspectives of people and encourages
people to develop their own solutions and to hold accountable local
authorities, national governments, international organisations and
corporations. "Governments have a fundamental responsibility to ensure
universal access to quality health care, … according to people's needs, not
according to their ability to pay," states the charter.

In response to the NHP, Ravi Duggal points out the critical

recommendations viz., establishment of epidemiological stations, targets
for demographic achievement and establishment of private curative sector
of NHP 1983 which NHP 2001 did not refer. He stresses the need for the
NHP to regulate the private health sector through statutory licensing and
monitoring of minimum standards by creating regulatory mechanisms. The
prescriptions in the policy in favour of strengthening of the private health
sector must be removed. He suggests a primary health care package
comprising of general practitioners/family physicians, referral care and
basic speciality services, immunisation against vaccine preventable
diseases, maternity services and services like pharmaceutical,
epidemiological, ambulance and contraceptive and health education.
Anant Phadke in his comparison of NHP with People's Health Charter
raises a few points. The policy does not state the essentials of good health.
Quoting from activists and academicians Davinder Kumar in his discussion
criticises the 'pay and be treated' policy in a country having a sizeable
population below poverty line. Prescriptions of policy fail to address
collapse of primary health care system, poor coverage of women's health
and prevention of infant mortality. Expenditure in public health system is
low to make it the most privatised health system in the world. Advantage of
India having lowest prices of drugs in the world will be lost if a drug policy
favouring public health concerns is not put in place before 2005.

Sandhya Srinivasan explains yet another aspect, which requires immediate

attention in the NHP. It is the attention to declining sex ratio, which was
caused by prenatal sex detection tests promoted by medical profession. Sex
selective abortions followed by prenatal sex detection tests are of wide
practice all over the country. Doctors are even hawking these techniques
with mobile sonography units. Private health sector which has grown
through subsidies for medical education, soft loans to set up medical
practice etc., are now privileges of the rich but the only option of the poor
as well.

Ravi Narayan discusses 'Health for All' in the context of People's Health
Assembly, where health and non-health networks came together to evolve
global and national solidarity in health. National Health Assembly
delegates attended the Global Health Assembly- the Global Charter - and
unambiguously endorses a call for action for health as a human right.
There are certain news clippings - comments of journalists on health
policy, which are reproduced in this section.

The second part of the panorama takes us through a historical over view of
health policy making in India culminating in the National Health Policy
1982 and its comments by activists and researchers. The need for a
National Health Policy has been evolved to serve the need of an integrated,
comprehensive approach towards development of medical education,
research and health services established to serve the health needs and
priorities of the country.
Ravi Duggal emphasises the relevance of Bhore Committee - Health
Survey and Development Committee, who assessed the health condition in
British India (in 1943) in comparison to developed countries. The present
health condition of India is below that of developed countries of 1940s.
The reasons attributed are insanitary conditions, defective nutrition,
inadequacy of the existing medical and preventive health organisation and
lack of health education. The major stress in the report was on making
health services available to all citizens, irrespective of their ability to pay.

The Declaration of Alma Ata in 1978 stressed the need to achieve fullest
attainment of health and to reduce the gap between the health status of
developed and developing countries. Primary health care has been
emphasised in the declaration.

Prior to the formation of National Health Policy, India n Council of Social

Science Research and India n Council of Medical Research organised a
meeting, which gave rise to certain recommendations for policy
formulation. On health sector formation of a National Population
Commission, improvement of nutrition through adequate food production,
improvement of environment to reduce infection, health education, an
alternative model of health care services, expansion and improvement of
MCH services, eradication of communicable diseases, training of health
manpower, formation of a drug policy, priority areas of research viz.,
epidemiology, communicable diseases, environmental research, drug
research and problems of rural water supply and sanitation, indigenous
medicine etc., were recommended. Recommendations were also made on
forming an administrative machinery at central and state governments and
financial management.

The National Health Policy 1982 was initiated in this context of high
population growth having an adverse effect on health of people.

Ravi Duggal in his critical review of health policy issues pointed out the
recommendations made by Bhore Committee for a universal and
comprehensive health care system in comparison with existing growth of
health care delivery system. A lion share of public health facilities is
concentrated in urban areas. Private health facilities are largely
uncontrolled and unregulated. The shortcomings of the policy, pointed by
Duggal, are its inability to define character of health sector in India ,
rejection of the so called western model in favour of the low cost
community based model and finally the failure to comment on private
health sector. Problem areas identified are beyond the purview of the
Ministry of Health, with independent policies ministry can make useful
contribution. He has identified certain issues for a new health policy.

Padma Prakash in her paper on 'Women: Blind Spot in Health Policy'

points out the failure of Alma Ata Declaration to reflect women's health,
neglect of women's health in policy and programmes and the blinkered
vision of women's health. This invisibility of women in health policy has
consequences for the nature of information collected and the manner in
which data are analysed.

It was the women's health issues that received attention during the period.
An initiative from VHAI and WAH! entitled 'Towards Comprehensive
Women's Health Policy and Programme' addressed issues of Ninth Five
Year Plan and the National Health Policy for the empowerment of women.
They reviewed various committees, historically, in relation to women's
health. They pointed out the very fact of low women's status despite
government policies, programmes and efforts. And thus recommended to
formulate a health policy responsive to women's health needs.
Phadke has explained drug policy, an important recommendation of the
ICSSR-ICMR panel, in his overview. He states the increase in drug
production with the India n Patent Act 1970. Even the recommendations
given by Hathi Committee were not used to prioritise drug production or
procurement in India . Government's response to the Committee's
recommendation to take prompt measures to eliminate irrational drug
combinations was not prompt. A rational drug policy has been popularised
by the Drug Action Groups.

The Draft National Policy on India n System of Medicine brought out by

the Ministry of Health and Family Welfare is also of importance in this
context.
It is one of the beautiful compensations of this life that no one can
sincerely try to help another without helping himself. --Charles Dudley
Warner