Five Reasons Why ‘National Health Policy 2017’ Is A Step In The Right Direction: As published in Swarajya Magazine on 23rd March 2017

Five Reasons Why ‘National Health Policy 2017’ Is A Step In The Right Direction

As we analyse the Indian policy discourse, we find that healthcare financing and service delivery continues to stand out as an exception. Not only does it remain to be one of the least understood sectors but also, probably, is the worst performing amongst all.

Even after 70 years of Independence, 45,000 mothers die each year during childbirth (highest in the world), 43.5 per cent of children under the age of five are underweight and malnourished (higher than Sub-Saharan Africa), and every year around 2,20,000 people lose their lives due to tuberculosis (highest burden in the world).

Maternity mortality rate 

Also, quite contrary to the Western perception - the three biggest killers in India are not infectious diseases but are, in fact, non-communicable diseases like heart disease (12 lakh deaths annually), lung disease (10 lakh deaths annually) and stroke (9 lakh deaths).

As a result of which, India’s healthcare indicators are not only worse than all the other BRICS countries and those with comparable growth statistics but are also lagging behind its neighbours like Bangladesh, Bhutan and Sri Lanka.

Health care crisis continues to exist despite the fact that over all these years, tax payer’s money has been continuously pumped to finance ad-hoc vertical schemes and piecemeal expansions of the fractured public health systems. Here it is important to note that healthcare spending in India (1 per cent of GDP) is also one of the lowest in the world.

Though the HLEG group in 2012 did recommend an increase in the public health expenditure to 2.5 per cent of GDP, no action in this regard was taken by the then ruling government. Still, it will be useful to take stock of how these resources have been spent and whether the so-called ‘investments’ made in the public health sector reaped any healthcare dividends.

Using the traditional indicators of health, we have already seen how poorly India fares on all most all of them. Alternatively, let us use the lens of healthcare financing to describe the actual plight of a poor patient in India.

Do we know that despite having an overarching National Health Mission for the past 12 years (started as NRHM in 2005 by the UPA government) and the presence of the so-called socialist model of healthcare financing, the out of pocket payments (OoP) in India (67 per cent) are one of the highest in the world.

It means that if an average Indian spends Rs 100 to seek medical care, up to Rs 67 is spent by his/her own pocket and less than Rs 30 is covered by the government and other methods of health insurance. Moreover, 70 per cent of OoP is on the purchase of drugs and diagnostics.

What is particularly disheartening is that every year about 6 crore Indian households fall below the poverty line due to catastrophic healthcare expenditures. And the majority of this financial burden falls on the underprivileged members of the society like the Dalits, tribals, rural and poor households.

Not surprisingly as high as 86 per cent of rural population and 82 per cent of urban population are still not covered under any scheme of health expenditure support/insurance system.

The Central Government, however, recently has brought over 12 per cent urban and 13 per cent of rural population under some form of health protection coverage like the Rastriya Swasthya Bima Yojana.

What is interesting to note is the large inter-state variation in the financial protection for healthcare provided by various states. The following data from the National Sample Survey Organisation (NSSO) 71st round reveals that states with the highest percentage of reimbursement of hospitaliastion expenses were Gujarat, followed by Maharashtra and Haryana, thus providing the best safety net against catastrophic healthcare spending.

Whereas Kerala, Karnataka and Chhattisgarh had only 2 per cent of their cases reimbursed for hospital expenses, and the other states fared even lower.

Safety net provided by the states, against catastrophic healthcare spending. Source: NSSO 71st round.

Yet the public narrative for health sector has remained unchanged since independence, focussing on merely inventing newer public programmes without imposing any incentive for improving either accountability or efficiency of healthcare delivery in the public sector.

Misguided by the dominant discourse of development economics and statist model for public health in India, current situation of district hospitals and health centres is marked by doctor absenteeism, drug stock outs and rampant corruption, all leading to delays in access, quality and accountability of healthcare.

Ultimately a poor rural Indian is left with only two choices:

One: Use a public health centre which offers poor quality of services.

Two: Go to a private hospital and access expensive care in the absence of any universal health coverage.

In light of the above, it becomes very pertinent for policy experts to analyse if we can afford to ignore the private sector and the choices people make while accessing health care.

According to government’s own NSSO estimates (71st round) nearly 70 per cent of the total health ailments in India are being treated at private facilities. To be even more precise, the same data shows that as much as 75 per cent of outpatient (OPD) care is exclusively private and more than 55 per cent of inpatient (IPD) care is sought from private hospitals in India.

Hence, it is rather surprising to see why and how the public discourse on healthcare has until now remained oblivious of the presence of private sector in healthcare.

Any narrative on Public-Private Partnership has been unfairly made out to be a shift towards abolition of public health systems and leaving the general population at the mercy of an unregulated and costly private sector - which is, in fact, far from the truth.

Hence an informed debate about the need for health insurance leading to universal health coverage never penetrated the public discourse, until the draft of the new National Health Policy 2017 was shared with the public for inviting suggestions two years ago.

After taking due consideration of the suggestions received, the health minister came out with the final recommendations of the policy. Let us see how this new health policy affects us and whether it fits into the healthcare needs of an average Indian.

First, the policy rightfully signals the coming of a health insurance era in India, leading to universal health coverage. Some analysts have gone to the extent of labelling these reforms as the Obamacare. India version!

This policy direction is also in alignment with the recommendations of the World Health Organisation which calls upon all the countries to adopt a health insurance model, thus providing universal health coverage against an essential package of primary, secondary, and tertiary services.

It will provide healthcare access to millions of poor households, reduce poverty arising out of catastrophic spending on healthcare and promote a significant reduction of out of pocket expenses, which in some cases, can mean the entire life savings of a BPL (below poverty line) household.

This is in contrast to the present scenario where only a handful of government employees and a miniscule of the formal sector have access to any sort of health insurance.

Second, the government commits to an increase in the public health expenditure from the current 1 per cent of GDP to 2.5 per cent, which will be the biggest jump in healthcare expenditure that India will see since the Independence.

And a majority of this expenditure is geared towards making drugs and diagnostics more affordable, thus addressing a major (70 per cent) proportion of out of pocket expenses.

Now the question arises, whether the government hospitals and health centres can alone shoulder the responsibility of treating the humongous disease burden of 120 crore Indians?

As of today, private sector accounts for 93 per cent of all hospitals (up from 8 per cent in 1947), 64 per cent of all beds, and 80 to 85 per cent of all doctors. As opposed to the common understanding, this penetration of the private sector holds equally true for the rural areas where 70 per cent of all the primary care visits are also to private health care providers.

Hence, as a third logical step, the National Health Policy recommends for a mix of public and private care to ensure that every insured individual, irrespective of caste, sex or religion should have a right to choice, efficiency and quality.

Thus, if implemented, a poor rural household won’t be forced to use poor quality of public health services only because of his inability to pay. Instead, the public facility would be incentivised to improve the quality of service delivery in the face of competition and efficiency from the private sector.

This however needs to be accompanied by proper regulation of the quality of care that even the private sector is providing.

Fourth, the need for focusing on non-communicable diseases like diabetes, heart and lung diseases, which have a lion’s share in India’s disease burden, has been rightly recognised, thus making for the most efficient use of the resources.

Finally, the policy gives a big push to health research as an important means for building evidence base for public health in India.

Though implementation remains to be seen, the new National Health Policy 2017 is a step in the right direction.

Moreover, this change in the public health narrative is also in alignment with the recommendations by the WHO, World Bank and the best practices worldwide, while being grounded to the contextual realities of the country.

Hence from a human rights perspective, it can be safely concluded that the proposed universal health coverage via health insurance with the right mix of public and private providers can soon fulfil the dream of seeking healthcare as a matter of fundamental right for every Indian.

This will especially touch the lives of poor and rural households, women, tribal and all the other socially weaker sections of the society; further fulfilling the directive principles of equitable distribution of wealth and resources across the citizens and the Vedanta Philosophy of “Sarve Santu Niramaya” (Let no one be ill).

Why I don’t mind being branded as a Jingoistic Bhakt? As published in BuzzTimes

Immediately after the unfortunate URI attacks took place this month, media started pouring with breaking news and prime times. The call for aggressive action against the Pakistani army started catching the headlines. There were demands for fighting a war, applying sanctions and even banning Pakistani artists in India. And I felt that finally, the demand for a strong action against Pakistan (except maybe symbolically trying to ban Paki artists) is gaining traction in Public. Moreover, this view was echoed by almost all news channels at least until the attacks were still fresh in our memory.

And then started another trend- Branding those who were talking about stricter action against Pakistan as “Jingositic Bhakts”. There was an entire wave of defense by the so called “liberal lefts” who started feeding- “Oh Bhakt Gan are behaving like a mob and war is not the solution”, “Let us not stoop down to the level of fighting for Indus waters”, “Music and Art are above Ind-Pak war”, “Chest thumping nationalists on News hour are spreading hatred” and that the “current proto-nationalist government is spreading divisive politics”.

Really???

Instead of shouting back at them with even a greater bang, I thought why not use Nietsche’s ‘Genealogy of Morals’ model to deconstruct why and what was happening. Nietsche talked about the rise of Slave Mentality vs the Master mentality in the medieval age. Oppression and aggression by rulers led a lot of societies including those in Europe and India, to develop the foundations for their own versions of Slave Morality. To forgive was Holy. Controlling your impulses and remaining nonviolent even in the event of war was a virtue. And Why? Because forgiving was the only option, we did not have the courage, power or resources to fight. Be nonviolent, because you are a slave and passive resistance is your biggest weapon. In Nietsche’s words Unable to put up a fight and cope with its struggle against itself, the sick will see its animal instincts, its earthly nature, as sinful, and horrible. Unable to free itself from these instincts, it attempts to subdue and tame itself as much as possible. Nietzsche concludes that “man would rather will nothingness than notwill.” And it was this thinking, which guided the moderate brand of politics in Congress during the 19th century and the majority of Gandhian led Freedom movement. I still believe, it wasn’t all that impractical considering we were being ruled by our masters- the British rulers. Though its important to note that India did not quite win its freedom with this brand of slave politics either. It was a freedom served to us by our erstwhile masters.  Just as how the 2nd World War and the economic impracticality of ruling large colonies led to the freedom of the rest of South Asia in 40s and 50s and Africa in 60s, so did India.

But even after independence and becoming “free”, this brand of Slave politics continued.Internationalizing the issue of Pakistan in UN, was our way of showing to the world, how “Great” and “Virtuous” we were. Sending back the captured POWs in the 1971 war without even extracting a strong bilateral agreement from Pakistan on the issue of LoC, was another stunt to show how “forgiving” we were. And now in the present times this has taken different forms- A home grown terrorist becomes a martyr; Azadi slogans which promote breaking India into pieces becomes an aspect of Freedom of Expression; Instead of pushing for conviction of Nirbhaya rapists; journalists run about making a documentary sympathizing with his weeping mother (which in fact she should) and worse if a News Channel is talking about a strong action against Pakistan, he is termed as a false “Jigoistic Bhakt”!

The answer to this lies in the age old slave morality that we have been carrying over our shoulders. We as a nation are afraid of our strengths. Or lets say we feel uncomfortable and awkward when it comes to doing what it takes to set things right.  So many people in the recent past have told me that they are scared of the new brand of “Bhakts”. They think that the bhakts are all too powerful and that they are afraid to support this brand of divisive politics. Is standing up and fighting against those who inflict terror on us in the name of religion, divisive? Well I thought vote bank politics based on the rhetoric of social and religious identities has been way more successful in dividing us than this. Another accusation is that the Bhakts are invoking hatred? Well is speaking an uncomfortable truth spreading hatred? The fact is,  that the so called liberal elite English media, finds it “virtuous” to cover up the hard realities of terrorism and appeasement politics but derides the “virtue” of the so called “Bhakts” in standing up against what’s wrong.

So let us pull away this shroud of Slave Morality and rise up to be Masters of our own fate.Be proud of our strengths and call a spade a spade. Though this does come with a warning to all of us, standing up and acting against Pakistan or Terrorists or Terror sympathizers doesn’t mean creating a brigade of Neo Nazis who are ready to take out swords on the drop of a hat; whether on Twittter or on the streets. Integral Humanism has been at the core of the Indian way of living. Though this Humanistic outlook should not be used as a proxy to shy away from strict action against the separatist elements.

Finally, if after all that I speak, write and do makes you still believe that I am a Jingoistic Bhakt. Then Yes, I don’t mind being branded as one!!

#‎Starbucks‬ ‪#‎Global‬ Poverty

 As it poured heavily today, I went to my favourite coffee shop and asked for a freshly brewed coffee. She said 2.5$ please. Just when I was contemplating that a freshly brewed coffee is so much cheaper than those fancy latte and frappé, I happened to read this statistic while browsing on the internet-"Nearly half of the world's population-3 billion people live on less than 2.5 $ a day". Confused/Ashamed/Speechless!

September 2015
boston

Contrarians are important

Contrarians are important- In a world of echo chambers where fads and panics are a norm- we need to pay much more attention to where our ideas are coming from, actively discount common opinions and keep track of contrarians-the oddballs who think and behave independently. Success depends greatly on the quality of exploration and that in turn relies on the independence and diversity of your information and idea sources.

Logic

Would you tell me, please, which way I ought to go from here?'
'That depends a good deal on where you want to get to,' said the Cat.
'I don't much care where -' said Alice.
'Then it doesn't matter which way you go,' said the Cat.
'- so long as I get SOMEWHERE,' Alice added as an explanation.
'Oh, you're sure to do that,' said the Cat, 'if you only walk long enough.

Lewis Carroll

Delhi-Bombay "Bubble"

Usually I am not perturbed by horrific demographic stats on India. Maybe I have gotten "used" to it. Maybe it is the default.
But just came across this stat which I could not help but share. "State of Children report on India notes that nearly 40% of adolescent children are out of school and nearly 43% of adolescent women are married before the age of 18".
And this is 2016. Where are these children? Why don't we see them? Why don't we talk about them(except in Habitat centre and Rajya Sabha TV!) leave alone doing anything about it. Is it the class difference? Is India all about the Delhi & Bombay bubble? Is it economics? Is it inequality? Or Social Norms? Geography? Sheer size? Development?

Ananya

            “Swastha Balika-Swastha Samaj”

          “Healthy Girl Child- Healthy Society”

                 

                                                     

WHY DO WE NEED TO TALK ABOUT IT?

WHY in India do we need to have a campaign dedicated solely to the girl child? Why couldn’t we simply talk about healthy children? Let me introduce you to some hard realities.  For every 1000 male children, we have 86 missing girl children. Surpringly, this ratio is far worse in urban “educated” areas than in its rural counter-parts and has in-fact been dipping since independence. Where did all these girls go? Do we know that a girl child in India is 75% more likely to die than a boy child? Why this disparity? If this isn’t enough to shake you up, then try and consume this piece of information- 50% of young girls in India are malnourished, 53% of girls in the age group of 5 to 9 years are illiterate and 1 out of 4 girls is sexually abused before the age of 4!

In a land where ‘girl child’ has historically been given the status of a Goddess, how did we come to a stage where millions of goddesses are malnourished, illiterate, weak and abused?

Poor Health outcomes of a girl child are a result of deeper rooted Social and Economic determinants. Even if she escapes a feticide, a girl child is less likely to receive immunization, nutrition or medical treatment compared to a male child due to inherent discrimination in an Indian home. Let us suppose she is fortunate enough to receive formal education, sadly enough she ends up in a school which can’t even offer her an operational toilet! Now let us not even begin to talk about sanitary and menstrual health. Hasn’t that been a big Taboo in Indian societies for generations? But what we do believe is in marrying off 48% of the women before the age of 18. This weak, uneducated and disempowered girl gives birth to a weaker and an unhealthier child; and the entire cycle of poverty, poor health and discrimination continues. 

WHAT DO WE DO ABOUT IT?

       Interestingly, modern day campaigns and write ups regarding social issues unduly harp about the innumerable problems and challenges that we face. Although it may be easier to sit and count what needs to be done. But it is much more difficult to not only find but act on practical and actionable solutions for the same. If I were to mention that ‘one’ (prima facie) thing that I learnt during my Masters training at Harvard, it would be the need for “context based solutions” for most of our Global Health and Development problems. Sitting 10, 000 miles away with no understanding of social and cultural contexts, we cannot be providing artificial solutions for very “real” problems like discrimination and marginalization of girl child. Hence solutions have to emerge from the problems itself and cannot be read in isolation for all practical purposes. Moreover, the solution lies not only in government & donor funded programs but in having a sustained change in social mindsets and norms.

This change begins at home. And it begins with a mother giving equal preference to both male and female child. We all know that a mother should not discriminate between them in matters of nutrition, education and access to formal health care when needed. But this rhetoric falls on deaf ears, when you try argue the same with the head of a rural household. “Utilitarian” logic teaches them, that a girl is financial liability which needn’t be invested upon in terms of education, health or employment. One day she will leave them & go to her husband’s house is what they say, thus giving them no economic dividends in return.

Gandhi once reiterated a Kantian logic, that human beings can’t be treated as a means to an end, but that they are an end in itself. This line of thought, has given rise to what today we know as the Human Rights approach. Here we don’t justify equal rights for the girl child on account of the fact that even girls can be taught and gainfully employed to become an “asset” for an economic and rational Indian household. But we demand the same because human rights are so intrinsic in nature that by virtue of birth alone, they need to be respected as such. Still, education and monetary compensation for young working women has unleashed an entire unexplored “utility” of female power.

The new government has rightfully recognized the need to make this a national priority. Haryana state which has historically been infamous for extremely low sex ratios, was chosen as a symbolic launchpad for the nationwide Beti Bachao Beti Padhao (BBBP) campaign. In fact, for the first time in history, Haryana has started showing a reversal in the downward trend for child sex ratio. Innovative ways of rebranding this message including the ‘Selfie with Daughter’ initiative started by a Sarpanch are being used to bring about a change in the social mindsets through training, sensitization, awareness raising and community mobilization on ground. And it is this attitude that we at “Swastha Balika”/Healthy Girl Child campaign are aiming to inculcate for a healthier tomorrow. This campaign plans to cover all the 29 states and UTs and reach every Indian household to bring about a change in our social-cultural mindset which are intended to successfully eliminate the discriminatory health seeking behaviors against and amongst girl children. We also plan to initiate discussions and create a sense of urgency around health sector reforms, particularly those that relate to the health & wellbeing of a girl child. This will include incorporating suggestions and ideas around redesigning of ICDS (Integrated Child Development Services) as a focal point for all round development of girl child, testing ‘Financial incentives for Doctors on delivering a girl child and to school authorities for retaining female students up until secondary school and a renewed focus on Health education of a girl child in at least  4 important domains including Nutrition, Sanitation, Menstrual Health, and Healthy Lifestyles & Yoga. And these recommendations collected from the common masses including you and me, complemented with evidence shared by Health and Policy experts, shall be thereafter compiled into an actionable document. This compilation of our experiences, learnings and suggestions to improve the health and social status of a girl child would then be circulated and disseminated across various domains including the CSO, multilateral development agencies, media, government authorities and most importantly back to where these came from- the people.

Dr. Ananya Awasthi

Masters in Global Health (Harvard University)

22/July/2016