Editorial Articles

volume-1 , 2017

Salient Features of National Health Policy 2017

Dr. Prashant Keshavani

'Health is wealth' is old adage reflecting wisdom and a healthy population is the goal of each and every country. No country can afford to neglect the issue of health, as health status of an individual plays an important role in human capital generation. The state's intervention in the area of public health comes with a clear cut logic that healthy workforce means productive workforce; and illness episodes can lead to loss of human capital, economic productivity as well as out of pocket expenditure. These economic reasons compel the state to invest and intervene in the area of health. Indian constitution gives 'the right to life' as a fundamental right under article 21; and the Supreme Court of India has articulated in several landmark judgments that the 'right to health' is integral to the 'right to life'. Right to health is dependent on access to health care. In Indian context, public health is governed by directive principles of state policy and subject of health is under the state list. The Constitution imposes a positive duty on the state under Article 47 to raise the level of nutrition and standard of living and to improve public health. Under the positive duty, state has responsibility to take care of the health of the population. For the delivery of their positive duties, the state needs guidelines and directions. Policies serve this purpose by providing specific guidelines, which will help in guiding the intervention in prioritized areas. Policies are rooted in context and time and their roles are advisory in nature. Any change in context and time will require revision in or reframing of these policies. This column presents the salient features of National Health Policy (NHP) 2017, which was approved by the union cabinet on 15th March 2017. Readers are advised to read the original policy document and backdrop to NHP, 2017 document released along with policy document, to develop a comprehensive understanding of the subject matter.
Past Efforts to Provide Health Care
Initial systematic efforts to provide health care in India were guided through five year plans as well as recommendations of high level committees such as Bhore committee, Sokhey committee, and Mudailar committee etc. After 30 years of its independence, Government of India introduced its' first national health policy in 1983. The aim of the NHP, 1983 was to achieve 'Health for all by 2000 AD'. NHP, 1983 clearly articulated 'state as service provider' and 'public provisioning as a model of service delivery'. India failed to achieve the goal of 'Health for all by 2000 AD'; and in light of change in epidemiological profile of the country, another policy document was released in 2002 with a major focus to tackle health inequalities. NHP, 2002 has promised to tackle not only the regional health inequalities, rather it has also promised to increase expenditure on health and improve rural health infrastructure in the country. Policy directions of NHP, 2002 resulted in interventions like National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM). Both the programmes were merged under National Health Mission in 2013. During this period India witnessed mixed results on certain fronts such as reduction in maternal mortality and infant mortality rate along with increase in institution deliveries. Indian public health system also witnessed marginal improvement in its rural health infrastructure. The targets set by NHP, 2002 as well as targets of millennial development goals (MDGs) have not been achieved.
From 'Health for All' to 'Health in All'
In the backdrop of renewed global effort under Sustainable Development Goals (SDGs) for action in health and high rates of mortality and morbidity, Indian government renewed its effort and released a draft of national health policy document in 2015. Comments were sought from the general public, stakeholders and public health experts. Various rounds of discussion and reviews of the draft health policy have given shape to the current NHP, 2017. NHP, 2017 promises 'assured health care for all at affordable cost' and changes the discourse of 'Health for all' to 'Health in all'. Provision of health care at affordable cost needs further discussion and review by policy experts as well as by public health managers. NHP 2017 acknowledges the change in epidemiological profile of the country and the situation that had arisen due to double burden of disease.
NHP 2017 articulates its goals as follows :
"The policy envisages as its goal the attainment of the highest possible level of health and wellbeing for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and 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 healthcare delivery" (NHP, 2017, p. 1).
Key Policy Principles
NHP 2017 proposes ten key policy principles to attain policy objectives. These key policy principles are: 1) Professionalism, Integrity and Ethics, 2) Equity, 3) Affordability, 4) Universality, 5) Patient Centred & Quality of Care, 6) Accountability, 7) Inclusive Partnerships, 8) Pluralism, 9) Decentralization, and 10) Dynamism and Adaptiveness. NHP 2017 states that these key policy principles will help in reducing mortality and morbidity as well as in improving wellness in population.
Specific Quantitative Goals
NHP 2017 also sets specific quantitative goals in three core areas to track attainment of policy objectives: a) Health Status and Programme Impact, b) Health Systems Performance, c) Health Systems strengthening. Some of the key quantitative indicators are following:
1.Increase Life Expectancy at birth from 67.5 to 70 by 2025.
2.Reduction of TFR to 2.1 at national and sub-national level by 2025.
3.Reduce under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
4.Reduce infant mortality rate to 28 by 2019.
5.Reduce neo-natal mortality to 16 and still birth rate to "single digit" by 2025.
6.Achieve global target of 2020 which is also termed as target of 90:90:90, for 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 therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
7.To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
8.To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.
9.More than 90% of the newborn are fully immunized by one year of age by 2025.
10.Reduction of 40% in prevalence of stunting of under-five children by 2025.
11.Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5 % by 2025.
12.Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts by 2020.
13.Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
14.Establish primary and secondary care facility as per norms in high priority districts (population as well as time to reach norms) by 2025.
15.Ensure district-level electronic database of information on health system components by 2020.
16.Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
Source: (NHP, 2017, p. 4 &5).
 Maternal and Child Health 
NHP 2017 has an emphasis to bring down maternal, neonatal, and infant deaths. This is in continuation to the past efforts of tackling maternal and child deaths as well as to fulfil its global commitment towards the issue under SDGs.
Communicable and Non-Communicable Diseases
NHP, 2017 also sets targets for TB and HIV. Tackling TB and HIV is important due to two specific reasons. First, India has significantly higher TB case loads i.e. 2.2 millions cases (WHO, 2015). Situation for TB is much more challenging due to drug resistant TB (Multi Drug Resistant (MDR) and Extreme Drug Resistant (XDR)) cases.  Second, TB is one of the major sources of opportunistic infections among HIV patients; is a reason for shortening their life expectancy, and affecting their quality of life. NHP 2017 also intends to tackle premature deaths due to non-communicable disease such as cardio-vascular disease, cancer, diabetes, and chronic respiratory diseases. 
Health Infrastructure
NHP, 2017 also proposes to improve rural health infrastructure in high priority districts by 2025 and availability of human resource in high priority districts by 2020. NHP, 2017 changes the nomenclature of existing health facility as "Health and Wellness Centers". These Health and Wellness Centers will provide comprehensive primary health care package, which will include geriatric health care, palliative care and rehabilitative care services. According to NHP, 2017 primary care must be assured and it proposes that 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.
Human Resource
NHP, 2017 also envisages mid-level service providers and public health management cadre. Mid-level service providers will help in addressing the short fall of human resource in rural and difficult areas as well as in filling the critical gap in service delivery. Chhattisgarh Govt.'s rural medical assistant (RMA) scheme has shown a way for mid-level service providers. NHP 2017 has picked up on this idea. Creation of mid-level service providers is proposed through appropriate courses like a B.Sc. in community health and/or through competency-based bridge courses and short courses. Besides this, NHP, 2017 also proposes to creation of Public Health Management Cadre in all States, based on public health or related disciplines, as an entry criteria. Medical & 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. Creation of public health management cadre will improve the management capacity and will bring very much needed social science perspective in programme implementation.
NHP, 2017 articulates to facilitate career growth of ASHA. It intends to support certification programme for ASHAs for their preferential selection into ANM, nursing and paramedical courses. Preferential selection of Mitanin for ANM training has shown a way to address the critical gap in human resource in Chhattisgarh. 
Monitoring and Evaluation
To facilitate evidence based planning and better monitoring of the health programme, NHP, 2017 promises to strengthen the health surveillance system and establish registries for diseases of public health importance by 2020. It also proposes similar measures to track measures of health system components.
NHP, 2017 envisages a bigger role for AYUSH and Yoga for promotive and curative services. Policy intends to ensure access to AYUSH remedies through co-location in public facilities.  It also suggests introducing Yoga in school and work places as part of promotion of good health. There is also an emphasis on research to validate the efficacy of AYUSH medicines.
Social Movement for Health
NHP, 2017 proposes a 'Swasth Nagrik Abhiyan'- social movement for health to improve environment for health. According to NHP, 2017 'Swasth Nagrik Abhiyan' will be based on coordinated action in seven core areas. These seven core areas are:

1.The Swachh Bharat Abhiyan
2.Balanced, healthy diet and regular exercise.
3.Addressing tobacco, alcohol and substance abuse
4.Yatri Suraksha - preventing deaths due to rail and road traffic accidents
5.Nirbhaya Nari - action against gender violence
6.Reduced stress and improved safety in the work place
7.Reducing indoor and outdoor air pollution
Source: NHP (2017, p. 6).
By bringing health policy document, Govt. has attempted to fill a policy gap and indicated the direction of intervention in the area of health. The policy has also articulated the political willingness to reduce mortality and morbidity as well as to fulfil its commitment toward attainment of sustainable development goals.
The author is Assistant Professor, TISS, Guwahati Campus.  
 Image: Courtesy Google