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Indian Journal of Community Medicine

Vol. 27, No. 2 (2002-04 - 2002-06)

Editorial

Sunder Lal

Prof. & Head Deptt. of SPM Pt. BDS PGIMS, Rohtak

The national health policy (NHP) of 1983 has been revised by the Govt. of India in 2002. The revised policy reiterates to achieve an acceptable standard of good health amongst the general population of the country1,2. The precise approach of the stated policy is to increase the access to decentralized public health system, ensure equitable access, increase the public health investment through contribution of central Govt, to enhance the contribution of NGO and private sector in health, to regulate the services of private and public sector, to initiate user charges and above all strengthen the delivery of primary health care in public sector. The policy has set time bound goals for identified national problems of malaria, tuberculosis, blindness, gastroenteritis, cholera and water and vector borne diseases, leprosy, HIV/AIDS etc. The national health policy also identifies the other public health problems of concern such as trauma and accidents, macro and micro-nutrient deficiencies, life style diseases and problems of aged to be tackled through concerted efforts1.

The components of NHP are critically analyzed and are being discussed hereunder. By no means it is an exhaustive account, this needs to be deliberated further at various fora; however, this can provide a good lead and stimulus to the planners, managers and teachers in the discipline of Community Medicine and other teaching faculties.

The process of formulation of National Health Policy 2002 had the advantage of having access to the experience of implementation of National Health Policy of 1983, World Development Report 1993, data of National Family Health Survey I and II, National Population Policy - 2000, World Health Report 2000, Census 2001 and data of economic reforms initiated in 1991 and 73rd and 74th Constitutional Amendment Acts promoting decentralization, local governance and women's participation.

Decentralized planning and implementation of services:

Access to decentralized public health system will be increased by establishing new infrastructure in deficient areas and by upgrading the infrastructure in the existing institutions. States have the primary constitutional responsibility to provide health care services to its people, however, the health care delivery system in many states tends to be centralized at the departmental level inspite of strong and effective presence of institutions of local self-government at village, block and district level. Decentralized management of health institutions especially those at primary level through Panchayati Raj Institutions (PRI) is strongly advocated in NHP 2002. The health care functionaries at the ground level now operate under various departmental authorities with control at the state level. There is an imperative need to bring in convergence in their work, even though it may not be possible to bring them under one administrative umbrella. Personnel like Anganwadi workers, health workers - male and female, gram sevikas, school teachers, development and agriculture workers can be brought on a common platform for effective convergence and delivery of health care at the primary level. PRIs are important means of furthering decentralized planning and programme implementation in the context of National Population Policy 2000 and NHP 2002. However, in order to realize their potential, they need to be strengthened by further delegation of administrative and financial powers of resource mobilization. Devolution of powers to PRIs is in different stages of development in the country, some of the states have already given the powers of management of subcentres and PHCs to PRIs. The experience of Kerala reveals several areas of conflict such as priorities of people versus those of Government, recruitment of staff, drug supply and allocation of funds, vertical programmes and centrally sponsored schemes and non involvement of health staff and people at policy formulation level3. This is new experience and it should be given a fair trial. Before the delegation of responsibility and devolution of financial and administrative powers to PRIs it is essential to build their capacities through interactive training sessions. It also requires reorientation of health functionaries to adjust to new environment and play their effective roles. Further, powers to raise funds through user charges and retention of these funds for development of services be vested locally. There should be financial autonomy and decentralization. Similarly, funds for maintenance of building and equipment be allocated at various functional levels to facilitate delivery of services and improve its quality.

Favourable environment for decentralization and devolution of powers should be created at district/sub- district/CHC/PHC and SC. At the moment, the programme managers and functionaries at these levels are unable to deploy medical, paramedical and other staff (TBAs and birth attendants/ health guides), as they have no control over subordinate staff. There is complete absence of freedom of action and inability to use available resources fully because the programme managers do not have any flexibility. The maintenance of buildings is poor as the funds are placed at the disposal of PWD, whose priorities may be different. The system is plagued with structural, administrative, systematic and operational problems. Decentralization as envisaged under NPP 2000 and NHP 2002 has to ensure that these barriers are broken sooner than later by devolution of powers and decentralization of functions and management at the level of district, CHC, PHC and subcentre under public health system. Adequate financial powers be delegated at these levels to enhance the work efficiency. Allowing powers of deployment of Medical Officers, Senior Medical Officers and Paramedicals to district Civil Surgeon/Chief Medical Officer is needed.

Community Needs Assessment Approach (CNAA) under RCH programme envisages consultation process with PRIs, women organizations, school teachers, anganwadi workers, traditional birth attendants and development functionaries for planning, organizing and implementation of services at the level of village and subcentre, however, the implementation of CNAA is quite tardy. CNAA is cardinal to NHP 2002 in the process of decentralization and involvement of community in the process of planning, implementation and evaluation of public health services4,5. Decentralized planning of public health services at the level of district and down below has not gone beyond compliance, signifying that the capacity of the system has been incapacitated due to decades long practice of designing top down plans and schemes on the one hand and near complete absence of freedom of actions on the other. The system sincerely obeys whatever comes from top and it passes the message to the lower formations and thereby discharges the function of post-office. There is near complete absence of desire to generate community based data for planning and evaluation purposes. The impetus provided by the European Commission to Sector Investment Programme for the decentralization is worth implementing in the direction of health reforms6. Subcentre action plan, PHC action plan, CHC action plan and District action plan have lot of sense and must be implemented to achieve the purpose of decentralized participatory local plans for local action supported by PRIs. Decentralization of fund flow mechanism through society model which has been experimented in various states under RCH programme has proved to be effective delivery system for implementation of targetted public health programmes. It should be adopted by all the states and at district level. This is partial solution to impediment in the flow of resources from the central government to programmes operated at the field level-like the national disease control programmes. Formation of health societies at the state and district level would facilitate direct transfer of funds from central government to the operating units at the field level without the usual budgetary constraints.

NHP envisages delivery of national public health programmes be implemented through autonomous bodies at state and district level. The management board or state and district societies can play this role effectively. The society model apart from regulating the funds flow mechanism should be responsible for larger role of planning and implementation of national health programmes. This is yet another attempt of decentralization of implementation of programme. The intervention of state health department may be limited to overall monitoring of achievement of programme apart from technical support. This mechanism may offer greater operational flexibility to management board of autonomous bodies as also facilitate well informed decision making. Thus, decentralization of programme management should also be reinforced by convergence of all vertical health programmes at district level and below is laudable approach to effect savings of time and money and to avoid duplication of efforts in the areas like IEC, training and unified delivery of services.

Financial resources:

The public health investment in the country over the years has been comparatively low. A progressive increase in the public health spending of which a substantial part is to come from the central government is a key factor in achieving the public health goals set in NHP 2002. The proportion of central government budgetary allocation for health out of the total budget remains stagnant at 1.3%. In the states, this proportion has progressively declined from 7% to 5%. The current per capita public health expenditure in the country is no more than Rs. 200. The central share in total health spending is about 15%. The poor financial health of state govts. and their inability to spend adequate resources for social infrastructure like health has contributed to overall decline in public health spending in health care infrastructure in the country. Taking this into consideration, it is planned under NHP to increase health expenditure to 6% of GDP with 2% of GDP appropriated to public health investment by the year 2010. The state should not only try to arrest the declining trend in public health expenditure but should restore it to 7% by 2005 and progressively increase it to 8% by 2010. The central govt. contribution would rise to 25% from existing 15% by 2010. The provisioning of higher public health investment will also be dependant upon the increased absorptive capacity of health administration to gainfully utilize the funds in the states. The NHP scores many plus points on the allocation of at least 55% of total public health investment appropriated to primary health care, 35% to secondary health care and 10% to tertiary health care.

The percentage of public expenditure on health to total health expenditure in India is 17.3% and the rest is out of pocket expenditure by clients (82.7%)7. More than two third of households (69%) normally use the private medical sector whenever a household member gets sick. Only 29% normally use public sector medical services. Reliance on private sector is higher in urban areas (74.8%)8. Thus the private sector accounts for three quarters of all health expenditure in India. Government expenditure in public health services will always be limited because of constraints of resources. Therefore, to enhance coverage of services the private sector and diverse systems of health care have to be alternate sources for secondary and tertiary care in particular and primary health care in general.

The state public health infrastructure responsible for provision of outdoor and indoor curative services is deficient on account of manpower, finances, essential drugs and laboratory investigations and equipments and consequently its poor utilization. It has been estimated that less than 20% of the clients seek public health OPD services and less than 45% seek indoor treatment. Private sector is the dominant provider of health care services with a substantial share of 80% in outpatient treatment and 55% in inpatient care. Due to absence of regulatory environment, the quality of services is variable in private sector and this may be true even in public sector. The NHP 2002 envisages strong and effective regulatory mechanisms for private and public sector by 2003 to prescribe norms for services and establishment of institutions. In principle the policy welcomes the participation of the private sector in all areas of health activities - primary, secondary and tertiary in urban, rural and tribal areas.

In the context of very large number of poor in the country (44.2% with income less than 1$ per day) the public health facility of government may not be able to provide coverage and services8. The policy envisages social insurance scheme funded by government for below poverty line people with service delivery through the private sector. This will be pilot tested in some districts for future public health policy in this area.

Similarly, NGOs will be involved in a big way. It is proposed to earmark 10% of budget of disease control programmes in respect of identified programme components to these institutions. The state shall be encouraged to hand over public health services outlets at any level of management by NGO and other institutions of civil society on `as is where is basis' along with normative funds earmarked for such institutions. India is a vast country and many alternative models for health care services of necessity are to be there, no single perspective model is to be thrust upon.

While inadequate resources allocation led to sub-optimal performance in public health in the country as a whole, there are wide variations in performance between states, between rural and urban areas, between rich and poor and men and women. These differentials impact directly on those sectors of the society who bear the double burden of poverty and social discrimination. NHP intends to identify and rectify the gaps in terms of infrastructure of SCs, PHCs and CHCs. The other measure proposed in the policy is increased public spending on primary health care system (55% of the allocated budget) to strengthen the base of health care delivery in rural, urban and tribal areas.

Policy should accord high priority to establish SCs, PHCs and CHCs in deficient areas, inaccessible and difficult areas and observe reduced population norms for these areas.

Entrusting the work of health care delivery to NGOs in difficult and remote areas or fill the gaps of manpower through contractual appointment for socially vulnerable, scheduled tribes, nomadic community and urban slum dwellers, efficient work schedule of health workers to accord priority to socially disadvantaged groups and location of health facility in close proximity of these groups, social insurance for below poverty line families can be another mechanism as proposed in NHP. Development of other infrastructure facilities through minimum needs programme and convergence of these facilities for disadvantageous groups will have larger impact on health9. Similarly, outreach services should reach this segment of population on priority basis. The public health infrastructure functions well below its installed capacity and it functions at sub-optimal level because of several deficiencies. Absence of essential drugs have led to poor demand of services. The system of SCs, PHCs and CHCs leaves much to be desired. Subcentres supplies are better organized because of central funding. Drug kits A and B are being supplied to SCs on regular basis apart from other equipments. NHP would commit financial resources from central Government for funding of the drugs and equipment costs of primary health centres to increase the utilization of public health facilities. Situation of PHCs and CHCs is precarious. Most new PHCs have no building and no vehicle and these function as dispensaries for limited hours. Shortfall in CHCs is alarmingly high at 58% and the 42% of the established CHCs function poorly because of non-availability of specialists. The referral services are poorly organized and hopefully the NHP 2002 accepts the challenge of making the existing CHCs fully functional by 2005 and complete the shortfall of CHCs by 2010 to build respectable referral support system for primary health care. Building CHC or PHC is no guarantee that these would function. Similarly, the allocation of 55% of budget to establish primary health care infrastructure is no guarantee that the services will become accessible. We must ensure that these institutions function well. Contracting the functioning of CHC/PHC to NGOs or private organizations can be experimented in such areas where the problem is quite acute. At the moment the health functionaries are accountable to government and bureaucracy and not to the people or people's organization. It is high time that such hard policy decision are taken to harness the good delivery of service and to realize the full potentials of CHCs and PHCs. Good leadership and governance at these levels is critical for effective functioning of teams and their sustained motivation. Flexible and differential approaches and strategies for establishment of infrastructure and delivery of health care needs to be designed for rural/urban/tribal areas and areas which lag behind, and concurrently their absorptive capacity be enhanced. We have district-wise indices and identified weak districts in various states. NHP should have explicitly stated these differential strategies. Policy of recruitment of locally resident ANMs for subcentre by PRIs should be given a serious thought to enhance the functioning of subcentre. Promotion of AWW to the level of ANMs with some additional training can be yet another approach.

Urban health services:

Over 80% of doctors, beds and hospitals are concentrated in cities and towns. Urban areas are home to 30% of population of India. Of this nearly 50% of the population lives in urban slums under precarious and sub human conditions devoid of basic amenities such as sanitation, adequate drinking water and health care facilities. Municipal corporations/committees provide symbolic health services in cities and towns. The challenge to organize primary health care service is a real one. The NHP conceives a two tier system in urban areas. Primary centre is seen as first tier covering a population of one lac with a dispensary providing an OPD facility and essential drugs and enabling access to all national health programmes and a second tier of urban health organization at the level of the government general hospital where referrals are made from primary centre. The funding of such a system will be borne jointly by local self government institutions, state and the central governments. NHP does not talk of urban slums and its approach is at variance with that of NPP 2000. It appears that NHP 2002 beats a different track on the issues of urban slums and indicates disintegrated services for national health programmes. The dichotomy of views and approaches are serious issues for resolution.

Control of communicable diseases:

The absence of an efficient disease surveillance network is a major handicap. National system for polio and HIV/AIDS surveillance as also for malaria is well established. The routine recognition, reporting and rapid response in respect of gastro-enteritis, cholera, ARI and JE is almost deficient. NICD has initiated integrated disease surveillance in some districts of the country but the routine reporting system is not being relied upon and the health workers who generate otherwise, voluminous data have not been trained well on the subject of significance of surveillance of diseases/deaths/disabilities. NHP envisages full operationalization of integrated disease control network from lowest rung of public health administration to the central government by 2005 by using high tech information technology and by covering private health care institutions and private practitioners. NHP disease surveillance strategy omits PRI and people from the surveillance system. It is quite surprising that surveillance system omits and deprives people as equal partners, whose lives it profoundly affects.

Baseline estimate for the incidence of common diseases like TB, malaria, blindness will be completed by 2005 and longer time frame is required for baseline estimates of non-communicable diseases like CVD, cancer, diabetes and accidental injuries. The valid criticism for revised 1983 health policy in 2002 is non establishment of nation-wide chain of sanitary cum epidemiological stations as also setting up of district epidemiological stations, to fulfill the long standing needs of surveillance of diseases and their epidemiological control as part of district plan. Thus the policy document failed to enhance the local capacity to deal with burden of diseases and disease surveillance programme. Disease surveillance can be more viable by involving PRIs, anganwadi workers and health workers in the rural settings and using organized infrastructure of urban slums. PHCs and CHCs systems at the moment are not encouraged to report notifiable communicable diseases to avoid the wrath of superior authorities. Effective measures to control outbreaks are resorted only on occurrence of outbreaks and sustainable and regular measures seldom ensured. On the front of medical education it is encouraging to observe that the policy enunciates to scale up the proportion of postgraduate seats in public health and family medicine discipline to the level of 25% of total seats. On the ground situation there is apparent discrimination against the discipline of Community Medicine. Most of the departments have no field practice areas to promote teaching and training programmes in the discipline. Their manpower is inadequate to develop future PG training and research persuits. As a matter of policy the immediate task should be to upgrade these departments through special budgetary allocation by the central/state government so that these departments produce specialists to manage the state health services and senior cadres of health services. The govt. of India and state govt. should have a policy for manpower planning and development and it should be made explicit that services at the level of CHC, district, state and central govt. the leadership of the programme management and service management functions are entrusted to persons holding the PG degree in Community Medicine10. Medical Council of India has regulation for medical education including Community Medicine discipline, but there are no regulations by the state or central govt. for service management at various levels, CHC, district, state and central govt. The Community Medicine specialist should be the stepping stones for the senior most cadres of health services. The policy must acknowledge this principle. In some of the states in India (Tamil Nadu - Chennai), the teachers without post graduate qualifications happen to be professor and head of the department of Community Medicine, which should be unacceptable situation for Medical Council of India.

The objectives and national demographic goals for 2010 formatted under NPP 2000 are relevant to NHP 2002. NPP addresses health care infrastructure, health personnels, reduction of infant and maternal mortality, achieving universal immunization against vaccine preventable diseases, prevention and control of communicable diseases, stress for under-served population, (urban slums, tribal population, hilly areas, displaced and migrant population), diverse health care providers, collaboration with NGOs, information, education and communication and providing for the older population etc. Thus several areas are common in both NPP and NHP, these should be persued in an integrated manner to achieve the common goals11. The NHP should explicitly state that both these policies have synergies and convergence rather than divergence and diverging approaches.

The need of the hour is to bring out convergence of services of several social sectors in particular ICDS, which is heading for universal coverage. Synergy of public health services and ICDS can usher in enhanced services for mothers and children, health system can't achieve without ICDS and vice versa, should be seriously realized and put into the framework of NHP explicitly11. The goals of reduction of IMR to 30 and MMR to 100/lac and reduction of LBW babies to 10% appear to be unreal and difficult to achieve by 2010. The IMR is static around 70 for the past many years and with present strategies it is unlikely to obey the command. Similarly, the current level of maternal mortality is very high and proportion of safe deliveries is low, unless the targetted interventions are focussed, we may not achieve the goal. Many of the weak performing districts in many states may not achieve these goals by 2010 and may achieve these well beyond 2020 even. Hence, the goals need to be determined and fixed region-wise/state and district-wise as we know the pace of performance.

Policy concludes by saying that improved standard of governance is a pre-requisite for the successful implementation of any policy. There has been an element of over-governance and too little has been done to decentralize and involve people, in the process of participatory planning-implementation and evaluation of services and decentralization and devolution should result into "people's health in people's hand". Service agencies should become accountable to people, their performance standards should be set and monitored by people's organization12,13. People have the right to information, health accounts on morbidity, mortality, malnutrition and disability as also spectrum of services and supplies at various levels should become accessible to people through improved information technology to have their regular reactions and feed back to improve the efficiency of system.

Goals to be achieved by 2000-2015.

  • Eradicate polio and Yaws
  • Eliminate Kala Azar and leprosy
  • Eliminate lymphatic filariasis
  • Achieve zero level growth of HIV/AIDS
  • Reduce mortality by 50% on account of TB, Malaria and other vector and water borne diseases
  • Reduce prevalence of blindness to 0.5%
  • Reduce IMR to 30/1000 and MMR to 100/Lakh
  • Improve nutrition and reduce proportion of LBW babies from 30% to 10%
  • Increase utilisation of public health facilities from current level of <20 to >75%
  • Establish an integrated system of surveillance. National Health Accounts and Health Statistics.
  • Increase health expenditure by Government as a % of GDP from the existing 0.9% to 2.0%
  • Increase share of Central grants to constitute at least 25% of total health spending

References:

  1. Ministry of Health & Family Welfare (Govt. of India). National Health Policy - 2002, New Delhi.
  2. Ministry of Health and Family Welfare (Govt. of India). National Health Policy - 1983, New Delhi.
  3. Imrana Quadeer, Kasturi Sen, Nayar KR. Politics of Decentralization lesson from Kerala - Public Health and Poverty of Reforms - The South Asian Predicament. New Delhi: Sage Publication India Pvt. Ltd; 2001. p.363-77.
  4. Ministry of Health and Family Welfare (Govt. of India). Manual on Community Needs Assessment Approach (Formerly Target Free Approach) in Family Welfare Programme, New Delhi; 1998.
  5. Ministry of Health and Family Welfare (Govt. of India). Reproductive and Child Health Programme - Scheme for Implementation, New Delhi; Oct. 1997.
  6. Deptt. of Family Welfare of India and European Commission Health and Family Welfare. Ninth Five Year Plan 1997-2002 Volume II. New Delhi: The Commission; 1997.
  7. World Health Report 2000. Health Systems Improving Performance. Geneva: World Health Organization; 2002.
  8. International Institute of Population Sciences (India). National Family Health Survey-2. Mumbai; 1998-99.
  9. Planning Commission, Govt. of India. Thematic Issues and Sectoral Programme. Ninth Five Year Plan 1997-2002 Volume II. New Delhi; 1997.
  10. Indian Council of Social Sciences, Indian Council of Medical Research, Indian Institute of Education (India). Health for All - an alternative strategy. Pune; 1981. p.90.
  11. Ministry of Health and Family Welfare (Govt. of India). National Population Policy - 2000, New Delhi.
  12. United Nations Children Fund (UNICEF) India Country Office. Right and Opportunities - The Situation of Children and Women in India. New Delhi: UNICEF; 1998.
  13. Ministry of Health and Family Welfare, Govt. of India. Health Manpower Planning. Production and Management, New Delhi; 1987.
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