Why India’s health sector needs political leadership

By Chandrakant Lahariya

The existing policy challenges in India’s health sector are too big for the federal and state ministries of health to address alone. Sustained leadership, especially from the Prime Minister and Chief Ministers, is needed if more progress is to be made.

Limited success means India is lagging behind

In the seven decades since independence, the health sector has had its fair share of successes. An increase in life expectancy, reduction in infant and maternal mortality, as well as the eradication of smallpox, poliomyelitis, maternal and neonatal tetanus, and yaws are reasons enough to celebrate.

However, low government spending, a weak primary healthcare system, and understaffing are persistent challenges. Even the poor prefer to attend private providers where they must pay for care from their own pockets. The result is an estimated 63 million people falling into poverty annually due to private healthcare costs. There are also considerable health inequities between regions and socioeconomic classes. Compared with countries such as Sri Lanka, Thailand, and China, which began developing their healthcare systems from a similar level, India now lags behind.

In 2002, India’s National Health Policy (NHP) proposed to increase the government spending on health to 2% of GDP by the year 2010. Fifteen years on, however, government spending stands at only 1.3% of GDP. Now, the NHP 2017 proposes to take spending to 2.5% of GDP by 2025. Will this new target be achieved? The evidence from past national and state budgets suggest not. Moreover, the Ministry of Finance generally blames the failure to meet spending targets on the low absorption capacity in the health sector, while the national and state ministries of health blame the failures on delays in transferring the funds to their departments.

Learning lessons from other initiatives

The implementation of previous government programs, such as the public cleanliness Swachh Bharat Mission, offers a number of lessons for the health sector. SBM is an example of the fast-paced and time-bound implementation of a government program in which every level of the administration focuses on monitoring progress and achieving targets. SBM’s success is due to the oversight and timely interventions of the highest political leadership. It is time to explore a similar approach for the health sector.

1. The first lesson is that it takes two to three years for any program to have a measurable impact. Therefore, governments are often reluctant to initiate programs in the second half of their mandate. In light of these constraints, the government should take advantage of recommendations made by the Joint Working Group (JWG) of NITI Aayog and the government of Uttar Pradesh. The JWG makes its recommendations available within six months of a new government taking office. As the JWG engages directly with the highest levels of political and technical leadership in developing its recommendations, this is the best way to overcome the ‘implementation chasm’ caused by poor coordination.
2. The second lesson is that many of the determining factors for the successful implementation of government programs are not under the remit of the same ministry. In the case of health care, the responsibility for improving the water supply, air quality, sanitation and roads, for achieving better nutritional outcomes and for health education, in particular for women and girls, are all outside the purview of the health ministry. The links between these areas are increasingly being recognised, but there is also need for multi-sector planning and a ‘health in all policies’ approach. The initiatives of different departments and ministries must be developed and planned in coordination, and progress should be monitored jointly.
3. Third, while private sector healthcare providers play an important role in the overall delivery of health services, any engagement from the government with the private sector is viewed with suspicion. This was seen most recently following the release of a draft document for Public-Private Partnerships (PPP). The document called for private health providers to work with district hospitals in tier 2 and 3 cities in order to deliver services in the fight against certain non-communicable diseases. The concerns raised about the spread of private healthcare means that new schemes should be accompanied by strong legislative and regulatory protections.
4. Fourth, many healthcare institutions have outlived their utility, for example, some older institutions that solely focusing on family welfare. There is a need to reform and re-design institutions to tackle the broader goals of public health and to contribute toward achieving India’s sustainable development goals (SDGs). Also, proposals such as the establishment of a national Indian Medical Service, and exploring options to enable the easy entry of technical experts into high positions at health policy institutions—including in the ministry of health—should be given serious consideration.
5. Finally, universal health coverage (UHC) is a widely accepted national health goal. However, after some initial enthusiasm for UHC and much discussion about the national health assurance mission (NHAM) between 2014 and 2016, the momentum seems to have been lost. The inclusion and re-articulation of the core principles of UHC as the central aim of NHP 2017 is a sign of hope, however, these ideals need to be given a more concrete shape in the form of actionable steps and an implementation road-map.

Considering the nature and extent of the challenges, it is essential that the highest level of political leadership provide direct and sustained oversight to improve the health system. One practical strategy would be for the Chief Minister and health minister of each Indian state to take personal responsibility to improve the health services in one specific district annually. This approach would cover each of India’s 130-odd districts by the end of only five years.

Good health is part of the social contract between the government and people, and it is essential to sustaining economic growth. As India celebrates seventy years of independence, this is an opportune time to revisit national priorities and to place public health higher on the policy and development agenda. Concrete steps can put India’s health system on track for unparalleled improvement by the time of India’s seventy-fifth year of independence.

This article was first published in The Pioneer on 15 Aug 2017.

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