INTRODUCTION
The National Health Policy (NHP) of 1983 and the NHP of 2002 have served well in guiding the approach for the health sector in the Five-Year Plans. Now 14 years after the last health policy, the context has changed in four major ways. First, the health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of noncommunicable diseases (NCDs) and some infectious diseases. The second important change is the emergence of a robust health care industry estimated to be growing at a rapid pace. The third change is the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty. Fourth, a rising economic growth enables enhanced fiscal capacity. Therefore, a new health policy responsive to these contextual changes is required.
The NHP 2017 builds on the progress made since the last NHP 2002. The primary aim of the NHP, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions—investments in health, organization of health care services, prevention of diseases and promotion of good health through cross-sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance.
GOAL, PRINCIPLES AND OBJECTIVES
Goal
- The attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies
- Universal access to good quality health care services without anyone having to face financial hardship as a consequence.
This would be achieved through increasing access, improving quality and lowering the cost of health care delivery.
The policy recognizes the pivotal importance of Sustainable Development Goals (SDGs). An indicative list of time bound quantitative goals aligned to ongoing national efforts as well as the global strategic directions has been detailed.2
Key Policy Principles
- Professionalism, integrity and ethics: The health policy commits itself to the highest professional standards, integrity and ethics to be maintained in the entire system of health care delivery in the country, supported by a credible, transparent and responsible regulatory environment.
- Equity: Reducing inequity would mean affirmative action to reach the poorest. It would mean minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. It would imply greater investments and financial protection for the poor who suffer the largest burden of disease.
- Affordability: As cost of care increases, affordability, as distinct from equity, requires emphasis. Catastrophic household health care expenditures defined as health expenditure exceeding 10% of its total monthly consumption expenditure or 40% of its monthly nonfood consumption expenditure, are unacceptable.
- Universality: Prevention of exclusions on social, economic or on grounds of current health status. In this backdrop, systems and services are envisaged to be designed to cater to the entire population—including special groups.
- Patient centred and quality of care: Gender sensitive, effective, safe, and convenient health care services to be provided with dignity and confidentiality. There is need to evolve and disseminate standards and guidelines for all levels of facilities and a system to ensure that the quality of health care is not compromised.
- Accountability: Financial and performance accountability, transparency in decision making, and elimination of corruption in health care systems, both in public and private.
- Inclusive partnerships: A multi-stakeholder approach with partnership and participation of all nonhealth ministries and communities. This approach would include partnerships with academic institutions, not-for-profit agencies, and health care industry as well.
- Pluralism: Patients who so choose and when appropriate, would have access to the Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) care providers based on documented and validated local, home- and community-based practices. These systems, inter alia, would also have Government support in research and supervision to develop and enrich their contribution to meeting the national health goals and objectives through integrative practices.
- Decentralisation: Decentralisation of decision making to a level as is consistent with practical considerations and institutional capacity. Community participation in health planning processes is to be promoted side by side.
- Dynamism and adaptiveness: Constantly improving dynamic organisation of health care, based on new knowledge and evidence with learning from the communities and from national and international knowledge partners, is designed.
Objectives
Improve health status through concerted policy action in all sectors and expand preventive, promotive, curative, palliative and rehabilitative services provided through the public health sector with focus on quality.3
Progressively Achieve Universal Health Coverage
- Assuring availability of free, comprehensive primary health care services, for all aspects of Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) and for the most prevalent communicable, noncommunicable and occupational diseases in the population. The Policy also envisages optimum use of existing manpower and infrastructure as available in the health sector and advocates collaboration with nongovernment sector for delivery of health care services linked to a health card, to enable every family to have access to a doctor of their choice, from amongst those volunteering their services.
- Ensuring improved access and affordability, of quality secondary and tertiary care services through a combination of public hospitals and well measured strategic purchasing of services in health care deficit areas, from private care providers, especially the not-for profit providers.
- Achieving a significant reduction in out of pocket expenditure due to health care costs and achieving reduction in proportion of households experiencing catastrophic health expenditures and consequent impoverishment.
Reinforcing Trust in Public Health Care System
Strengthening the trust of the common man in public health care system by making it predictable, efficient, patient centric, affordable and effective, with a comprehensive package of services and products that meet immediate health care needs of most people.
Align the Growth of Private Health Care Sector with Public Health Goals
Influence the operation and growth of the private health care sector and medical technologies to ensure alignment with public health goals. Enable private sector contribution to making health care systems more effective, efficient, rational, safe, affordable and ethical. Strategic purchasing by the Government to fill critical gaps in public health facilities would create a demand for private health care sector, in alignment with the public health goals.
Specific Quantitative Goals and Objectives
The indicative, quantitative goals and objectives are outlined under three broad components viz. (1) health status and programme impact, (2) health systems performance and (3) health system strengthening. These goals and objectives are aligned to achieve sustainable development in health sector in keeping with the policy thrust.
Health Status and Programme Impact
Life expectancy and healthy life:
- Increase life expectancy at birth from 67.5 to 70 by 2025.
- Establish regular tracking of disability-adjusted life years (DALYs) index as a measure of burden of disease and its trends by major categories by 2022.
Mortality by age and/or cause:
- Reduce under-five mortality to 23 by 2025 and maternal mortality ratio (MMR) from current levels to 100 by 2020.
- Reduce infant mortality rate to 28 by 2019.
- Reduce neonatal mortality to 16 and stillbirth rate to “single digit” by 2025.
Reduction of disease prevalence/incidence:
- Achieve global target of 2020 which is also termed as target of 90:90:90, for human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), i.e. 90% of all people living with HIV know their HIV status, 90% of all people diagnosed with HIV infection receive sustained antiretroviral (ARV) therapy and 90% of all people receiving ARV therapy will have viral suppression.
- Achieve and maintain elimination status of leprosy by 2018, kala-azar by 2017 and lymphatic filariasis in endemic pockets by 2017.
- To achieve and maintain a cure rate of more than 85% in new sputum positive patients for tuberculosis (TB) and reduce incidence of new cases, to reach elimination status by 2025.
- To reduce the prevalence of blindness to 0.25/1,000 by 2025 and disease burden by one-third from current levels.
- To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.
Health Systems Performance
Coverage of health services:
- Increase utilisation of public health facilities by 50% from current levels by 2025.
- Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by 2025.
- More than 90% of the newborn are fully immunised by 1 year of age by 2025.
- Meet need of family planning above 90% at national and subnational level by 2025.
- 80% of known hypertensive and diabetic individuals at household level maintain “controlled disease status” by 2025.
Cross-sectoral goals related to health:
- Relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025.
- Reduction of 40% in prevalence of stunting of under-five children by 2025.
- Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).
- Reduction of occupational injury by half from current levels of 334/100,000 agricultural workers by 2020.
- National/State level tracking of selected health behaviour.
Health Systems Strengthening
Health finance:
- Increase State sector health spending to more than 8% of their budget by 2020.
- Decrease in proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.
Health infrastructure and human resource:
- Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts by 2020.
- Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
- Establish primary and secondary care facility as per norms in high priority districts (population as well as time to reach norms) by 2025.
Health management information:
- Ensure district-level electronic database of information on health system components by 2020.
- Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
- Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.
POLICY THRUST
Ensuring Adequate Investment
The policy proposes a potentially achievable target of raising public health expenditure to 2.5% of the GDP in a time bound manner. It envisages that the resource allocation to States will be linked with State development indicators, absorptive capacity and financial indicators. General taxation will remain the predominant means for financing care. The Government could consider imposing taxes on specific commodities—such as the taxes on tobacco, alcohol and foods having negative impact on health, taxes on extractive industries and pollution cess. Funds available under Corporate Social Responsibility (CSR) would also be leveraged for well-focused programmes aiming to address health goals.
Preventive and Promotive Health
The policy articulates to institutionalise intersectoral coordination at national and subnational levels to optimise health outcomes, through constitution of bodies that have representation from relevant nonhealth ministries. The policy prerequisite is for an empowered public health cadre to address social determinants of health effectively, by enforcing regulatory provisions.
The policy identifies coordinated action on seven priority areas for improving the environment for health:
- The Swachh Bharat Abhiyan
- Balanced, healthy diets and regular exercises
- Addressing tobacco, alcohol and substance abuse
- Yatri Suraksha—preventing deaths due to rail and road traffic accidents
- Reduced stress and improved safety in the workplace
- Reducing indoor and outdoor air pollution.
The policy also articulates the need for the development of strategies and institutional mechanisms in each of these seven areas, to create Swasth Nagrik Abhiyan—a social movement for health. It recommends setting indicators, their targets as also mechanisms for achievement in each of these areas.
Preventive and promotive care is to be built upon, along with a two-way continuity with curative care, provided by health agencies at same or at higher levels. Interventions are to include early detection and response to early childhood development delays and disability, adolescent and sexual health education, behaviour change with respect to tobacco and alcohol use, screening, counselling for primary prevention and secondary prevention from common chronic illness—both communicable and NCDs. Focus is on extending coverage and ensuring quality of the existing package of services.
Investment and action in school health is to be done by incorporating health education as part of the curriculum, promoting hygiene and safe health practices within the school environment and by acting as a site of primary health care. Promotion of healthy living and prevention strategies from AYUSH systems and Yoga at the workplace, in the schools and in the community would also be an important form of health promotion.
Greater focus is to be provided on occupational health. Worksites and institutions would be encouraged and monitored to ensure safe health practices and accident prevention, besides providing preventive and promotive health care services.
The ASHA will also be supported by other frontline workers like health workers (male/female) to undertake primary prevention for NCDs. They would also provide community- or home-based palliative care and mental health services through health promotion activities. These workers would get support from local self-government and the Village Health Sanitation and Nutrition Committee (VHSNC).
In order to build community support and offer good health care to the vulnerable sections of the society like the marginalised, the socially excluded, the poor, the old and the disabled, the policy recommends strengthening the VHSNCs and its equivalent in the urban areas.
“Health Impact Assessment” of existing and emerging policies, of key nonhealth departments that directly or indirectly impact health would be taken up.
Organisation of Public Health Care Delivery
The policy proposes seven key policy shifts in organising health care services.
- In primary care—from selective care to assured comprehensive care with linkages to referral hospitals
- In secondary and tertiary care—from an input oriented to an output-based strategic purchasing
- In public hospitals—from user fees and cost recovery to assured free drugs, diagnostic and emergency services to all
- In urban health—from token interventions to on-scale assured interventions, to organise Primary Health Care delivery and referral support for urban poor. Collaboration with other sectors to address wider determinants of urban health is advocated.
- In National Health Programmes—integration with health systems for programme effectiveness and in turn contributing to strengthening of health systems for efficiency.
- In AYUSH services—from stand-alone to a three-dimensional mainstreaming.
Free primary care provision by the public sector, supplemented by strategic purchase of secondary care hospitalisation and tertiary care services from both public and from nongovernment sector to fill critical gaps as a short-term measure would be the main strategy of assuring health care services. Strategic purchasing refers to the Government acting as a single payer. The order of preference for strategic purchase would be public sector hospitals followed by not-for-profit private sector and then commercial private sector in underserved areas, based on availability of services of acceptable and defined quality criteria. In the long run, the policy envisages having fully equipped and functional public sector hospitals in these areas, with public facilities remaining the focal point in the health care delivery system. Situation-specific measures will be provided for tribal and socially vulnerable population groups. Outreach of public health care will be enhanced through Mobile Medical Units (MMUs), etc. with active engagement with nongovernment sector. In order to provide access and financial protection at secondary and tertiary care levels, the policy proposes free drugs, free diagnostics and free emergency care services in all public hospitals.
To address the growing challenges of urban health, the policy advocates scaling up National Urban Health Mission (NUHM) to cover the entire urban population within the next 5 years with sustained financing.
For effectively handling medical disasters and health security, the policy recommends that the public health care system retain a certain excess capacity in terms of health infrastructure, human resources, and technology which can be mobilised in times of crisis.
Mainstreaming of the different health systems will be done by increasing research to add to the common pool of knowledge, providing access and informed choice to the patients, providing an enabling environment for practice of different systems of medicine, an enabling regulatory framework and encouraging cross referrals across these systems.
Primary Care Services and Continuity of Care
This policy denotes important change from very selective to comprehensive primary health care package which includes geriatric health care, palliative care and rehabilitative care services. The facilities which start providing the larger package of comprehensive primary health care will be called “Health and Wellness Centres”. Every family would have a health card that links them to primary care facility and be eligible for a defined package of services anywhere in the country. Health centres are to be established on geographical norms apart from population norms. For this purpose, human resources development strategy will be developed, effective logistics support system and referral backup ensured, existing subcentres will be upgraded and Primary Health Centres (PHCs) will be reoriented to provide comprehensive set of preventive, promotive, curative and rehabilitative services. Digital health for two-way systemic 8linkages between the various levels of care viz. primary, secondary and tertiary is envisaged to ensure continuity of care.
It also recommends providing access to assured AYUSH health care services, support documentation and validation of local home and community-based practices, research and validation of tribal medicines.
Secondary Care Services
The policy aspires to provide at the district level most of the secondary care which is currently provided at a medical college hospital. Basic secondary care services, such as cesarean section and neonatal care would be made available at the least at subdivisional level in a cluster of few blocks. To achieve this, policy therefore aims:
- To have at least two beds to be made available per thousand population, distributed in such a way that it is accessible within golden hour rule. This implies an efficient emergency transport system. The ten categories of specialist skills are to be available within the district. Additionally four or at least five of these specialist skill categories to be available at subdistrict levels. This may be achieved by strengthening the district hospital and a well-chosen, well-located set of subdistrict hospitals.
- Resource allocation that is responsive to quantity, diversity and quality of caseloads provided.
- Purchasing care after due diligence from nongovernment hospitals as a short-term strategy till public systems are strengthened. A responsive and strong regulatory framework will be available to guide purchasing of care from nongovernment sector so that challenges of quality of care, cost escalations and impediments to equity are addressed effectively.
In order to develop the secondary care sector, comprehensive facility development with human resources, especially specialists, are to be prioritised. The network of blood banks across the country will be expanded to ensure improved access to safe blood.
Reorienting Public Hospitals
The public hospitals would provide universal access to a progressively wide array of free drugs and diagnostics, while maintaining adequate standards of diagnosis and treatment. An information system with comprehensive data on availability and utilisation of services is required in public as well as in nongovernment sector hospitals. State public health systems should be able to provide all emergency health services other than services covered under national health programmes.
Closing Infrastructure and Human Resources/Skill Gaps
Districts and blocks which have wider gaps for development of infrastructure and deployment of additional human resources would receive focus. Financing for additional infrastructure or human resources would be based on needs of outpatient and inpatient attendance and utilisation of key services in a measurable manner.9
Urban Health Care
Primary health care needs of the urban population will be addressed with special focus on poor populations living in listed and unlisted slums, other vulnerable populations such as homeless, rag-pickers, street children, rickshaw pullers, construction workers, sex workers and temporary migrants, with utilization of AYUSH personnel, for-profit and not-for-profit sector for urban health care delivery. Achieving convergence among the wider determinants of health—air pollution, better solid waste management, water quality, occupational safety, road safety, housing, vector control, and reduction of violence and urban stress, will be focused upon. Health care needs of the people living in the peri-urban areas would also be addressed under the NUHM. Further, NCDs like hypertension, diabetes which are predominant in the urban areas would be addressed under NUHM, through planned early detection and better secondary prevention. Improved health seeking behaviour, influenced through capacity building of the community-based organisations and establishment of an appropriate referral mechanism, would also be important components of this strategy.
NATIONAL HEALTH PROGRAMMES
RMNCH+A Services
The policy strongly recommends strengthening of general health systems to prevent and manage maternal complications, to ensure continuity of care and emergency services for maternal health and to comprehensively address factors affecting maternal and child survival, by focusing upon the social determinants through developmental action in all sectors.
Child and Adolescent Health
Focus is on accelerated achievement of neonatal mortality targets and “single digit” stillbirth rates through improved home-based and facility-based management of sick newborns. District hospitals must ensure screening and treatment of growth-related problems, birth defects, genetic diseases and provide palliative care for children. School health programmes to include health and hygiene as a part of the school curriculum. Special emphasis to be given on health challenges of adolescents. Reproductive and sexual health should address issues like inadequate calorie intake, nutrition status and psychological problems linked to misuse of technology, etc.
Interventions to Address Malnutrition and Micronutrient Deficiencies
Focus would be on augmenting initiatives like micronutrient supplementation, food fortification, screening for anaemia and multiple micronutrient deficiencies, with focus on the more vulnerable sections of the population. The present efforts of iron folic acid (IFA) supplementation, calcium supplementation during pregnancy, iodized salt, zinc and oral rehydration salts/solution (ORS), vitamin A supplementation, needs to be intensified and increased. Other strategies include outreach to every beneficiary, intensive monitoring and 10developing a strong evidence base of the burden of collective micronutrient deficiencies. Synergy is required between related departments like Women and Child Development, Education, Water Sanitation and Hygiene (WASH), Agriculture and Food and Civil Supplies, with the Ministry of Health and Family Welfare (MOHFW) on the role of convener.
Universal Immunisation
Priority would be to further improve immunisation coverage with quality and safety, improve vaccine security as per National Vaccine Policy 2011 and introduction of newer vaccines based on epidemiological considerations. The focus will be to build upon the success of Mission Indradhanush and strengthen it.
Communicable Diseases
For Integrated Disease Surveillance Programme (IDSP), the policy advocates the need for districts to respond to the communicable disease priorities of their locality, through network of well-equipped laboratories backed by tertiary care centres and enhanced public health capacity to collect, analyse and respond to the disease outbreaks.
Strategies to combat HIV and TB coinfection and increased incidence of drug-resistant TB will include more active case detection, access to free drugs, greater involvement of private sector, preventive and promotive action in the workplace and improvement in living conditions.
For control of HIV/AIDS focused interventions on the high-risk communities [men who have sex with men (MSM), transgender, female sex workers (FSW), etc.] and prioritised areas, is recommended. There is a need to support care and treatment for people living with HIV/AIDS through inclusion of first-, second- and third-line ARV, Hep-C and other costly drugs into the essential medical list.
To carry out leprosy elimination, the proportion of grade 2 cases amongst new cases will become the measure of community awareness and health systems capacity, keeping in mind the global goal of reduction of grade 2 disability to less than 1/1,000,000 by 2020. Accordingly, the policy envisages proactive measures targeted toward elimination of leprosy from India by 2018.
The challenge of drug resistance in Malaria should be dealt with by changing treatment regimens with logistics support as appropriate. New National Programme for Prevention and Control of Japanese Encephalitis (JE)/Acute Encephalitis Syndrome (AES) should be accelerated with strong component of intersectoral collaboration.
The policy recognises the interrelationship between communicable disease control programmes and public health system strengthening. Every one of these programmes requires a robust public health system as their core delivery strategy. At the same time, these programmes also lead to strengthening of health care systems.
Noncommunicable Diseases
The policy recommends to set-up a National Institute of Chronic Diseases including Trauma. An integrated approach with screening for the most prevalent NCDs and secondary prevention 11is envisaged. This would be incorporated into the comprehensive primary health care network with linkages to specialist consultations and follow-up at the primary level. Emphasis on medication and access for select chronic illnesses on a “round the year” basis would be ensured.
Screening for oral, breast and cervical cancer and for chronic obstructive pulmonary disease (COPD) will be focused in addition to hypertension and diabetes. Programmes for prevention of blindness, deafness, oral health, endemic diseases like fluorosis and sickle cell anaemia/thalassemia etc. will be supported.
The policy focus is also on research. It emphasises developing a protocol for mainstreaming AYUSH as an integrated medical care and promotes research in traditional systems of medicine.
Focus will also be on health needs of the aging community, growing need for palliative and rehabilitative care for all geriatric illnesses and continuity of care across all levels.
The policy recognises the critical need of meeting the growing demand of tissue and organ transplant in the country and encourages widespread public awareness to promote voluntary donations.
Mental Health
This policy will take into consideration the provisions of the National Mental Health Policy 2014 with simultaneous action on the following fronts:
- Increase creation of specialists through public financing and develop special rules to give preference to those willing to work in public systems.
- Create network of community members to provide psychosocial support to strengthen mental health services at primary level facilities.
- Leverage digital technology in a context where access to qualified psychiatrists is difficult.
Population Stabilisation
The NHP recognises that improved access, education and empowerment would be the basis of successful population stabilisation. The policy imperative is to move away from camp-based services with all its attendant problems of quality, safety and dignity of women, to a situation where these services are available on any day of the week or at least on a fixed day. Other policy imperatives are to increase the proportion of male sterilisation from less than 5% currently, to at least 30% and if possible much higher.
WOMEN'S HEALTH AND GENDER MAINSTREAMING
There will be enhanced provisions for reproductive morbidities and health needs of women beyond the reproductive age group (40+), in addition to package of services already available.
GENDER-BASED VIOLENCE
Women's access to health care needs to be strengthened by making public hospitals more women friendly and ensuring that the staff has orientation to gender-sensitivity issues. Health 12care to the survivors/victims need to be provided free and with dignity in the public and private sector.
SUPPORTIVE SUPERVISION
For supportive supervision in more vulnerable districts with inadequate capacity, the policy will support innovative measures such as use of digital tools and human resource strategies like using nurse trainers to support field workers.
EMERGENCY CARE AND DISASTER PREPAREDNESS
The policy supports development of earthquake- and cyclone-resistant health infrastructure in vulnerable areas, development of mass casualty management protocols for Community Health Center (CHC) and higher facilities and emergency response protocols at all levels, creation of a unified emergency response system, linked to a dedicated universal access number, with network of emergency care that has an assured provision of life support ambulances, trauma management centres—1/3,000,000 population in urban areas and 1/1,000,000 population in rural areas.
MAINSTREAMING THE POTENTIAL OF AYUSH
Yoga would be introduced much more widely in school and workplaces as part of promotion of good health as adopted in National AYUSH Mission (NAM). Other focus areas would be standardising and validating Ayurvedic medicines, and improving quality control of drugs; capacity building of institutions and professionals; building research and public health skills for preventive and promotive health care; linking AYUSH systems with ASHAs and VHSNCs.
For mainstreaming of AYUSH with general health system addition of a mandatory bridge course that gives competencies to mid-level care provider with respect to allopathic remedies is contemplated. The policy recognises the need for integrated courses for Indian System of Medicine, Modern Science and Ayurgenomics, so as to sensitise practitioners of each system to the strengths of the others.
The policy seeks to strengthen steps for farming of herbal plants, along with market linkages in processing of medicinal plants.
TERTIARY CARE SERVICES
Tertiary care services are to be organised along lines of regional, zonal and apex referral centres. Government should set up new Medical Colleges, Nursing Institutions and AIIMS, addressing regional disparities in distribution of these institutions. Periodic review and standardisation of fee structure and quality of clinical training in the private sector medical colleges are to be undertaken. Operationalisation of mechanisms for referral from public health system to charitable hospitals will be worked out and private institutions should ensure that deserving patients can be admitted on designated free/subsidised beds.
The policy recommends establishing National Healthcare Standards Organisation and to develop evidence-based standard guidelines of care applicable both to public and private 13sector. Partnership to be developed with nongovernment sector through empanelling the socially motivated and committed tertiary care centres into the Government efforts, to close the specialist gap. To expand tertiary services, the Government would additionally purchase select tertiary care services from empanelled nongovernment sector hospitals to assist the poor.
HUMAN RESOURCES FOR HEALTH
The policy supports measures aimed at continuing medical and nursing education and on the job support to providers, especially those working in professional isolation in rural areas, using digital tools and other appropriate training resources. Policy recommends development of leadership skills, strengthening human resource governance in public health system, through establishment of robust recruitment, selection, promotion and transfer postings policies.
Medical education and service: The policy recommends strengthening existing medical colleges and converting district hospitals to new medical colleges to increase number of doctors and specialists, in States with large human resource deficit. The policy recognises the need to increase the number of postgraduate seats; expand the number of AIIMS like centres; Tele-education, Tele-CME, Tele-consultations and access to digital library, through National Knowledge Network.
Other recommendations are a common entrance examination advocated on the pattern of NEET for undergraduate entrance at All India level; a common national level Licentiate/exit examination for all medical and nursing graduates; a regular renewal at periodic intervals with Continuing Medical Education (CME) credits accrued; reviewing Multiple Choice Question (MCQ)-based entrance test for postgraduates medical courses; revise the undergraduate and postgraduate medical curriculum; review existing institutional mechanisms to regulate and ensure quality of training and education being imparted.
To attract and retain doctors in rural areas, the policy proposes financial and nonfinancial incentives, creating medical colleges in rural areas; preference to students from under-serviced areas, realigning pedagogy and curriculum to suit rural health needs, mandatory rural postings, transparent career progression guidelines are valuable strategies.
To attract and retain specialists, proposed measures include recognition of educational options linked with National Board of Examination and College of Physicians and Surgeons, creation of specialist cadre with suitable pay scale, upgradation of short-term training to medical officers to provide basic specialist services at the block and district level, distance and continuing education options for general practitioners in both the private and the public sectors, performance linked payments and popularise Doctor of Medicine (MD) course in Family Medicine or General Practice.
Mid-level service providers: Courses like BSc in community health and/or through competency-based bridge courses and short courses, to be offered to create health personnel to provide services at the subcentre and other peripheral levels. These bridge courses could admit graduates from different clinical and paramedical backgrounds like AYUSH doctors, BSc Nurses, Pharmacists, GNMs, etc. Locale based selection, a special curriculum of training close to the place where they live and work, conditional licensing, enabling legal framework and a 14positive practice environment will ensure that this new cadre is preferentially available where they are needed most, i.e. in the under-served areas.
Nursing education: Measures suggested are—establishing cadres like Nurse Practitioners and Public Health Nurses, developing specialised nursing training courses and curriculum (critical care, cardiothoracic vascular care, neurological care, trauma care, palliative care and care of terminally ill), establishing nursing school in every large district or cluster of districts of about 2,000,000–3,000,000 population and establishing Centres of Excellence for Nursing and Allied Health Sciences in each State, along with improving regulation and quality management of nursing education.
ASHA: This policy supports certification programme for ASHAs for their preferential selection into Auxiliary Nurse Midwife (ANM), nursing and paramedical courses; enabling engagements with nongovernmental organisations (NGOs) to serve as support and training institutions for ASHAs; revival and strengthening of Multipurpose Male Health Worker cadre; adding a second Community Health Worker based on geographic considerations, disease burdens, and time required for multiple tasks to be performed by ASHA/Community Health Worker.
Paramedical skills: Training courses and curriculum for super specialty paramedical care, etc. would be developed. Planned expansion of allied technical skills—perfusionists, physiotherapists, occupational therapists, radiological technicians, magnetic resonance imaging (MRI) technicians, laboratory technicians, audiologists, optometrists, pharmacists, with local employment opportunities, is a key policy direction.
Public health management cadre: The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria. Medical and health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training, would also be considered. States could decide to locate these public health managers, with medical and nonmedical qualifications, into same or different cadre streams belonging to Directorates of health.
Further, the policy recognises the need to continuously nurture certain specialised skills like entomology, housekeeping, biomedical waste management, biomedical engineering, communication skills, management of call centres and even ambulance services.
FINANCING OF HEALTH CARE
The policy advocates allocating major proportion (up to two-thirds or more) of resources to primary care followed by secondary and tertiary care. A robust National Health Accounts System would be operationalised to improve public sector efficiency in resource allocation/payments. Operational costs would be in the form of reimbursements for care provision and on a per capita basis for primary care. Items like infrastructure development and maintenance, nonincentive cost of the human resources, i.e. salaries and much of administrative costs, would however continue to flow on a fixed cost basis.
Total allocations would be made on the basis of differential financial ability, developmental needs and high priority districts to ensure horizontal equity. A higher unit cost or some 15form of financial incentive payable to facilities providing a measured and certified quality of care is recommended.
Purchasing of health care services: The existing Government financed health insurance schemes shall be aligned to cover selected benefit package of secondary and tertiary care services, purchased from public, not-for-profit and private sector in the same order of preference, subject to availability of quality services on time as per defined norms, and adhering to standard treatment protocols by public and nongovernment hospitals.
For need-based purchasing of secondary and tertiary care from nongovernment sector, trusts or registered societies would be created at Centre and State levels with institutional autonomy. The payments will be made by the trust/society on a reimbursement basis for services provided.
COLLABORATION WITH NONGOVERNMENT SECTOR/ENGAGEMENT WITH PRIVATE SECTOR
The policy suggests exploring collaboration for primary care services with not-for-profit organizations where critical gaps exist, as a short-term measure. Collaboration can also be done for specialised human resources. The policy supports voluntary service in rural and under-served areas by recognised health care professionals.
Private sector is encouraged to invest which may entail contracting, strategic purchasing, etc. The policy advocates for contracting of private sector in the following activities:
Capacity building: Outsourcing of training of teachers to strengthen school health programmes by adopting neighbourhood schools for quarterly training modules.
Skill development programmes: Recognising that there are huge gaps in technicians, nursing and paranursing, paramedical staff and medical skills in select areas, the policy advocates coordination between National Council for Skill Development, MOHFW and State Government(s) for engaging private hospitals/private general medical practitioners in skill development.
Corporate social responsibility: CSR is an important area which should be leveraged for filling health infrastructure gaps in public health facilities across the country. The private sector could use the CSR platform to play an active role in the awareness generation through campaigns on occupational health, blood disorders, adolescent health, safe health practices and accident prevention, micronutrient adequacy, antimicrobial resistance, screening of children and antenatal mothers, psychological problems linked to misuse of technology, etc. The policy recommends engagement of private sector through adoption of neighbourhood schools/colonies/slums/tribal areas/backward areas for health care awareness and services.
Mental health care programmes: Training community members to provide psychological support to strengthen mental health services in the country.
Disaster management: Private sector can contribute to medical relief, post trauma counselling/treatment, by pooling their infrastructure and human resources for quick deployment during disasters and emergencies and help in creation of a unified emergency response system.
Strategic purchasing as stewardship: The policy advocates building synergy with not-for-profit organisations and private sector, subject to availability of timely quality services as 16explained earlier, through schemes like Aarogyasri and Rashtriya Swasthya Bima Yojana (RSBY). The aim would be to improve health outcomes and reduce out of pocket payments while minimising moral hazards. Preference is to be given to private hospitals/institutes collaborating for Central Government Health Scheme (CGHS) empanelment. Government would collaborate with the private sector for operationalising health and wellness centres to provide a larger package of comprehensive primary health care across the country, addressing specific gaps in public services like diagnostics services, ambulance services, safe blood services, rehabilitative services, palliative services, mental health care, telemedicine services, managing of rare and orphan diseases.
Enhancing accessibility in private sector: Charitable hospitals and not-for-profit hospitals may volunteer for accepting referrals from public health facilities. The private sector could also provide for increased designated free/subsidised beds in their hospitals for the downtrodden, poor and others toward societal cause.
Role in immunisation: The policy recognises the role of the private sector in immunisation programmes and advocates their continued collaboration in rendering immunisation service as per protocol.
Disease surveillance: Toward strengthening disease surveillance, the private sector laboratories could be engaged for data pooling and sharing. All clinical establishments would be encouraged to notify diseases and provide information of public health importance.
Tissue and organ transplantations: Tissue and organ transplantations, voluntary donations and awareness generation are areas where private sector provides services.
Make in India: Toward furthering “Make in India”, the private domestic manufacturing firms/industry could be engaged to provide customised indigenous medical devices to the health sector and in creation of forward and backward linkages for medical device production. The policy also seeks assured purchase by Government health facilities from domestic manufacturers, subject to quality standards being met.17
Health information system: The objective of an integrated health information system necessitates private sector participation in developing and linking systems into a common network/grid which can be accessed by both public and private health care providers. Collaboration with private sector consistent with Metadata and Data Standards (MDDS) and Electronic Health Records (EHRs) would lead to developing a seamless health information system. The private sector could help in creation of registries of patients and in documenting diseases and health events.
Incentivising private sector: To encourage participation of private sector, the policy advocates incentivising the private sector through inter alia (1) reimbursement/fees, (2) preferential treatment to collaborating private hospitals/institutes for CGHS empanelment and in proposed strategic purchase by Government, subject to other requirements being met, (3) nonfinancial incentives like recognition/acknowledgment/felicitation and skill upgradation to the private sector hospitals/practitioners for providing public health services and for partnering with the Government of India/State Governments in health care delivery and (4) through preferential purchase by Government health facilities from domestic manufacturers, subject to quality standards being met.
REGULATORY FRAMEWORK
The regulatory role of the MOHFW needs urgent and concrete steps toward reform. This will entail moving toward a more effective, rational, transparent and consistent regime.
Professional education regulation: The policy calls for a major reform in this area. It advocates strengthening of six professional councils (Medical, Ayurveda Unani and Siddha, Homeopathy, Nursing, Dental and Pharmacy) through expanding membership of these councils between three key stakeholders—doctors, patients and society in balanced numbers. The policy supports setting up of National Allied Professional Council to regulate and streamline all allied health professionals and ensure quality standards.
Regulation of clinical establishments: A few States have adopted the Clinical Establishments Act 2010. Advocacy with the other States would be made for adoption of the Act. Grading of clinical establishments and active promotion and adoption of standard treatment guidelines would be one starting point. Protection of patient rights in clinical establishments (such as rights to information, access to medical records and reports, informed consent, second opinion, confidentiality and privacy) as key process standards would be an important step. Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes/complaints regarding standards of care, prices of services, negligence and unfair practices. Standard Regulatory framework for laboratories and imaging centres, specialised emerging services such as assisted reproductive techniques, surrogacy, stem cell banking, organ and tissue transplantation and Nanomedicine will be created as appropriate.
Food safety: The policy recommends putting in place and strengthening necessary network of offices, laboratories, e-governance structures and human resources needed for the enforcement of Food Safety and Standards (FSS) Act, 2006.
Drug regulation: Prices and availability of drugs are regulated by the Department of Pharmaceuticals. This policy encourages the streamlining of the system of procurement of drugs; a strong and transparent drug purchase policy for bulk procurement of drugs; and facilitating spread of low cost pharmacy chain such as Jan Aushadhi stores linked with ensuring prescription of generic medicines; education of public with regard to branded and nonbranded generic drugs.
Medical devices regulation: The policy recommends strengthening regulation of medical devices and establishing a regulatory body for medical devices. Post market surveillance programme for drugs, blood products and medical devices shall be strengthened to ensure high degree of reliability and to prevent adverse outcomes due to low quality and/or refurbished devices/health products.
Clinical trial regulation: Transparent and objective procedures shall be specified, and functioning of ethics and review committees will be strengthened. The Global Good Clinical Practice Guidelines, which specifies standards, roles and responsibilities of sponsors, investigators and participants would be adhered to. Irrational drug combination will continue to be monitored and controlled and appropriate regulatory framework for standardisation of AYUSH drugs will be ensured.18
Pricing—drugs, medical devices and equipment: Timely revision of National List of Essential Medicines (NLEM) along with appropriate price control mechanisms for generic drugs, and also for the list of essential diagnostics and equipment, shall remain a key strategy.
VACCINE SAFETY
The policy advocates commissioning more research and development for manufacturing new vaccines, including vaccines against locally prevalent diseases. It recommends building more public sector manufacturing units to generate healthy competition; uninterrupted supply of quality vaccines, developing innovative financing and creating assured supply mechanisms with built in flexibility. Units such as the integrated vaccine complex at Chengalpattu would be set up and vaccine, antisera manufacturing units in the public sector upgraded with increase in their installed capacity.
MEDICAL TECHNOLOGIES
Making available good quality, free essential and generic drugs and diagnostics, at public health care facilities is recommended. The free drugs and diagnostics basket would include all that is needed for comprehensive primary care, including care for chronic illnesses. At the tertiary care level too, at least for geriatric and chronic diseases, most drugs and diagnostics should be free or subsidised with fair price selling mechanisms for most and some co-payments for the well-to-do.
PUBLIC PROCUREMENT
Quality of public procurement and logistics is a major challenge to ensuring access to free drugs and diagnostics through public facilities. An essential prerequisite that is needed to address the challenge of providing free drugs through public sector, is a well-developed public procurement system.
AVAILABILITY OF DRUGS AND MEDICAL DEVICES
The policy advocates the need to incentivise local manufacturing of medical devices in consonance with the “Make in India” national agenda, and regulate the use of medical devices so as to ensure safety and quality compliance as per the standard norms. The policy also recommends and prioritises establishing sufficient labelling and packaging requirements on part of industry, adequate medical devices testing facility and effective port-clearance mechanisms for medical products.
MANUFACTURING OF ESSENTIAL DRUGS AND VACCINES
Public sector capacity in manufacture of certain essential drugs and vaccines is also essential. These public institutions need more investment, appropriate human resource policies and governance initiatives to enable them to become comparable with their benchmarks in the developed world.19
ANTIMICROBIAL RESISTANCE
The problem of antimicrobial resistance calls for a rapid standardisation of guidelines, regarding antibiotic use, limiting the use of antibiotics as Over-the-Counter medication, banning or restricting the use of antibiotics as growth promoters in animal livestock. Pharmacovigilance including prescription audit inclusive of antibiotic usage, in the hospital and community, is a must in order to enforce change in existing practices.
HEALTH TECHNOLOGY ASSESSMENT
Health Technology Assessment is required to ensure that technology choice is participatory and is guided by considerations of scientific evidence, safety, consideration on cost-effectiveness and social values. The NHP commits to the development of institutional framework and capacity for Health Technology Assessment and adoption.
DIGITAL HEALTH TECHNOLOGY ECOSYSTEM
Recognising the integral role of technology (eHealth, mHealth, Cloud, Internet, etc.) in the health care delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy aims at an integrated health information system which will serve the needs of all stakeholders and link systems will be rolled out across public and private health providers at State and National levels consistent with MDDS and EHRs. The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real-time data, are key strategies of the National Health Information Architecture.
Application of digital health: The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Subdistrict hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilisation of National Knowledge Network for Tele-education, Tele-CME, Tele-consultations and access to digital library.
Leveraging digital tools for AYUSH: Digital tools would be used for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level health care providers and for household level preventive, promotive and curative practices.
HEALTH SURVEYS
The scope of health, demographic and epidemiological surveys would be extended to capture information regarding costs of care, financial protection and evidence based policy planning and reforms. The policy recommends rapid programme appraisals and periodic disease-specific surveys to monitor the impact of public health and disease interventions using digital tools for epidemiological surveys.20
HEALTH RESEARCH
The policy recognises the key role that health research plays in the development of a nation's health. In knowledge-based sector like health, where advances happen daily, it is important to increase investment in health research.
Strengthening knowledge for health: The policy envisages strengthening the publicly funded health research institutes under the Department of Health Research, the apex public health institutions under the Department of Health and Family Welfare, as well as those in the Government and private medical colleges. Research that will be encouraged include health systems and services research, medical product innovation (including point of care diagnostics and related technologies and use of internet) and fundamental research in all areas relevant to health—such as Physiology, Biochemistry, Pharmacology, Microbiology, Pathology, Molecular Sciences and Cell Sciences. Drug research on critical diseases such as TB, HIV/AIDS, and malaria may be incentivised, to address them on priority.
Policy aims to promote innovation, discovery and translational research on drugs in AYUSH and allocate adequate funds toward it. Research on social determinants of health along with neglected health issues such as disability and transgender health will be promoted.
Creation of a Common Sector Innovation Council for the Health Ministry that brings together various regulatory bodies for drug research, the Department of Pharmaceuticals, the Department of Biotechnology, the Department of Industrial Policy and Promotion, the Department of Science and Technology, etc. would be desirable.
Drug innovation and discovery: Government policy would be to both stimulate innovation and new drug discovery as per health needs and affordability. Similar policies are required for point of care diagnostics and medical equipment for use in rural and remote areas. Convergence is required between drug research institutions, drug manufacturers and premier medical institutions.
Development of information databases: There is also a need to develop information databases on a wide variety of areas that researchers can share. This includes ensuring that all unit data of major publicly funded surveys related to health, are available in public domain in a research friendly format.
Research collaboration: The policy on international health and health diplomacy should leverage India's strength in cost-effective innovations in the areas of pharmaceuticals, medical devices, health care delivery and information technology, along with international cooperation.
GOVERNANCE
Role of centre and state: The policy recommends equity sensitive resource allocation, strengthening institutional mechanisms for consultative decision-making and coordinated implementation, between the Centre and the State, as the way forward. Besides, better management of fiduciary risks, provision of capacity building, technical assistance to States to develop State-specific strategic plans, through the active involvement of local self-government and through community-based monitoring of health outputs is also recommended.21
Role of Panchayati Raj institutions: Panchayati Raj institutions would be strengthened to play an enhanced role at different levels for health governance, including the social determinants of health. There is need to make community-based monitoring and planning (CBMP) mandatory, so as to place people at the centre of the health system and development process for effective monitoring of quality of services and for better accountability in management and delivery of health care services.
Improving accountability: The policy would be to increase both horizontal and vertical accountability of the health system by providing a greater role and participation of local bodies and encouraging community monitoring, programme evaluations along with ensuring Grievance Redressal Systems.
LEGAL FRAMEWORK FOR HEALTH CARE AND HEALTH PATHWAY
The policy while supporting the need for moving in the direction of a rights based approach to health care is conscious of the fact that threshold levels of finances and infrastructure is a precondition for an enabling environment, to ensure that the poorest of the poor stand to gain the maximum and are not embroiled in legalities. The policy therefore advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realising health care as a right in the future.
IMPLEMENTATION FRAMEWORK AND WAY FORWARD
The NHP 2017 envisages that an implementation framework be put in place to deliver on these policy commitments. Such an implementation framework would provide a roadmap with clear deliverables and milestones to achieve the goals of the policy.