India’s new National Health Policy sets a very low bar for better public health

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Last week, the Union Cabinet approved the National Health Policy, finally adopting a plan that has been in the drafting stage for more than a year and a half. The new policy will replace the 2002 Health Policy, which was preceded by the first National Health Policy of independent India in 1983.
Neither the 2002 policy nor the 1983 policy have been very effective in achieving what they set out to do. Many targets set in the 1983 policy have not been met even till date. For example, the 1983 policy projected that all births would be attended by trained attendants by the year 2000. One in four births were still not supervised by a trained attendant in 2015.
The 2002 policy had stated: “Broadly speaking, NHP 2002 focuses on the need for enhanced funding and an organisational restructuring of the national public health initiatives in order to facilitate more equitable access to the health facilities.” In the 15 years since, public funding as a percentage of GDP has languished at 1.1%, compared to a global average of 4.9%. Furthermore, healthcare access continues to elude the poor. The 2017 policy admits that “growing incidences of catastrophic expenditure due to health care costs” are estimated to be “one of the major contributors to poverty”.
We can choose to believe that the new policy will actually galvanise change. What we must then examine are the quantum of change proposed in the targets set out, what concrete mechanisms for change have been proposed, and if there is evidence that these will lead to better public health outcomes. We must also ask whether proposals in the policy are in sync with policies in the health sector in the past three years since the NDA government came to power. The National Health Policy 2017 has actually rolled back promises in two significant areas. The policy proposes that the government undertake an increase in health expenditure as a percentage of GDP from the existing 1.15% to 2.5 % by 2025. The draft policy released in 2015 had promised that this will be achieved by 2020. In other words, in 18 months, the government has already doubled the number of years it forecasts will be necessary to increase public spending on health to 2.5% of GDP. Even if this is achieved, it will be half of what the World Health Organisation recommends as optimum public spending on health.
If we now contrast this with public spending by the central government in the last three years, there is a clear gap between claims and rhetoric on health. The Union Budget of 2015-’16 effected a 5.7% cut in total allocation to the health sector. The 2016-’17 budget allowed a marginal rise of just 5% when adjusted for inflation and there was a similar marginal increase in the 2017-’18 budget. In fact, the sum allocated in the 2017-’18 budget is less than the 2011-’12 allocation when adjusted for inflation.The National Health Policy 2017 has also retreated from tentative claims that the government had started making that healthcare would be made a justiciable right. The policy now says: “The policy therefore advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realising healthcare as a right in the future”.
The policy also falls short on ambition with other targets. The document says that the target that life expectancy at birth should be 70 years will be achieved in 2025. This future target is less than what both Sri Lanka and Bangladesh have already achieved.The policy has set targets that mortality for children below the age of five should be brought down to 23 deaths per 1,000 live births and that neonatal mortality should be brought down to 16 deaths per 1,000 live births, both to be achieved by 2025. These rates would still be more than twice of what Sri Lanka has already achieved – 9.8 for mortality of children under five years and 5.4 for neonatal mortality. Clearly, the National Health Policy’s targets are a decade or more behind what our South Asian neighbours have already achieved.
The 2017 policy, contrary to claims about it made in Parliament, is part of the same vision that reduces the government’s investment in welfare and opens up public services to private actors.

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