On the occasion of World Health Day on April 7, Prime Minister Narendra Modi had said that his Government is leaving no stone unturned in providing quality healthcare that is accessible and affordable. Making an effort in this direction, the Health Ministry under the administrative acumen of the Health Secretary, CK Mishra, is working on a war footing to galvanise the sluggish healthcare system of India to deliver affordable health and well-being to the last man in the row. However, the real challenge in the path for Universal Health Coverage lies in effective implementation which calls for cementing consensus between State Governments and the Centre. In a candid conversation with Bureaucracy Today, Union Health Secretary Mishra speaks about the increasing coordination between the Centre and the States in the recent times and also sheds light on other issues like making generic medicines available to people and the regulation of the private healthcare sector which are of top priority for his Ministry.
Over the years, successive Governments at the Centre have concentrated on preventive healthcare in India. Though the approach has seen a mixed bag of success with the eradication of diseases like smallpox and polio from the country, it has been unable to make much headway in creating a universal healthcare system for all citizens. This has resulted in the private sector becoming the dominant healthcare provider in India which has led many households to incur catastrophic health expenditure which threatens their capacity to maintain a basic standard of living.
However, things seem to be changing now with the Health Ministry working on a strategy to make affordable healthcare universal.
“There are two things which are critical on my mind and we are working on them right now. One is how do we access universal healthcare. So far the Government has been able to provide healthcare to people in a vertical manner. For example, we go in for malaria treatment at one place but we choose another place for TB treatment. The Health Ministry is currently working on how to integrate healthcare at the sub-centre level. The critical step is to create a platform where integrated healthcare delivery is available. The second critical issue that is playing on my mind is that of reducing the cost of treatment,” Health Secretary CK Mishra tells
Making headway in this regard, the Ministry recently released the National Health Policy 2017 which proposes free drugs, free diagnostics and free emergency care services in all public hospitals. The policy endorses that the public hospitals would provide universal access to a progressively wide array of free drugs and diagnostics with suitable leeway to the States to suit their context.
“Health is a State subject and the Union Health Ministry is trying to give guidance to the States with financial support. Our basic job is to create a national programme, put it in a State framework and then handhold the States so that they can actually implement the programme,” the Secretary says.
For the success of any health scheme, it is pertinent that both the Centre and the States are on the same page and work together to deliver.
In this context, Mishra says, “As far as the National Health Mission is concerned, the coordination between the Union Health Ministry and the States is excellent. We have a perfect platform of working relationship between the States and the Centre, largely because we have given them (the States) a free hand. The freedom of the States in the National Health Mission is enormous. The Centre draws up the contours of the national health policy but the States make up their own plans within that policy.”
Elucidating how the States are on board, the senior bureaucrat says, “Earlier there was a 75:25 sharing between the Centre and the States in regard to a health scheme. We switched over to 60:40 last year. Not one State Government complained because they saw value in the programme and was willing to invest more. This is just one example of how the Centre and the States are working together. Earlier, such camaraderie between the States and the Centre was not there.”
The usual problem with the States, the Health Secretary says, “is always the capacity issue. In States like Odisha, Bihar and Uttar Pradesh, the issue of capacity has always been a constraint. There is an argument going on at the Central level that the Union Government should incentivise States which are doing well in the area of health and de-incentivise those which are not doing well. I personally don’t buy this argument. It is very good to incentivise States which have done well but if you start de-incentivising States which have not done well, the impact will be on the person who is seeking healthcare. I feel that the Central Government’s job is to do much more stronger handholding in those States where health capacities have not been built so that they can be brought on a par with other States. For example, today close to 60 percent of the newborns in India are in eight States. These eight States also account for 60-70 percent of the maternal deaths. Now if one argues that these are non-performing States, the Indian situation will never improve. It is these States where the Centre needs to concentrate on. It has a special plan for such States so that they may come up. And there is a desire in these States to do well. Earlier this (desire) was not there. We need to capitalise on that.”
ADVOCATING GENERIC DRUGS USE
Advocating the use of generic drugs, Prime Minister Narendra Modi recently said in Surat that his Government might look at “legal arrangements” to make the prescription of generic medicines compulsory.
Against this backdrop, Mishra says, “The Health Ministry has always been advocating the use of generic medicines. India is the largest producer of generic drugs in the world and there is no reason why we should not use most of these medicines. Generic medicine is the strength of the Indian pharmaceutical industry. The Medical Council of India has recommended to doctors to prescribe generics. The Centre has also written to the States to use generics.”
However, the only caveat, the IAS officer says, is that “we need to be very careful in two things – appropriate availability of generic medicines and their quality. If these two things are monitored closely, then there is no reason why we cannot go ahead with generic medicines.”
Mishra, however, admits that making the use of generic medicines compulsory will be a challenge in India. But he quickly adds, “If we want to bring up our healthcare system, we have to take on this challenge. And we have already started working on that.”
Replying to a query if such a policy will adversely impact the Indian pharmaceutical industry, the bureaucrat says, “If we look at the patented drugs, they are only 9-10 percent of the total medicines. Using generic drugs was never about using patented drugs. There are certain disease conditions where patented drugs would be essential but wherever there is the availability of generic form, we should do that.”
He further says that the Health Ministry is coming up with a regulation where every medicine manufacturer will have to give the generic name of the composition.
Echoing PM Modi’s words, Mishra says, “We have not yet taken any legal route but we are seeing if we have to take steps to push this (prescribe and use generic drugs)...perhaps through a legal course. The ultimate aim is to benefit the patient in whatever route we take it.”
Generic medicines are drugs whose patents have expired, so any manufacturer is allowed to make them. This brings down the cost. The actual cost of manufacturing a drug is relatively low.
ALIGNING PVT HEALTHCARE SECTOR WITH PUBLIC GOALS
The Health Ministry is looking towards influencing the operation and growth of the private healthcare sector and medical technologies in India to ensure their alignment with public health goals. The National Health Policy 2017 envisages enabling of the private sector’s contribution to make healthcare systems more effective, efficient, rational, safe, affordable and ethical. As per the policy, strategic purchasing by the Government to fill critical gaps in public health facilities would create a demand for the private healthcare sector in alignment with the public health goals.
However, the private healthcare sector in India is hugely unregulated. In this context, the Health Secretary says, “Bringing the private sector into the national framework of healthcare is a critical issue as it largely falls in the domain of State Governments. However, we are making our efforts towards that. To regulate the private healthcare, there is the Clinical Establishment Act which regulates clinical establishments and prescribes minimum standards of facilities and services.”
When Bureaucracy Today points out that the Act has been implemented only in nine States, the IAS officer admits the fact and says, “There is a huge disconnect. Even the nine States have not implemented the Act fully. We are now telling the States that they don’t need to pick up the Central Clinical Establishment Act, they can have their own law. The States are free to do that. The idea is not to be intrusive but to get some amount of parity in the treatment and the healthcare quality across the country. I have been working with the private sector through various industry bodies. There seems to be a consensus that they would like to come together and form something which is of common interest. It is not about money. It goes much beyond that.”
He further says, “In regulatory aspect, we must reduce harassment of the industry and make things easy (like smooth paperwork and documentation). We have made changes in various rules and regulations so that things become easy. But quality is our concern. We will intervene on quality.”
The provision of free primary healthcare by the public sector supplemented by the strategic purchase of secondary care hospitalization and tertiary care services from both the public and non-government sectors to fill critical gaps would be the main strategy of the Health Ministry to assure healthcare services in India. The Ministry is envisaging strategic purchase of secondary and tertiary care services as a short-term measure. 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 ones and then commercial private sector in underserved areas, based on the availability of services of acceptable and defined quality criteria. In the long run, the policy envisages to have fully equipped and functional public sector hospitals in these areas to meet the secondary and tertiary healthcare needs of the population, especially the poorest and marginalized.
The proposed National Healthcare Policy advocates a positive and proactive engagement with the private sector for a critical gap filling towards achieving National goals. One form is through engagement in public goods, where the private sector contributes as part of CSR work or on contractual terms with the Government. The other is in areas where the private sector is encouraged to invest which implies an adequate return on investment on commercial terms which may entail contracting and strategic purchasing.
ONLINE DATABASE OF MEDICINES
Aiming at bringing down the wastage of medicines due to their expiry, the Union Health Ministry has rolled out an online database of medicines stocked at Government-run health centres. The Ministry is also digitizing various Government-run health centres, including primary health centres, community health centres and hospitals.
“Through this move, we are trying to monitor the usage and wastage of drugs. Public facilities have a typical problem. While some drugs remain unused, some go out of stock. This IT-backed programme will help us to monitor the drugs inventory and replenish the supply to avoid an out-of-stock situation. We can easily transport unused medicine from one public healthcare centre to some other Government centre where it is required,” the Health Secretary says.
The effort of the Ministry has paid off with as many as 21 States in the country pushing the IT infrastructure.