A Marthanda Pillaia,c, Muhammed Shaffib,c
a. National President Elect (2014-15) Indian Medical Association, New Delhi, India;
b. Convener, Research Cell, Indian Medical Association Kerala State;
c. Global Institute of Public Health, Ananthapuri Hospitals, Thiruvananthapuram, Kerala.

Corresponding Author: Dr. Muhammed Shaffi MBBS, MPH, MBA Assistant Professor, Global Institute of Public Health, Ananthapuri Hospitals, Thiruvananthapuram, Kerala 695029. Email: fmshaffi@gmail.com

ABSTRACT

India has elected a new government. Health has received unprecedented attention over the last decade though it’s far from required. There are lots of issues, which the new government has to address on a priority basis. The country needs a comprehensive health policy and a strategy to mitigate health effects due to developmental activities. Drug prices need to be regulated and out of pocket expenses should be cut down

Prescription for a ‘healthy’ government

India- the largest democracy in the world has selected a new government to manage the country for the next five years. Before elections, political parties have come up with their own manifestos listing scores of items based on deliberations within party and in public. Health should be the top priority for any elected government along with education. National Rural Health Mission might have brought in some changes as far as infrastructure or human resources are considered1. But India being a vast country, with huge disparities in terms of health needs and health care provisions, the one-size-fit-all approach will not apply anymore

Now-a-days, Universal health care is the buzzword. However it should be carefully noted that universal access to more basic services like safe water, sanitation, nutrition and basic primary health care services are still a dream for a large proportion of our citizens even today. There are many different ministries and departments, which deal with many key determinants of health, other than the health ministry and the department. Activities by the Social welfare department (nutrition, women’s education), local self-government department (sanitation, waste management), public health engineering (drinking water), petroleum and chemicals (pharmaceutical production) have to be coordinated and overseen by the Prime-Minister himself to see that we are on the right track to achieve Universal Health overage.

Trade Related Intellectual Property Rights (TRIPS) provisions have started to show the devastating effects on access to medicines2. Environmental issues and climate change are posing great threats to the very existence of human beings. Lifestyle changes, especially in food habits are taking a heavy toll. India is becoming the capital of Non communicable diseases, when at the same time we are still finding it hard to combat the age-old problem of communicable diseases. Health care in India should be the one of the core focus of the new government giving due importance to core issues in health care delivery and social determinants of health and we submit the following agenda for a ‘healthy government’

A National Health Policy needs to be formulated after extensive state level and regional level consultations in line with Bhore committee recommendations3 and considering the achievements so far in the areas of Millennium Development Goals (MDG). Health should be acknowledged as a basic right by the Parliament. ‘Right to health care’ bill should be passed by the parliament by 2015 – (amendment and addition of article 21 B). With a meager 1% GDP spend on health by Government4, it seems impossible to achieve even basic health goals even in another decade. We urge to raise the public spending on Health to at least to 1.5% of GDP by 2015 and to 3% by 2020. However in-order to ensure that the system absorb the amount budgeted; design and implement a well-targeted Policy on Human Resources for Health. A well-established public health cadre with adequate training is essential to implement health programs timely and effectively.

For every 100 Rupees spend on health, Seventy Rupees is from out of pocket5. Although health insurance is often projected as a panacea to this problem, it will in the long run be detrimental to a strong public health provision as it happened with the American model. More than Sixty percentage of health care delivery is catered to by the private sector in India. Proper utilization of the facilities including manpower and infrastructure in private sector through empanelment, retainership, and other PPP models should be thought off. Expenditure on drugs was found to constitute the major part (70%) of out-of-pocket (OOP) health care expenditure in India. There should be a national drug distribution system- covering both public and private sector without putting the burden of the cost on the patients. Spend at least 0.5% of GDP on this national drug distribution system. There should be a national laboratory network established linking all public and private labs accredited using quality standards. In addition, the government supported health insurance schemes like RSBY should cover the cost of outpatient services as well, which at present covers only the in-patient cost.

Our patent rules should be pro-people rather than supporting greedy industrial motives. Priority should be to secure the people’s rights of access to affordable and quality healthcare, without allowing monopoly or cartels. At the same time, there should be systems in place to check and ensure the quality of drugs produced, marketed and used in the country- irrespective of whether the company is national or international. Government should use it’s power to neutralize the patent barriers which block the development of cheaper generic versions of drugs; monitor and regulate the prices of cancer drugs in market and bring all the patented cancer drugs into the ambit of drug price control mechanism; use the provision of compulsory licensing on molecules which can make a big difference on lives of thousands of cancer patients in this country.

It is sad to note that even when major developmental projects are being sanctioned, the potential impact on health- either directly or through environmental impact is under-looked. Health impact assessment should be made mandatory for all major developmental projects. Tax concessions to be given to companies manufacturing low-salt, low-fat packaged food. Health Tax should be levied on high-fat, high-salt food products. Junk foods should be prohibited from being sold within 100 meters of schools. Impose 200% health tax on all tobacco products. Legislations making plain packaging mandatory should be brought in. Effective public campaign to reduce consumption of alcohol should be started. Alcohol rationing should be considered to reduce the consumption

The staff pattern is decades old in many of the Indian states and should be revisited and changed considering the changes in health care needs. There should be some uniformity and basic norms brought in these matters across the country, even while acknowledging that health is a state subject. Family Doctor system should be promoted. Nursing cadre trained in Emergency care, palliative and geriatric care should be deployed in all PHCs and above. A comprehensive ‘Human resources for health need assessment’ study should guide the policies of the government in deciding to start new medical and paramedical institutions in the country

Cardiology care centers should be opened in in all district hospitals with an aim to prevent deaths due to cardiac arrest, at least in ‘Set-up, Operate and Transfer ‘(SOT) mode. Dialysis centers should be allowed in all blocks- based on need, at least in PPP mode. Health research should be promoted, both by public institutions and private institutions. Government should come up with a National Elderly Health Mission. E-Health -Smart Health card – telemedicine – should be supported adequately with funds, infrastructure and human resources.

An Independent Medical Ombudsman mechanism should be established to take care of medical care related disputes in national, state and regional levels. Establishment of National Institutes of Public Health in line with the IITs/IIMs should be promoted. Indian Medical Services should be established in line with the Indian Civil Services, Engineering Services and Judicial services to attract talent to manage our health sector. The recruitment of doctors should be managed by a separate recruitment board and not left to the common public service commission and should be done annually, based on vacancy status. The Medical Council of India (MCI) should be made truly independent so that it will act as a real watchdog of the professional conduct of Doctors. Priority should be given to ensure quality in medical education and research in the country. The curricula and syllabi of medical education should be revised to address the changing health problems; ‘Clinical skills lab’ should be established in all govt. medical colleges, Promote new specialties in medical education like Family Medicine, Emergency Medicine, Geriatrics and Palliative care, Establish Medical Grants commission (MGC) in line with UGC to support Medical and Health Universities and medical colleges and to promote quality medical education and health research in the country.

End Note

Author Information 

  1. Prof. Dr. A Marthanda Pillai, President Elect of Indian Medical Association (2014-15) is the Director of the Global Institute of Public Health, Thiruvananthapuram. He is a senior consultant neurosurgeon and Honorary Professor of Bioethics and serves in the Governing Council of Kerala University of Health Sciences
  2. Dr. Muhammed Shaffi, Currently an Assistant Professor at Global institute of public health, has worked previously with World Health Organization as a surveillance medical officer and Medical consultant (TB Control) and as deputy medical coordinator with MSF (Spain) India mission

Conflict of Interest: None declared

References

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  2. Department of Technical Cooperation for Essential Drugs and Traditional Medicine, World Health Organization. [Source]
  3. J Bhore RA, Banerjee AC. In: Report of the Health Survey and Development Committee. Division P, editor. Delhi: Government of India; 1946.
  4. World Health Organization. Global Health Expenditure database. accessed on 10th Jan, 2014. [Source]
  5. Yarlini Balarajan S Selvaraj and S V Subramanian. Health care and equity in India. 2011 Feb 5; 377(9764): 505–515. [Pubmed] | [Crossref]