Over the last 10-15 years, there has been a drastic shift in the disease burden pattern in India from communicable to non-communicable diseases (NCDs). In the present scenario, NCDs have taken a driver seat, accounting for 53% of disease burden and 60% of all deaths in India, and increasing rapidly. What’s more worrisome is the high out-of-pocket expenses incurred by individuals due to NCDs which often leads them into poverty.
Therefore, the need of the hour is to have a more aggressive and strategic approach to address the disease burden. The Ministry of Health and Family Welfare is already undertaking several key initiatives in this regard under the National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), and the recently released National Health Policy suggests directives with a clear focus on addressing and tackling NCDs, with emphasizes on screening, prevention, financing and patient care.
To know more about the Ministry’s plan of action, especially after the new health policy, PFCD engaged in a candid conversation with Shri Rajeev Kumar, Director in Union Ministry of Health & Family Welfare.
Q. How do you analyse the New National Health Policy 2017? How it will provide a boost in the Ministry’s efforts to address NCDs?
A. The new national Health Policy is a milestone for planning and strategy in health sector as it was developed after a rigorous process of considering suggestions from over 5,000 stakeholders as well as consultations with the State Governments and other prominent influencers. One of the most crucial aspects is a suggestive increase in public health spending to 2.5% of GDP in a time-bound manner, which has been a call from all quarters.
So far as NCDs are concerned, prevention, screening, treatment, support, rehabilitation and palliative care, all aspects are important. Moreover, the whole of the society and whole of the Government response is
needed to prevent and control NCDs. New Health Policy envisages this strategy and underlines the importance of focusing our efforts on prevention and control of NCDs.
The Policy would guide the efforts to address NCDs as it focuses on several key aspects, including preventive and promotive healthcare, strengthening of primary healthcare services, capacity building, and universal access to good quality services without anyone having to face financial hardship as a consequence.
To deal with the shortage of health workforce, the policy advocates development of mid-level service providers, nurse practitioners, public health cadre to improve availability of appropriate health human resource.
Additionally, the policy proposes to provide free drugs, free diagnostics and free emergency and essential healthcare services in all public hospitals as it constitutes the major portion of out-of-pocket expenditure.
Q. NCDs are the leading causes of death and disease
burden worldwide. Each year, about 60% of the total deaths registered in India are due to NCDs. The economic and social ramifications of growing NCDs are disastrous. How is the Ministry of Health & Family Welfare gearing up to address the fast-changing disease pattern in the country?
A. Under the National Health Mission (NHM), up to thedistrict level, the States are being supported to provide accessible, affordable and quality health care through National Health Programme (NHP).
Under NPCDCS, a programme being implemented under NHM, the Government of India is implementing interventions up to the district level. It has focus on awareness generation, screening and early diagnosis of persons with high level of risk factors and their treatment and referral (if required) to higher facilities for appropriate management, development of human resource and setting
up of infrastructure such as NCD clinics.
Some of the key initiatives currently being undertaken are:
Guidelines for implementation of the National Dialysis Programme have been developed and shared with the States. Under the programme, more than 1 lakh patients have undergone about 11 lakhs dialysis sessions in various district hospitals in the country.
Operational guidelines have already been released for implementing population level screening for diabetes, hypertension and common cancer (breast, cervical and oral). The training of frontline workers – the Accredited Social Health Activist (ASHA) and Auxiliary Nurse Midwife (ANM) – will also be initiated while detailed protocols for treatment, referrals and follow-up on these disease conditions will be provided.
The Central Government, through its hospitals, augments the efforts of the State Governments for providing health services in the country. Under Pradhan Mantri Swasthya Suraksha Yojana (PMSSY), six new All India Institute Of Medical Science (AIIMS) have been made operational. Meanwhile, the upgradation of identified government medical colleges/institutions for higher specialty facilities has been undertaken.
Under the Tertiary Care Cancer Centre (TCCC) Scheme, the Government of India is assisting States to set up / establish State Cancer Institutes (SCIs) and TCCCs across the country.
AMRIT (Affordable Medicines and Reliable Implants for Treatment) stores are being set up, where essential lifesaving medicines for cancer and CVDs are being provided at a substantial discount.
Q. There seems to be growing realization that screening and primary care needs to be effectively strengthened in the country in the wake of the growing cases of NCDs.
A. Screening and primary care are considered as the two most crucial aspects when it comes to effectively managing and addressing NCDs. The early diagnosis and screening of NCDs, coupled with strong primary care settings will help us onset the rise in the number of NCD cases. As already mentioned earlier, the Ministry is
already working towards the screening of five major NCDs, as part of which 1,000 sub-centres would start undertaking screening soon across 100 districts across the country soon.
National Health Mission and several schemes, such as Pradhan Mantri Swasthya Suraksha Yojana (PMSSY), Tertiary Care Cancer Centre scheme, provide support to the State Governments for strengthening of health infrastructure at primary and secondary level.
The new National Health Policy envisages providing a larger package of assured comprehensive primary healthcare through the ‘Health and Wellness Centers’, which includes care for major NCDs, mental health, geriatric healthcare, palliative care and rehabilitative care services. The policy also advocates for a need to allocate major proportion of resources to primary care and aims to ensure availability of two beds per 1,000 population distributed in a manner to enable access within golden hour.
Q. Is the ministry planning a national check-up programme to screen the general population of early signs and symptoms of diabetes, hypertension, and cancer?
A. The Government of India is already implementing a National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke, in all the State Governments and Union Territories (UTs) under National Health Mission (NHM). The programme has objectives of awareness generation among masses and of opportunistic screening for common NCDs. It is recognised that prevention and screening are important in our strategy to prevent and control NCDs in the country. The Government of India is initiating population level screening for common NCDs, such as hypertension, diabetes and common cancer i.e., breast, cervical and oral.
Under this programme, the frontline health workers such as ASHAs and ANMs, inter alia are being leveraged to carry out screening and generate awareness about the risk factors of NCDs. Initially, 100 districts across the country are identified for implementation of the programme. The Union Government has already shared the operational guidelines under this scheme with the States/ UTs with the request to submit their proposals in their state specific Programme Implementation Plans (PIPs) for assistance under the National Health Mission.
The Union Government has already shared the operational guidelines under this scheme with the States/ UTs with the request to submit their proposals in their state specific Programme Implementation Plans (PIPs) for assistance under the National Health Mission.
Q. Despite increasing demands to increase the current level of public spend from the current level to address the growing NCD burden, the ministry seems to be facing a bigger challenge of inequity in terms of the capacity displayed by some states to deliver. How is NCPCDS dealing with the situation?
A. There is no denying of the fact that capacity of the States in delivering healthcare vary across India. There are flagship programmes like NHM, PMSSY under which the efforts of the States are supplemented to provide equitable, affordable and accessible healthcare. There are multiple mechanisms through which resource allocation to the States are linked with status of development, absorptive capacity and other financial indicators. The States are incentivized to increase spending on public health as well as to improve the delivery of healthcare. There are some externalities which negatively impact the healthcare delivery in certain areas. These are addressed through different policy options. The new National Health Policy envisages increase in health expenditure as percentage of GDP upto 2.5 % by 2025. Our TCCC schemes also provide support to underserved areas. In many of the schemes, the State share is around 10% for hilly and NE States, while it is quite higher for others. NPCDCS has two components, one under NHM and another to provide tertiary care for cancer. The same mechanisms, as explained above are used to promote equity in terms of capacity to deliver healthcare.
Q. Fighting NCDs require a multi-stakeholder approach; active support from other ministries. How is MoHFW involving other ministries in its endeavour?
A. In response to the growing burden of NCDs, the Government of India has developed a draft National Multi Sectoral Action Plan (NMAP 2017-2022) for prevention and control of NCDs to guide multi-sectoral efforts towards attaining the National NCD objectives. The action plan is based on four strategic areas (Integrated and Multisectoral Coordination Mechanisms; Health Promotion; Health Systems Strengthening; Surveillance, Monitoring, Evaluation and Research) with a goal to promote healthy choices, reduce preventable morbidity, avoidable disability and premature mortality due to NCDs in India through a whole of government approach.
The NMAP was circulated to 39 Departments under various Union Government Ministries for their inputs on action plan as well as requesting them to appoint a Nodal Officer at the level of Joint Secretary to coordinate their response within the NMSAP framework. Out of the all, about 31 Ministries/Departments have also nominated their Nodal Officers for coordination for the NMSAP.
The MoHFW has organized several inter-ministerial consultations on the NMAP for prevention and control of NCDs. The objectives of the consultation are to enhance the engagement of the Government stakeholders including NCD Nodal Officers in endorsement and implementation of the NMAP, thereby facilitating the transition from commitment to action for national NCD response.
Engaging other sectors to address NCDs
The policy thrust areas include emphasis on preventive and promotive health which is very important in prevention and management of NCDs by engaging all ministries. The policies build on the commitments of other ministries such as balanced healthy diet and regular exercises, addressing tobacco, alcohol and substance abuse, Yatri Suraksha to address road traffic accidents, reduced stress and improved safety at work place and reducing indoor and outdoor air pollution. The policy also includes ‘Health Impact Assessment ‘of existing and emerging policies of key non-health departments that directly or indirectly impact health. This has been recommended by WHO and has not been implemented in India so far.
Implementation and Accountability for implementing NHP 2017
A policy is only as good as its implementation. Many major recommendations of the last two health policies were not implemented. That happens to policies in other sectors as well. Assigning the implementation work to one of the three departments within the Ministry of Health and Family Welfare – Department of Health and Family Welfare, Department of AIDS Control and Department of Health Research – will reduce the complications and make that particular department accountable. There is also a need to have an implementation monitoring cell which will directly report to the minister about the advancements. The policy does mention implementation framework which has been developed by the Ministry itself. The implementation framework should include clear deliverables and milestones as well as assign clear responsibility and accountability for accomplishing the commitments mentioned in the policy.
Need for a cadre of professionals to manage health programmes
The policy strongly states the need for establishing the Public Health Cadre with qualified and trained health managers to run the national health programmes including non-communicable diseases by specialised health managers. It is high time that these cadres are set up to manage a complex programme like NCDs which involve engaging stake holders outside health sector. The states like Tamil Nadu and Maharashtra which have public health cadres are doing much better in managing NCDs than those without such cadres.
NHP 2017, developed with an extensive consultative and participatory process, is comprehensive in addressing NCDs and related goals. It commits to achieving various goals and targets set in SDGs and UN High Level Meetings on NCDs. However, looking at the past government policies, its implementation remains a concern. An implementation and accountability framework with clearly stated and time bound milestones needs to be developed and monitored by the honorable Health Minister himself and the PMO.
How to Address the Issue of Inadequate Financing for Health Care Needs
India has seen a rapid transition in its health needs over the recent years, with non-communicable diseases (NCDs) now accounting for 53% of disease burden and 60% of deaths. On a positive side, the National Health Policy 2017 has recognized the growing burden of NCDs and the increasing impoverishment due to high out-of-pocket expenditure on health. The policy also envisages to provide complete access to primary, secondary and tertiary services to all segments of the society through preventive, promotive and curative care.
However, what’s worrisome is the low public spending on health which has remained stagnant in the range between 0.9% to 1.2% of GDP from 1990 till present. The WHO World Health Statistics 2015 has also placed India among the bottom countries considering its public spending on health. These under investments in health care result in lower worker productivity and poorer health outcomes. These low levels of expenditures combined with the low penetration of health insurance mean that most Indians purchase their healthcare not through insurance but through direct out-of-pocket payments.
India’s budgetary policies over the past few years show the country’s inclination towards the non-developmental factors, while expenditure on developmental issues such as health and education has persistently taken a back seat. India, with 17.84% of the world’s population, is at high risk of economic implications due to the growing burden and pre-mature mortality because of NCDs.
When talking about the health insurance coverage, over 70% of the country’s 1.3 billion residents are uninsured. This is largely attributed to low enrollment in some of the central and state government health schemes, and the lack of a robust private health insurance market. Moreover, there are also substantial differences across the health insurance schemes regarding the scope of benefits covered. In general, most of the plans do not cover primary care and outpatient medicines, essential components for preventing and managing NCDs.
Considering the country’s diverse healthcare needs and limited financial resources, it is imperative for the Government to consider diverse financing coverage and reimbursement options to meet the health care needs of all citizens, including the expansion of government insurance programs, employer and other private supplemental insurance options innovative financing models, and public-private partnerships.
One such potential solution is a multi-payer approach that would 1) increase enrollment in current government plans, 2) expand government insurance cover to those up the economic scale, reaching the middle class who don’t qualify for government cover but cannot afford private insurance, 3) expand employer/private insurance as supplemental options for those who want to and can pay. This is similar to the approach pursued by Indonesia that recently passed health reform with the intent that all would be covered by 2019.
Adequately financing health care in India will require a significant increase in government and private sector funding and insurance coverage. Fortunately, India has the central and state government health plans in place that could, with the appropriate funding, extend coverage to low income populations currently eligible but not enrolled. Use of a multi-payer approach that expands private health insurance to those not eligible for government programs would transform out-of-pocket spending today to health insurance premiums funded through worker and employer contributions. These contributions would be supplemented by government support to assist lower income working households. The contributions could be paid either through payroll tax or through income related monthly contributions.
To achieve these goals, expanded coverage would also have to address the large differences in benefits covered in existing plans, and the financial coverage limits on what the plans pay. Moreover, the other two financing functions of developing risk pools and approaches for purchasing services would have to be part of the reform.
PFCD in the News
Low Healthcare Spend Worrying Deccan Herald, June 24, 2017
PFCD Chairman Dr. Kenneth Thorpe says lack of focus on health can have serious implications, not just on the state of the health of people and the misery that it causes, but also in dragging the economy of the country down several notches. What is worse is that the shooting figures of the disease burden and deaths in the country are being fought with dismal figures of public spend on health care. There’s extremely high, about 61% out-of-pocket expenditure, one of the highest in the world, and very low health insurance coverage: only 25% of the population, again one of the lowest in the world. Until the Cabinet cleared the Health Policy, healthcare spend was pegged at a little more than 1% of the GDP. The new policy is aimed at universal health coverage for all and recognises that there are many critical gaps in public health services which would be filled by strategic purchasing.
Experts say the number of diabetics in India is expected to touch 120 million over the next two decades. “Type 2 Diabetes is likely to lead to the biggest epidemic and public health issue in human history, posing a huge barrier to economic development,” says Dr Kenneth Thorpe, chairman, Partnership to Fight Chronic Disease (PFCD). “We need a multi-sectoral approach that fosters partnerships among the government, NGOs and corporate companies,” says Dr Thorpe. “Government policies and incentives such as tax benefits, underwriting and facilitating bank loans—especially to supplement care in underserved and difficult-to-reach areas—are vital to attracting private investments in the healthcare sector,” says Dr Thorpe.
Focus on NCDs : The Earnest Work is Showing Results ET Healthworld, June 1, 2017
PFCD Chairman Dr. Kenneth Thorpe says good health is one of the most crucial building blocks for human development. If we look at India and its socioeconomic and demographic parameters, the threat looming due to NCDs is alarming. Today, India is world’s fourth largest economy, presenting a multitude of business opportunities for global communities. What truly sets it apart is its demographic dividend of 1.27 billion people and the largest number of young workers in the world. The occurrence of NCDs is mostly in the population under the age of 60 years. Moreover, all forms of NCDs either lead to prolonged treatment cycles or premature death! This is threatening to a nation’s development and its economy as the most productive section of the society is getting significantly impacted.
Balancing the Healthcare Act The Financial Express, May 11, 2017
Dr. Kenneth Thorpe, Chairman, PFCD, says, “India’s unprecedented potential for growth is inexplicably marred by one of its more fundamental traits—falling short in ensuring health and social welfare. Despite positive growth indicators and economic progression, the country has lacked relentlessly in catering to the health requirements of the public, empirically validated in its measly budgetary outlays and inefficient execution in expending allocated funds. A coherent analysis of India’s budgetary policies for health over the past few years paints a dismal picture, with the government persistently prioritising non-developmental factors (such as preservation of country’s defence, law and order, maintenance of the general organs of the government, and so on) over developmental expenditure (items of expenditure designed to promote economic development and social welfare)”.
High blood pressure causes 7.5 million deaths worldwide, about 12.8% of the total deaths in a year, according to recent estimates by the World Health Organization (WHO). Hypertension is one of the most common non-communicable diseases in India, says Kenneth Thorpe, Chair of the Partnership to Fight Chronic Disease (PFCD). Building awareness about hypertension, particularly the risks and causative factors, can help tackle the growing disease burden. The risk of hypertension is greater if you’re above the age of 35, overweight, have a family history, mild kidney disease, or are a smoker. Lack of timely diagnosis is contributing to spiralling numbers. It is important to ensure that we put a lid on this dangerous condition.
Cancer Ravages Health as well as Personal Resources in India Huffpost, May 7, 2017
“You have cancer”. These terrifying words resonate in the ears of someone diagnosed with the dreaded disease. And for their family, the first thoughts are about the affordability of the treatment. In a low-resource country like India, it is one of the most catastrophic Non-Communicable Diseases (NCD) today. The numbers are damning: 12.5 lakh new cases are diagnosed every year and around 28 lakh cases of cancers are prevalent at any given point of time. It also claims lives of about 6.8 lakh patients per year. says PFCD Chairman Dr Kenneth E Thorpe.