A policy is only as good as its implementation (Photo courtesy: pixabay.com)
The CII proposes a "composite" and "hybrid" model based on following tenets for implementing the Universal Health Coverage (UHC) in India in faster and efficient manner with utmost economy.
• The model aims at developing a basic and essential UHC package, consisting of primary, secondary and tertiary care, which would be affordable and accessible to every citizen, inclusivity all components of care - "Primary", "promotive" and "preventive".
• The model proposes to strengthen primary healthcare and other determinants of health like safe drinking water, sanitation, and nutrition by making it the core focus of the Government and public health system
• It proposes utilization of health insurance for providing secondary care package of Rs 60,000 topped by tertiary care package of Rs 2 lacs to all
CII also proposes that at present the Government of India and State Governments are running disparate schemes for healthcare e.g. RSBY, Arogyashri, Tamil Nadu Health scheme, CGHS, ESIS, and programs like NRHM, all running parallel to each other, often duplicating efforts and scarce resources. It is necessary that all schemes are brought under one umbrella for efficient pooling and management. The proposed model fits quite well with the Government of India's intent to increase health spend from 1.1 percent to 3 percent over a period of 10 years.
Meanwhile, Voluntary Health Association of India (VHAI) called the draft policy a vision document. "There is a basic difference between a vision document and a national policy. The present draft reads more like a vision document which is aspirational. A national policy should be result focused and should have a specific time frame with clear articulation on resource needs. It should essentially concentrate on what Government intends to do, both in its regulatory and developmental roles. The document can be short and crisply written, and lot of the verbosity and repetition in the draft can be pruned."
"There should be a strong monitoring system to review and monitor progress on achievement of the goals set in the NHP. This should be an integral part of the Policy. This should not be restricted by budgetary cuts and constraints, which are implementation problems," it added.
VHAI stated that the goal of National Health Policy should focus on, saying, "Health is not about drug, disease management and doctor but about healthcare with appropriate focus on prevention and wellness."
On the goals, principles and objectives in the draft, VHAI said, "among the ‘key principles' listed, preventive/promotive or public health should be added. It is a serious omission. There should be stronger emphasis on equity as a basic principle. The global principle of ‘no one should be left behind' as a key component of the post 2015 development agenda must be echoed in the national policy framework. We should also add principles of comprehensive healthcare and justice. The principle of affordability should be removed as it is contrary to the principles of Equity and Universality."
VHAI in its observation on draft policy said that the key areas of concern not addressed in the draft policy include:
•Specific Areas that need amplification- Tuberculosis and Diabetes are two areas which need stronger write ups. Malnutrition and combating Anaemia in women and children again need more discussion.
•Community Monitoring of Government programs - The policy of the country is to encourage more Community Monitoring of government programs. This does not come out strongly enough in the Policy Document.
•Youth Health: There is no discussion of Youth health in Draft NHP-2015. The picture of healthy adolescents and youth of our country has been rapidly changing in recent years due to sedentary lifestyles, diet changes, and attitudes of youth towards health. Adolescents face a myriad of health challenges including sexual and reproductive health, drug/substance abuse, and exercise but most of the problems faced by adolescents and youth have common antecedents and are preventable. There is a need for special focus on the much neglected/ ignored adolescent and youth group in this policy document. These policies should be youth empowerment programs which are need-based and gender sensitive. They must be integrative and holistic in their approach rather than having, for example, separate programs for sexual and reproductive health, drug/substance abuse, diet and exercise.
•Elderly care, emergency care, disaster preparedness, and mental health are mentioned without discussing the integration of the already existing policies on these issues.
•No mention of inter-ministerial integration of schemes and programs of matter related to health in the implementation process.
•Dental Health is included only under NCDs, and no mention of eye care at all. These should be covered separately.
AHPI and KPMG
"In time to come, we hope to see a happy and healthy India under the National Health Assurance Mission, launched by Government of India. The mission should be able to integrate promotive, preventive and curative segments and include associated subjects like safe drinking water, sanitation and sustainable environment. Government must accord priority to collect demography and disease related data to support policy and plans," said Dr Girdhar J Gyani director general, Association of Healthcare Providers India (AHPI).
In its review of National Health Policy 2015 (draft) along with KPMG, AHPI said that the government needs to collaborate to add more infrastructure such as healthcare set-ups at each delivery level to meet the demand of a growing population. Moreover, prioritize infrastructure development according to geographical needs. Commenting on the public health expenditure of the GDP which is proposed to be increased to 2.5 percent from the current share, AHPI said that the government should ensure effective utilization of existing budgets. It is imperative to achieve adequate distribution of the increased budget in areas of high priorities both strategically and geographically.
AHPI says that the policy recognizes the problem of increasing OOP expenditure; advocates establishment of National Health Account system for normative resource allocation and payment mechanism and also suggests the reduction in healthcare cost borne by the poor in the private sector by using public insurance schemes. However, it recommends a discussion around universal health insurance for the masses and restructuring of government insurance scheme to ensure smooth implementation and implementation of transparent payment process.
AHPI also suggests that the government look at the drug delivery model of Tamil Nadu and Rajasthan and urge other states to replicate the same.
In his observation, Mr Nilaya Varma, partner, IGS-Advisory Management, KPMG in India said "today the Indian healthcare system stands at a cross-road. In the last one decade, even though Indian healthcare has taken leaps in terms of becoming a medical tourism destination, the delivery system both public and private, continues to remain elusive to the section of society with high healthcare needs. With efforts to meet health targets envisioned under Millennium Development Goals getting either off-track or dawdling, it becomes imperative for Indian healthcare stakeholders to revisit the policy and identify any gaps in the actions taken."
Urging India to have a specific policy for the rare diseases, Mr Harsha K Rajasimha, entrepreneur and co-founder of the Organization for Rare Diseases India (ORDI) said, "Creating a better environment for rare disease diagnosis and treatment is necessary for equitable medical access. In that process, we can trigger advances also in other areas of medical research. A rare disease policy will help us to better manage this new aspect of medical care for our communities."
In their review of the Health Policy (draft) submitted to government of India, ORDI has specified that by virtue of being rare diseases, they do not elicit the enthusiastic attention of researchers, medical practitioners and drug manufacturers. As a result, diagnosis is invariably delayed. In almost all cases, delays in diagnosis extend the suffering of patients and caregivers. Perhaps more importantly, the exclusion of rare diseases from the medical curricula in our country compounds the problem of diagnosis, research and development for patient care and its management, and for creating the infrastructure for diagnosis and treatment. In reality, there is considerable scope for rare disease investigation to enrich conventional medical research in areas such as personalized medicine.
The need for an Orphan Drug Act (ODA) arises from the need to encourage awareness and incentivize manufacturers to develop drugs for rare diseases. Citing example from the US, ORDI said almost all orphan drug requirements in the US are covered by medical insurance. Additionally, in the US most companies have created a scope for reduced or zero fee provision of drugs for a limited number of needy patients. India need to replicate some of the best examples globally, it said.
Further, ORDI recommends having a National database on rare diseases in India. Database monitoring would imply having a register that integrates details of rare disease drug manufacturers and rare disease medications and devices, research and development institutes, and consumers.
ORDI also urge the government to integrate rare disease curriculum into medical education.
Part of the solution to making rare disease treatment affordable is spreading the cost over the population. Medical insurance, which covers rare diseases, is one step in that process. This along with the mechanisms within an ODA for promoting research, drug manufacture and cross subsidy can help to dilute the intractable problem of affordability for rare disease patients, said ORDI.
Welcoming the draft of the National Policy, Mr Javali Sudhir Pai, ED & CEO, Vikram Hospital, said "The draft National Health Policy 2015 (NHP) is path breaking in many ways. The goals are ambitious but sensible enough to address the need of the hour. Issues relating to high maternal mortality rate, infant mortality rate, malnutrition, burgeoning health care costs are a threat to economic survival of the nation as a whole. Major policy initiatives are needed to change this and "the policy addresses all the issues with a pragmatic approach."
The emphasis on clinical trials and the need for it is a very good policy initiative. Encouraging clinical trials in India helps introduction of new products faster and access to drugs that are otherwise not available, though clinical trials will go a long way in saving lives of diseased. Asystem to ensure quick approval of clinical trials of new drugs is imperative to good health," he said.
Speaking on the health policy, Mr Shrikant Ganduri, EVP and head - LifeSciences and IT Knowledge Banking, Yes Bank said, "National Rural Health mission (NRHM) to be used for effectively as an instrument for strengthening health system. NRHM free care to be extended to a larger set of diseases."
Further he said, government should provide incentives to private healthcare providers to setup Healthcare delivery centers in rural areas. "The target of public spend of 2.5 percent for GDP, should be relooked as India-like countries like Brazil and Thailand have a higher public spend of 3-4 percent."
"Health awareness agenda should be strengthened on the lines of brand campaigns like "Swacch Bharat Abhyan" and strict timelines based state wide access to free drugs and diagnostics has been done in states like Rajasthan and Tamil Nadu. India government should consider such programs," said Mr Ganduri.
A policy is only as good as its implementation. Past policies have faced innumerable constraints in implementation. The National Health Policy therefore envisages that an implementation framework be put in place to deliver on these policy commitments. Such an implementation framework would specify approved financial allocations and linked to this measurable numerical output targets and time schedules.
National Health Policy sets an ambitious target of healthcare expenditure at 2.5 percent of the GDP. This is an important benchmark as currently the healthcare expenditure is just 1.04 percent of GDP. Government has taken a bold and right step, hope it continuous.
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