If the five-year governance cycle of an elected government is seen as a 50-over match, we are now at the 20-over mark. In the health sector, the ‘strike rate’ of reform has been rather slow and the ‘asking rate’ for success is mounting. It may be that the team’s strategy is to begin cautiously, size up the situation and then make bold moves. If so, the time to step up the pace has arrived.
The performance in the health sector has to be evaluated on two levels: of the health ministry by itself and, more important, of the government as a whole. The ministry can claim some credit. The Indradhanush programme of expanded immunization is now beginning to overcome the challenge of low coverage. The resolute defence of large pictorial warnings on tobacco packs, holding firm against the frenzied onslaught of the tobacco industry, is laudable. The Rashtriya Swasthya Bima Yojana (RSBY) has moved to the health ministry from the labour ministry and can now team up with the National Health Mission (NHM) to provide a pathway to integrated primary and secondary care. RSBY is soon to emerge in a new avatar as the Rashtriya Swasthya Suraksha Yojana (RSSY), with a higher level of financial coverage to vulnerable families. Traditional medicine (Ayush) is getting a determined boost and the department of health research has a dynamic new leader.
At the level of the whole government, the major thrust for safeguarding health has come in the form of Swachh Bharat, which aims to provide sanitation and potable water to the many millions who have been deprived. A less recognized feature of this programme, reducing air pollution, also needs to become more prominent. Measures to increase supply cooking gas to poor families will help to reduce damage from indoor air pollution associated with solid cooking fuels. Price control of many commonly needed drugs, and the expansion of Jan Aushadi stores selling generic drugs, are welcome measures.
Despite these gentle placements, the big strokes have been missing. The parliamentary standing committee on health has correctly questioned the low level of central financing for health and the hasty devolution of central schemes to the states. Though a higher allocation has been made for RSSY, the NHM languishes with a frozen budget. This undermines primary healthcare. The National Urban Health Mission is yet to be launched. Programmes for prevention and control of cardiovascular diseases, diabetes, cancers, respiratory disorders and mental illness are yet to gather steam. The disconnects between primary-ambulatory care and advanced-hospitalized care are growing wider.
What is not yet clear is the intended strategy for health sector reform. Is there a clear vision for Universal Health Coverage (UHC), which is now part of our national commitment to the Sustainable Development Goals? At persistently low levels of public financing, can UHC really advance? How will comprehensive, continuous care be provided cost-effectively, if primary care continues to be neglected? Why is the draft National Health Policy gathering dust without ownership within the government? What has happened to the promise to deliver essential drugs and diagnostics free of cost at public facilities? Is UHC now for the states to design and deliver, while the centre confines its contribution to the limited remit of NHM as it exists and RSSY as it expands? How will the huge gaps in health workforce numbers and skills be bridged?
In some cases, the Supreme Court has stepped in as the third umpire, with helpful decisions. The dissolution of the Medical Council of India (whose governance put the Board of Cricket Control of India in the shade), the directive to conduct the National Eligibility Entrance Examination for medical college admissions and the disapproval of extortionist capitation fee are well-judged decisions that have spared the government the pains of initiating difficult reforms in medical education. It is, however, now for the health ministry to use those gifted ‘lives’ to bring forth well-framed legislation for creating a National Commission on Human Resources for Health, to radically restructure health professional education to meet national needs and attain contemporary global standards.
In a federal polity, the centre’s performance in health cannot be judged in isolation from that of the states. As the mandate for design and delivery of health programmes shifts increasingly to the states, it will be the responsibility of the centre to convene the states to create consensus on the preferred path to UHC. This framework has to provide common commitments, while retaining flexibility for accommodating state-specific priorities.
Health sector reform and revitalization cannot proceed through disconnected measures that deal with some pieces and not the whole system. A grand vision and clear strategy are needed, which engages a whole-of-government approach. It requires the decisive leadership of the prime minister to take the team to victory on this difficult pitch. Will the captain step up to the crease please?
The author is president, Public health Foundation of India.