Healthcare is a state responsibility according to the Constitution of India (article 42, ‘Provision for just and humane conditions of work and maternity relief’ and article 47, ‘Duty of the State to raise the level of nutrition and the standard of living and to improve public health’).
Each state has its own healthcare delivery system in which both public and private (for-profit as well as non-profit) parties operate. While states are responsible for the functioning of their respective healthcare systems, certain responsibilities also fall to the central government, namely aspects of policymaking, planning, guiding, assisting, evaluating and coordinating the work of the various provincial health authorities, and providing funding to implement national programmes. The organisational structure of the healthcare system is as follows:
- at the national level, the organisation consists of the Union Ministry of Health and Family Welfare (MoHFW);
- at the state level, the organisation is under the state department of health and family welfare of each state. Each state department is headed by a minister and has a secretariat under the charge of the Secretary or Commissioner (Health and Family Welfare) belonging to the cadre of the Indian Administrative Service;
- at the regional level, each regional and zonal setup covers three to five districts and acts under authority delegated by the State Directorate of Health Services;
- the district-level structure of health services is a middle-level management organisation that provides a link between the state and the regional structures on one side, and the peripheral-level structures (such as primary health centres and sub centres) on the other;
- at the sub-divisional (administrative division) level, healthcare services are rendered through the office of the Assistant District Health and Family Welfare Officer; and
- at the community level, one community health centre has been established for every 80,000 to 1.2 million members of the population, and the centres provide basic specialty services in general medicine, paediatrics, surgery, obstetrics and gynaecology.
National health policy, 2017
The National Health Policy, 2017 has been introduced in guiding the approach for addressing the health sector. The primary aim of the National Health Policy, 2017 is to prioritise the role of the government in shaping healthcare systems and includes:
- investments in health;
- organisation of healthcare services;
- prevention of diseases and promotion of good health through cross-sectoral actions, access to technologies;
- developing human resources;
- encouraging medical pluralism;
- building a knowledge base;
- developing better financial protection strategies; and
- strengthening regulation and health assurance.
The key principles of the National Health Policy, 2017 are:
- professionalism, integrity and ethics: the policy aim to maintain highest professional standards, integration and ethics in healthcare delivery supported by a regulatory environment;
- equity, affordability and universality: reducing inequality so that healthcare services are provided to all and minimising disparity on account of gender, poverty, caste, disability, other form of social inclusion and geographical barriers;
- patient-centered and quality of care: evolve and disseminate standards to ensure quality of healthcare;
- accountability: assign financial and performance accountability, transparency in decision-making and elimination of corruption in the healthcare system;
- inclusive partnerships: partnership with academic institution, not for profit agencies and the healthcare industry;
- decentralisation; and
- dynamism and adaptiveness.
The principles of National Health Policy, 2017 are:
- ensuring adequate investment: the policy proposes to increase the healthcare expenditure from 1.5 per cent of the GDP to 2.5 per cent of the GDP by 2025 in a time-bound manner;
- preventive and promotive health: the policy envisages complementing the international ‘Health in All’ approach with Health for All in India. The policy empowered the public health cadre to address social determinants of health effectively, by enforcing regulatory provisions. The policy identifies coordinated action on seven priority areas for improving the environment for health:
- the ‘Swachh Bharat Abhiyan’ campaign to clean up streets;
- balanced, healthy diets and regular exercise;
- addressing tobacco, alcohol and substance abuse;
- Yatri Suraksha - preventing deaths due to rail and road traffic accidents;
- Nirbhaya Nari - action against gender violence;
- reducing stress and improving safety in the workplace; and
- reducing indoor and outdoor air pollution.
The National Health Policy, 2017 proposes seven key policy shifts in organising healthcare services that includes:
- primary care - from selective care to assured comprehensive care with linkages to referral hospitals;
- secondary and tertiary care - from an input-oriented to an output-based strategic purchasing;
- public hospitals - from user fees and cost recovery to assured free drugs, diagnostic and emergency services to all;
- infrastructure and human resource development - from a normative approach to a targeted approach to reach under-serviced areas;
- urban health - from token interventions to on-scale assured interventions, to organise primary healthcare delivery and referral support for urban poor. Collaboration with other sectors to address wider determinants of urban health is advocated;
- national health programmes - integration with health systems for programme effectiveness and in turn contributing to strengthening of health systems for efficiency; and
- AYUSH services - from stand-alone to a three-dimensional mainstreaming.
The Ayushman Bharat programme has been introduced to address the health sector holistically, ensuring primary, secondary and tertiary care systems, covering both prevention and health promotion. Two important arms of the programme are given below.
Health and wellness centres
Health and wellness centres have been created to make healthcare approachable to every individual. The centres are designed to provide comprehensive healthcare, including for non-communicable diseases and maternal and child health services. These centres will also provide free essential drugs and diagnostic services. Also, contributions to these centres from the private sector (through corporate social responsibility) and philanthropic institutions is also envisaged.
National Health Protection Scheme
The second flagship programme under Ayushman Bharat is the National Health Protection Scheme, designed to cover approximately 500 million beneficiaries, that will provide insurance coverage of up to 500,000 rupees per family per year for secondary and tertiary care hospitalisation.
The Draft National Health Policy recommends distribution of responsibility and accountability between the Centre and the states in meeting the objectives of the Health Care System.
The policy also set up the basic background and assesses the development of economics and health systems so as to include a Health Rights bill making health a fundamental right. Thus, to make healthcare a justiciable right is to imply that its denial is an offence. Questions that need to be addressed are manifold, namely:
- When healthcare is a state subject, is it desirable or useful to make a central law?
- Whether such a law should mainly focus on the enforcement of public health standards on water, sanitation, food safety, air pollution etc, or whether it should focus on health rights - access to healthcare and quality of healthcare.
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