The new National Health Policy (NHP) of the Narendra Modi government has several distinct features. It attempts to capture the socio-economic and epidemiological changes over the past 15 years. It sets an ambitious task of raising public health expenditure to 2.5 per cent of the GDP (from the current 1.3 per cent) and envisages private sector collaboration in a big way.
Union Health Secretary C.K. Mishra explains the enormity of the government's commitment towards health - a 20 per cent increase in budgetary allocation every year till 2025 - in an exclusive interview with Business Today's Joe C. Mathew. Edited excerpts:
How is NHP 2017 different from earlier health policies?
There are two or three key differences. The previous policy spoke about primary health provisioning in verticals like malaria and TB while we are now talking about comprehensive health care, including non-communicable diseases (NCDs). We are also looking at free universal primary care and the private sector coming in as a partner for strategic gap-filling for the first time. There are also clear-cut milestones. As we talked to all state governments before finalising the policy, the states are on board.
Can you give us the key timelines?
From next year till 2022, we have set timelines. We have spoken about universal [disease] screening, which will be launched this year. More districts will be added to the programme, and the entire country will be covered by 2020. Similarly, if you look at the reforms in medical education, we have said that we will do it within the next three years. Regulatory reforms will also be done over the next three years.
Are all these plans within the ministry's purview?
Wherever they are, it is our responsibility to see that they are getting done. The only thing not in my hands is increasing spending on health to 2.5 per cent of GDP. But when the policy gets approved by the highest body of the country, it means there is a commitment towards providing resources.
How much should you get as budgetary allocation if you go by the target?
We need to grow at 20 per cent. We have got 27 per cent more than the previous year; so, this year's budget is not bad. But then, last year's base was small, and this year's will be larger. It means we will need a larger amount next year. It is a rough calculation. But yes, we need 20 per cent year-on-year growth till 2025. Together, the states and the Centre are spending Rs 2 lakh-odd crore every year. We need to reach about Rs 8 lakh crore, provided GDP keeps growing at the same pace.
Will the implementation depend on resources?
A policy document is a document of intent where you project what you want to do. If you want to implement a policy, you have to have a programme-based paper. We have a framework where we have taken the individual items suggested in the plan and then apportioned when and what will be done for the next seven-eight years.
The only caveat is some projects are revenue-intensive and some are not. Those which are not revenue-intensive, and where we only need to make them a part of an existing programme or create new programmes for them within our overall structure, we will be able to do it. For projects where money will be required from the next financial year, we will start demanding the money. That is the way we have planned it. The thinking is more or less convergent.
We are talking about digital inclusion in a big way. Is there any promising pilot?
Several pilots are on. As for digital, something is going on in Odisha, some in Andhra. Some states are experimenting with the health management information system (HMIS) and some are working on electronic health records (EHR). We must carefully look at the pilots. If a pilot does not have the potential to scale up, it does not make sense to take it forward.
Are pilots going national?
Health is not a small thing. Some people are working on an insurance model, some on the spine of the insurance model, others on the EHR model, and some on digital health records and telemedicine. We have a portal where states upload the best practices and innovations that they are doing. When a state tells us what it is doing, we share it with other states. Once there is acceptance for scaling it up, we make it a part of our funding programme. Many pilots get scaled up like this.
What is the strategic gap-filling that the private sector will do?
We would provide government services, especially in primary and secondary health care, which would cover up to the district hospital level. But there are some services which we may not be able to provide at primary and secondary levels. We will get those services from the private sector through strategic purchases. If we are not able to do a CT scan in a primary health centre or at the district level, we can purchase that service. It will be a convergence of resources available to private and public sectors.
Have you signed memorandums of understanding (MoUs) with private entities or associations?
All MoUs are signed by state governments, and they have signed many. Uttarakhand has signed an MoU with a hospital to provide heart care. Himachal has an MoU with Apollo for trauma care. Himachal and Tripura are also into telemedicine.
But the public-private partnership (PPP) experience has not been encouraging so far.
It was encouraging, but the scale was not there. It is all about scale. We are doing it at a smaller level right now. Slowly the confidence will grow and the scale will also grow.
Is there a financial implication?
In most of the cases where finance is needed, it will be done through the National Health Mission, which involves 60:40 sharing (between the Centre and states). That is why we have kept the tertiary sector out as it is not part of the national mission.
Will it include preventive care?
We launched a pre-diagnostic programme last year, which is also a part of the policy. We were aware that within a state, there might not be enough capacity to provide the entire range of radiology or pathology services. So, we came up with a hub-and-spoke PPP model. Under this model, state governments bid to get the private provider and that provider chooses five or six regions within the state for its hub. Then, the spokes go to villages, collect samples and electronically transmit results. Andhra Pradesh was the first state to take it up; it has been proven that the cost can be very low. If you back it up with a good IT infrastructure and monitoring so that any wrongdoing can be flagged, it can be an excellent model. This is where the private sector and the public sector will converge.
The policy talks about increasing health care spending to 2.5 per cent of the GDP. Does it mean massive private linkages?
When we are talking about 1.3 per cent or 2.5 per cent of GDP, we are talking about budgetary support. Linkages with the private sector can be leveraged for other things that go beyond it. Let us take NCDs or cancer treatment. We have a huge load of diabetic patients who ultimately become cardiovascular or kidney patients. Good primary health care can screen and catch these cases early. There may be an initial investment, but down the road, in tertiary care, you are saving a lot of money on treatment. The concept I keep talking about and which is the basis for the entire policy is that we should invest in health care and not just in hospital care. If you invest more in health care, you will need less hospital care.
How do you plan to reduce costs?
India's out-of-pocket expenditure is very high at 58 per cent. Of this, 70 per cent is spent on drugs and diagnostics. That is why we started two schemes for free drugs and diagnostics last year. Free diagnostics and medicines are given to people who go to public health care facilities. But some people go to private facilities as well. If we can take away the cost of drugs and diagnostics, back it up with generic drugs and cheaper radiology and pathology available outside, the out-of-pocket expenditure will come down. But that could be a slow process.
The Prime Minister said there would be legal changes to ensure generic prescription. Is it being done?
We have already acted on that. The Medical Council of India (MCI) has told all doctors that generic medicines should be prescribed. We have also instructed all central government hospitals to start prescribing generic drugs. And we have requested state governments to instruct their facilities to do the same. The first thing is to introduce it in all government facilities. The MCI is for everyone. We have been talking to the Indian Medical Association and other medical associations to push it through the government. We are simultaneously working on the issue of availability, which is critical to the entire programme.
NITI Aayog is talking about a balance between affordability and availability. It proposes delinking the entire drug pricing from the National List of Essential Medicines.
That is NITI Aayog's suggestion.
Did the health ministry come up with it?
No, it did not. I would say price control is one of the tools. If we can work out a bigger mechanism through which we can make affordable drugs available, it is fine. Amrut stores, for example, are selling only high-end drugs. We are getting a concession of about 60 per cent of the maximum retail price, which we are passing on to buyers. So, there is a scope to make drugs available at affordable prices. It can have various dimensions, and price control is one. If you can work out some better mechanism, you should do so. There should be some mechanism where drugs can be sold at an appropriate price.