The first National Health Policy (1983) has guided the development in health sector for last two decades. In line with the changing health scenario and overall increasing role of privatisation in the national economy, National Health Policy 2002 has been brought out by the Ministry of Health and Family Welfare, Government of India.
In the National Health Policy 2002, achievements in health sector during last 50 years have been reviewed. Notable among these are eradication of small pox and country certified free of guinea worm, final steps towards eradication of poliomyelitis, increase in life expectancy, decrease in death rate, infant mortality rate, birth rate, massive reduction in leprosy and malaria and development of vast health infrastructure (Annexure 1).1
Providing continuum to the Health Policy 1983, the strategy of primary health care has been adopted as the key strategy in the new Health Policy, with emphasis on equitable access to health services through:
- A decentralised public health system.
- Increasing public health investment, with greater allocation for primary health level.
- Strengthening and extending public health services.
- Enhanced contribution of private and NGO sector targeted towards the groups which can afford to pay for services.
Overall objective of the new health policy is to achieve an acceptable standard of good health amongst the general population of the country.
Within this broad objective, specified time bound goals have also been defined (Annexure 2).
DETERMINANTS OF ACCESS TO HEALTH SERVICES
Financial Resources: Over the years, the proportion of Central Government budgetary allocation for health out of the total budget remains stagnant at 1.3%. In the states this proportion has progressively declined from 7.0% to 5.5%. It has been felt that inability to provide adequate resources for social infrastructure like health has contributed to overall decline in public spending on health care infrastructure in the country.1
Taking this into consideration, it is planned to increase health sector expenditure to 6.0% of GDP, with 2.0% of GDP being appropriated to public health investment by year 2010. The states should try not only to arrest the declining trend in public health expenditure but should restore it to 7% of the budget by 2005 and 8% by 2010. To help the states, it envisages to increase the central share in total health spending of the states from present 15% to 25% by 2010.
Equity: To meet the objective of reducing various types of inequities and imbalances: inter-regional, rural-urban and between socio-economic classes, the most cost effective method would be to increase sectoral outlay in the primary health sector.
In order to ensure that access to primary health care will be maximised, at least 55% of public health investment will be in primary health care, 35% in secondary health care and the balance 10% in tertiary health care.
IMPROVING PUBLIC HEALTH INFRASTRUCTURE
The policy recognises that on account of resource constraints, the supply of drugs by the state governments is grossly inadequate. As the patients have to buy drugs and there being little use for diagnostic services at the peripheral level, potential beneficiaries do not utilise their services. The policy envisages kick-starting the revival of Primary Health System by providing some essential drugs under central government funding. This measure is expected to create a demand for other professional services from the local population, which in turn will boost the general revival of activities in these service centres and improve utilisation of their services.
In order to update the health personnel, and equip them for new assignments, the policy envisages more frequent in-service training of public health medical personnel at the level of medical officers as well as paramedics.
As the global experience shows that it is investment in primary health sector rather than aggregate health expenditure that positively affects public health indices, the policy places greater reliance on primary health structure for the attainment of improved public health outcome on an equitable basis.
Extending Public Health Services
The policy has suggested considering utilisation of services of Licentiate Medical Practitioners and practitioners of Indian Systems of Medicine and Homeopathy for providing services in under-served areas on lines of services rendered by nurse practitioners in several developed countries. Scope of use of paramedical manpower of allopathic disciplines, in a prescribed functional area adjunct to their current functions, would also be examined for meeting simple public health requirements.
The need for simplification of recruitment procedures and rules for contract employment, in order to provide trained manpower in under-served areas has been recognised.
Human Resource Development
Medical and Dental Colleges
In order to overcome the problem of uneven distribution of medical and dental colleges in various parts of the country, the policy envisages the setting up of a Medical Grants Commission for funding new government medical and dental colleges in different parts of the country. The Medical Grants Commission will also fund upgradation of the infrastructure of existing colleges so as to ensure improved standard of medical education.
The need for inclusion of geriatric disorders and disciplines of contemporary medical research has also been emphasised. It has also been suggested that additional postgraduate seats should be created in the disciplines where manpower is deficient.
Specialisation in Public Health and Family Medicine
To alleviate the shortage of specialists in public health and family medicine, the policy has suggested gradual increase in the proportion of postgraduate seats in these disciplines in the medical institutions so that 1/4th of the seats are earmarked for these disciplines. This will be given due weightage while sanctioning new post-graduate seats in future. The policy has suggested post-graduation in public health for not only doctors but also for non-medical graduates from other development sectors like public health engineering, microbiology and other natural sciences.
In the interest of patient care, the policy emphasises the need for an improvement in ratio of nurses vis-a-vis doctors/beds. To meet the increased demand in government and private sector, the need for central government subsidy for setting up and running of training facilities on a decentralised basis has been recognised. The need for setting up of training courses for super-speciality nurses required for tertiary care institutions has also been recognised. Besides increasing the ratio of degree holding vis-a-vis diploma holding nurses, it is envisaged to improve the skill level of nurses.
Delivery of National Public Health Programmes
The policy envisages key role for the central government in designing national programmes with active participation of states. Centre is also to provide financial support besides technical support, monitoring and evaluation at the national level.
For optimal utilisation of Public Health infrastructure at the primary level, gradual convergence of all health programmes under a single field umbrella is envisaged. However, vertical programmes on major diseases are to continue till moderate levels of prevalence are reached.
The policy also favours programme implementation through autonomous bodies at state and district level to facilitate greater operational flexibility and well informed decision making. This means adoption of society model at the state and district level for programme implementation.
The policy also favours decentralised implementation of national disease control programmes through local self-government institutions. For this financial incentives to these institutions are proposed.
Involvement of Non-Government Organisations
In principle the state would encourage handing over of public health service outlets at any level for management by NGOs and other institutions of civil society, on ‘as-is-where-is’ basis, along with the normative funds earmarked for such institutions.
In order to utilise their high motivational skills, it has been suggested that at least 10% of the disease control programme budget should be earmarked for implementation through these institutions.
Involvement of Private Sector
The policy welcomes participation of the private sector at all levels of health care i.e. primary, secondary and tertiary. However, based on past experience, its contribution is expected mostly in urban primary and tertiary sector and moderate in secondary sector.
It is also proposed to study the feasibility of providing services through private sector, supported by social health insurance scheme, funded by the government. The results of pilot projects in this regard can provide the basis of future public health policy. Such a mechanism is required in view of very large number of poor in the country, for whom it is difficult to conceive of an exclusive government structure to provide health services.
Drugs and Vaccines
For cost effective public health care, the policy favours treatment regimens based on a limited number of essential drugs of generic nature, use of proprietary drugs will be prohibited in government sector while in private sector use of non-essential drugs will be discouraged through fiscal disincentives. Production and sale of irrational combinations of drugs would be prohibited through drug standards statute.
To ensure uninterrupted supply of vaccines at an affordable price for the National Programme for Immunisation, not less than 50% of the requirement of vaccines/sera to be sourced from public sector institutions.
Population Stabilisation: Population stabilisation and general health initiatives, when effectively synchronised, have a synergistic effect on the socio-economic well-being of the people. Therefore, synchronised implementation of National Health Policy and National Population Policy has been emphasised. In line with this the health policy has adopted socio-demographic and health goals set up in the National Population Policy 2000 in order to realise its objective of achieving an acceptable standard of good health of the general population of the country.
Intersectoral Contribution to Health: Health status of people depends on adequate nutrition, safe drinking water, basic sanitation, a clean environment and primary education, especially girl child and access to basic health services.
The health policy has emphasised that interface should be smooth between independent policies of these interconnected sectors. However, no guidelines or recommendations have been made for these sectors, as it is in the domain of their respective policies.
Information Education Communication: The emphasis is on dispelling myths and dissemination of information to those population groups which cannot be effectively approached by using only the mass media. This will be effected through inter-personal communication and folk and other traditional media to bring about a behaviour change. The IEC programme would set specific targets for the association of PRIs/NGOs/Trusts in such activities.
NHP-2002 also envisages giving priority to school health programmes which aim at preventive health education, providing regular health check-ups and promotion of health seeking behaviour among children.
MEDICAL ETHICS AND LEGISLATION
Medical Ethics: NHP 2002 envisages that in order to ensure that common patient is not subjected to irrational or profit driven medical regimens, a contemporary code of ethics be notified and vigorously implemented by the Medical Council of India. The need for watch on research in areas like gene manipulation and stem cell research has been emphasised so that existing guidelines and statutory provisions are constantly reviewed and updated.
Norms for Health Care Personnel: The policy recommends introduction of minimum statutory norms for deployment of doctors and nurses in medical institutions under the provisions of the Indian Medical Council Act and Indian Nursing Council Act respectively.
Regulation of Standards in Paramedical Disciplines: NHP-2002 recognises the need for setting up of statutory professional councils for paramedical disciplines to register practitioners, maintain standards of training and monitor performance.
Enforcement of Quality of Standards for Food and Drugs: The policy envisages progressive strengthening of food and drug administration in terms of both laboratory facilities and technical expertise. It also envisages progressive raising of the standards of food items so that ultimately these are close to Codex specifications and drug standards will be at par with most rigorous ones adopted elsewhere.
NATIONAL DISEASE SURVEILLANCE NETWORK
The policy envisages full operationalisation of an integrated disease control network from the lowest rung of public health administration to the central government by 2005. The network will also get information from private health sector which will greatly strengthen the capacity of the public health system to counter focal outbreaks of seasonal diseases.
The policy envisages to establish a database of common diseases and health services available in the country and a system of national health accounts.
Base line estimates for common diseases like TB, malaria and blindness are to be completed by 2005. It has been proposed to establish appropriate statistical methods for periodic updating of these baseline estimates.
The policy envisages establishing databases in the long term for non-communicable diseases like cardiovascular diseases, cancer, diabetes and accidental injuries and communicable diseases like hepatitis and Japanese encephalitis.
The policy envisages an increase in government funded health research to a level of 1% of the total health spending by 2005 and up to 2% by 2010. Domestic medical research would be focused on new therapeutic drugs and vaccines for tropical diseases like TB and malaria, as also on the sub-types of HIV/AIDS prevalent in the country. Emphasis will also be laid on operational research for cost effective delivery of drugs and vaccines to general population. Fiscal incentives are envisaged to encourage private entrepreneurs for medical research for new molecules/vaccines.
OTHER IMPORTANT AREAS
The policy envisages setting up of an organised urban primary health care structure with two tiers. First tier as primary centre is to cover a population of one lakh, with OPD facility, essential drugs and access to all national health programmes. Second tier is to be at the level of government general hospital for referral from primary centres. Funding for urban primary health care system is proposed to be borne jointly by local bodies, state and central governments.
It is also proposed to set up fully equipped trauma centres in large cities to reduce accident mortality.
The policy envisages a network of decentralised mental health services for management of common mental disorders through general duty medical staff.
Upgrading of infrastructure of mental health institutions for in-door patients has also been envisaged at the central government expense, so as to secure the human rights of this vulnerable segment of society. The programme covers 241 districts in the country.
Various recommendations of the policy with regard to expansion of primary health sector infrastructure will facilitate increased access of women to basic health care.
The policy commits the highest priority of the central government to funding of the identified programmes for women's health. The policy also recognises the need to review the staffing norms of public health administration to meet the specific requirements of women in a more comprehensive manner.
Environment and Occupational Health
The policy envisages that policies and programmes of environment related sectors be such that there is reduced health risk to the citizens and consequently disease burden.
Periodic screening of workers for health conditions particularly high risk ones associated with their occupation has also been envisaged.
Medical Facilities for Overseas Users
The policy strongly favours encouragement of provision of medical facilities on payment basis to overseas patients. For this it has been proposed that all fiscal incentives available to exporters of other goods and services be extended to providers of such services.
Impact of Globalisation on Health Sector
To safeguard the health security in the post-TRIPS (Trade Related Aspects of Intellectual Property Rights) era, the policy envisages a national patent regime for the future, which while being consistent with the TRIPS, avails of all opportunities to secure for the country, under its patent laws, affordable access to medical and other therapeutic discoveries. The government will also exert its full influence at all international fora, to secure commitments of the nations to lighten the restrictive features of TRIPS in its application to health sector.
IMPLEMENTATION AND ACHIEVEMENTS
The key strategies in National Health Policy 2002 have been Primary Health Care Approach, decentralised public health system, convergence of all health programmes under a single field umbrella, strengthening and extending public health services and enhanced contribution of private and NGO sector in health care delivery. It also recommends increase in public spending for health care.
Launch of National Rural Health Mission (NRHM) in 2005 is a major step towards adoption of these strategies. In 2013 National Urban Health Mission (NUHM) was approved by the Union Cabinet. With the launch of NUHM both the missions were combined under overall umbrella of National Health Mission (NHM).2
Most health programmes have been integrated under NHM. State and District Programme Implementation Plans are being developed to effect decentralisation. Indian Public Health Standards have been prepared for Sub-centre, PHC, CHC, Sub-divisional/Sub-district Hospital, and District Hospital, which lay down standards for personnel, physical infrastructure, delivery of services and management. This will strengthen the service delivery, improve its quality and ensure public accountability through Patient Welfare Committees and Citizens’ Charter. For an autonomous action, society model has been adopted at state and district level under NHM and other programmes. Universalisation of Integrated Child Development Services (ICDS) Scheme and revised liberal norms for setting up of Anganwadis and mini-Anganwadis will further strengthen health and nutrition services in the country and increase access of vulnerable groups of population to these services. In line with National Health Policy, states are coming up with different models of Public Private Partnership as detailed in NHM. A variety of schemes for Community Based Health Insurance and social risk pooling are coming up in different states. Rashtriya Swasthya Bima Yojana which covers BPL workers in the unorganised sector and their families is a major step in this direction.
Outlay for health sector in twelfth five year plan is 3.35 times that of eleventh plan, maximum increase being for the Department of AIDS Control at 2.5% of GDP. 3
Financial management reform process has begun with starting of system of National Health Accounts and financial allocation as a single package for all health programmes, on the basis of District and State Programme Implementation Plans. It is hoped that this will overcome the problem of different budget heads and five year financial cycles.
In Twelfth Plan mental health programme has been envisaged to be strengthened and expanded further. For better occupational health, training of physicians has been recommended.
To ensure health manpower requirements and quality health care, Twelfth plan has recommended setting up of National Commission for Human Resources and Health (NCHRH) as an overarching regulatory body for medical education and allied health sciences with the dual purpose of reforming the current regulatory framework and enhancing the supply of skilled human resource in the health sector. The proposed Commission would subsume many functions of the existing councils. It has also called for legislation for registration of clinical establishments.
For achieving integrated surveillance, Integrated Disease Surveillance Project was launched in 2004 which has been converted into a programme in 2012. There has been considerable progress in reporting by the districts as well as reporting units. Nation-wide network of computers, linking districts with states and centre through broadband and satellite and use of information technology has revolutionised data transmission and analysis. Current priority of the programme is to get data on a regular basis from large hospitals and laboratories, both in government as well as private sector to monitor disease and detect outbreaks at an early stage. As a result of these measures there has been increase in early detection of outbreaks in various parts of the country. The system has helped containment of Avian and Pandemic Influenza.
To reduce accident mortality a trauma care network has been designed so that no trauma victim has to be transported for more than 50 km to a designated hospital having trauma care facilities. For this purpose an equipped basic life support ambulance is to be deployed by National Highways Authority of India, Ministry of Road Transport and Highways, at a distance of 50 km on the designated National Highways. Out of the identified 140 hospitals, the trauma centres in 118 hospitals were funded under the trauma scheme, 20 hospitals were funded under PMSSY scheme and 2 trauma centres in Delhi i.e. Dr. RML Hospital and AIIMS were developed with their own funds. There is proposal for development of another 85 new Trauma Care Centres on the same pattern during the twelfth plan period.4
In certain areas the goals and targets set under the National Health Policy have been achieved or significant progress has been made. In other areas, success is yet far from goals.
Leprosy and yaws have been eliminated as per the goals. Not only the target of zero level growth of HIV/AIDS has been achieved, there has been decline from 0.47% (prevalence of infection) in 2002 to 0.26% in 2015.5 Tuberculosis control has been another success story, with decline of deaths from 5 lakh per annum, at the beginning of the programme to 2.4 lakh per annum in 2014-15.6
Malaria has shown a decline from about 2 million cases per year in nineties to 0.88 1.10 million cases per annum in 2014. However, high proportion of P. falciparum and continuing high morbidity and drug resistance in North Eastern states and tribal belt of other states is a matter of concern.7 Dengue is expanding in newer areas but there has been decline in Case Fatality Rate from 3.3% in 1996 to 0.9% in 2011 due to better case management. Number of deaths due to Kala-azar has declined from 1,419 (1992) to 4 deaths in 2015 (till October), but morbidity situation is nowhere close to elimination which was to be achieved by 2010. The date for elimination has subsequently been extended to 2015 as per tripartite agreement between India, Nepal and Bangladesh.8 Annual Mass Drug Administration started in endemic districts in 2004 has brought down microfilaria rate from 1.24% in 2004 to 0.44% in 2014. Sustained decline over the next year will indicate whether we can achieve the goal of elimination of Lymphatic Filariasis by 2015. Vaccination of children 1-15 years has been started against Japanese Encephalitis in the endemic districts. Effect of this and other measures should be visible in the form of decline in cases and deaths in the coming years.9
With intensification of Polio eradication activities and introduction of bOPV there has not been any case of confirmed polio due to wild poliovirus in India since 13th January 2011. As the country has not reported any case due to wild poliovirus for three years, the South-East Asia Region of the WHO has been declared polio-free on 27th March 2014.10
Infant and Maternal Mortality continue to be high in relation to Health Policy goals. However, efforts under NHM in the recent years on increasing institutional deliveries and providing emergency obstetric care through government health facilities or Public Private Partnership models have brought down Maternal Mortality Ratio from 400 to 167 per lakh live births as per the data from SRS 2013.11 Infant Mortality Rate has decreased rapidly with skilled attendance at birth, home based newborn care and implementation of IMNCI. According to SRS 2016 Infant Mortality Rate in the country is 39 per thousand live births.12
The prevalence of blindness has declined marginally from 1.1% (2001-02) to 1%. It is double the target of 0.5% by 2010. Significant increase in cataract surgery in the recent years and progress in other activities should help in decrease of preventable blindness.13
Improvement in health indicators in the coming years needs sustained political commitment, further increase in financial support, improved management, active public participation in management of public health facilities and accountability of health system to people at large. The reforms in the form of decentralised management, convergence in provision of services under various programmes, social health insurance schemes and Public Private Partnerships need to continue and be strengthened further.
Government has taken a decision to formulate a new Health Policy in the light of the changes that have taken place in the country's health sector scenario since the formulation of the National Health Policy 2002. Accordingly the draft new National Health Policy 2015 has been placed in public domain on 30th December, 2014 for wider stakeholder consultations.14
|Achievements Through the Years|
Current achievement (source, year)
I. DEMOGRAPHIC CHANGES
Male 65.8; Female 69.3
Crude birth rate
21.0 (SRS 2016)
Crude death rate
6.7 (SRS 2016)
39 (SRS 2016)
II. EPIDEMIOLOGICAL SHIFTS
Malaria (cases in million)
1.1 (Dir. NVBDCP 2014)
Leprosy cases per 10,000 population
0.69 (AR 2015-16, MOHFW)
Smallpox (No. of cases)
Guinea worm (No. of cases)
Polio (No. of cases)
SC 1,53,655; PHC 25,308;
Dispensaries and Hospitals (total)
Beds (Pvt 8 Public)
9,60,233 (CBHI 2016)
ANM 7,36,262; HV 55,689
|Goals to be Achieved by 2005-20151|
Further increase to 8%
- National Health Policy 2002. Department of Health, Ministry of Health & Family Welfare, Govt. of India, Nirman Bhawan, New Delhi.
- MOHFW, Govt. of India. Framework for Implementation, National Health Mission 2012-17. MOHFW, Govt. of India, Nirman Bhawan, New Delhi. Available from http://vikaspedia.in/health/nrhm/national-health-mission/nrh-framework-for-implementation, retrieved on 4.7.2014.
- Planning Commission. Health in Twelfth Five Year Plan 2012–2017), Vol III, New Delhi, SAGE Publications India Pvt Ltd, 1–46.
- MOHFW. Assistance to States for Capacity Building for Developing Trauma Care Facilities in Government Hospitals on National Highways. Annual Report 2014-15. Ministry of Health & FW, Govt of India, New Delhi; P 176–178.
- Annual Report (2015-16), National AIDS Control Organisation, M/o H & FW, Govt. of India, New Delhi
- Revised National Tuberculosis Control Programme. Annual report 2014-15, MOHFW, Govt. of India New Delhi 2013 p. 121–123
- MOHFW. Malaria in National Vector Borne Disease Control Programme. Annual Report 2015-16. Ministry of Health & FW, Govt. of India, New Delhi.
- MOHFW. Kala-azar in National Vector Borne Disease Control Programme. Annual Report 2015-16. Ministry of Health & FW, Govt. of India, New Delhi.
- MOHFW. Elimination of Lymphatic Filariasis. Annual Report (2015-16), M/O Health & FW, Govt. of India, Nirman Bhawan, New Delhi.
- WHO Country Office for India. Poliomyelitis. [Cited 2015 Dec 20]. Available from http://www.searo.who.int/india/topics/poliomyelitis/en/
- Registrar General and Census Commissioner India. Special bulletin on Maternal Mortality in India 2010-12 December, 2013. [Cited 2015 Dec 20]. Available from http://www.censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_Bulletin-2010-12.pdf.
- Registrar General and Census Commissioner India. SRS Bulletin, July 2016; 50(1) Vital Statistics Division, West Block I, Wing I, 2nd Floor, R K Puram, New Delhi-110066
- National programme for Control of Blindness. DGHS, MOHFW, GOI, N. Delhi 2010. [Cited 2015 Oct 10] Available from http://npcb.nic.in/
- MOHFW. Health Policy. Annual Report (2014-15), M/O Health & FW, Govt. of India, Nirman Bhawan, N. Delhi, P 31–32.