Concern over private sector tilt in India’s new health policy
Dinesh C Sharma.Lancet 24th Januray 2015.

The Indian Government’s draft national health policy, which many experts view as a step away from universal health coverage, is out for public consultation.

The much-awaited health policy of India’s right-wing Government, which took office in May, 2014, proposes “health assurance” for all, but has raised fears about the greater role it envisions for the private sector in achieving this goal.

The goal of the draft National Health Policy (NHP) unveiled last month is to attain “the highest possible level of good health and wellbeing through preventive and promotive health care orientation in all developmental policies, and universal access to good quality health-care services without anyone having to face financial hardship as a consequence”.
The policy promises “universal availability of free, comprehensive primary health care services as an entitlement”, while secondary and tertiary care services would be made available through “a combination of public hospitals and strategic purchasing of services from private health sector”.
The draft does not offer any timeframe or roadmap for rollout of the plan.

India’s current health-care system is one of the most privatised globally, with the private sector providing 80% of outpatient and 60% of inpatient care resulting in catastrophic out-of-pocket expenses for people with a low income.

The government spending on health is an abysmal 1% of gross domestic product, which is less than 30% of total health spending.

Meanwhile, the private sector is growing because it remains unregulated while enjoying tax breaks and government subsidies. The need for regulation of the private sector finds a mention in the NHP but only in vague terms, without spelling out concrete steps like implementation of the Clinical Establishments Act approved in 2010, which empowers the government to set standards of care and fee structure for private facilities.

Nachiket Mor, health economist and a member of the high-level expert group on universal health coverage set up by the previous government, said: “The policy envisages building a fragmented system in which primary, secondary, and tertiary care will be in the form of self-contained silos, potentially even offered by different types of players and linked to each other by a very slim digital thread, instead of taking a more integrated patient-centric approach.”

Although the NHP acknowledges the government’s role in financing health care and promises a modest increase in state spending, it seems to limit its role to merely being a purchaser of services.

Amit Sengupta, New Delhi-based global coordinator of the People’s Health Movement, comments: “The policy claims that priority would be to ‘purchase’ services from public facilities and not-for-profit private facilities, but it also foresees purchasing from for-profit private facilities. It is not clear why it shies away from saying that the government will do both—finance and provide services based on needs and priorities.”

To facilitate purchase of care from the private sector, all existing state-funded insurance schemes are supposed to be clubbed into a single-payer system.

“The payment models proposed for hospital-based care takes a fee-for-service approach without explicitly requiring hospitals to take on the risks and management responsibilities of patient wellbeing by building carefully integrated networks of primary, secondary, and tertiary facilities”, feels Mor. “Such a model runs the risk of exacerbating the current situation, which is already very hospital-centric even in progressive states like Kerala”.

Prabhat Jha, director of the Centre for Global Health Research, University of Toronto, who is presently doing a prospective study of premature mortality in India,

said: “While it is unrealistic to think that all delivery of care can be ensured only through the public sector, the role of the private sector has been overemphasised in the NHP ignoring the fact that many people are getting over-charged and receiving unnecessary procedures. Indeed, the quality of care is uneven in large private hospitals.”

Instead, Jha suggests that the private sector could be involved in delivery of some financing schemes such as Janani Suraksha Yojana in which cash assistance is given for institutional deliveries even if they are done in private hospitals. “Public finance need not mean public delivery”, he adds.

Lack of explicit affirmative action to ensure equity is another area of concern.
Anup Karan, associate professor at the Indian Institute of Public Health in Gandhinagar, added: “Past experience shows inequitable distribution of state subsidies, with rich and well-to-do people utilising more services from public sources, cornering the bulk of the subsidies. Although all citizens have an equal right, the poor must have greater share of public subsidy to ensure equity. NHP is silent on this.” A reluctance to commit to free availability of essential and lifesaving drugs also exists, said Sengupta. Drugs account for a large share of out-of-pocket expenses.

In Jha’s view, India needs a policy that steers it away from a US-style health-care system, which has lots of private finance and relatively poor outcomes.

G Mohan.