|Year : 2016 | Volume
| Issue : 1 | Page : 40-50
Draft national health policy 2015: A critical appraisal
Faruque U Ahmed
Senior Adviser; International Clinical Epidemiological Network (INCLEN), New Delhi, India
|Date of Web Publication||23-Feb-2016|
Faruque U Ahmed
Rtd. Director NEIGHRIMS, Shillong. "AHMED VILLA" Seujpur, 4th. Bye lane , Dibrugarh, Assam - 786001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Revising a health policy of any country is a periodic procedure dependent on the change of demographic profile, current health status of the population including epidemiological changes in disease prevalence pattern, and progress made under the earlier policies. Along with it, newer research revelation of the natural history of the existing and emerging health problems, availability of newer technology as well as changing sociopolitical commitment to improve the health status of the population are the driving forces in the change of policy. Draft National Health Policy (NHP) 2015 is an attempt for the same. A review of the draft has been undertaken. The chapter on introduction is crisp and clear. Situation analysis of the draft is sketchy and without any reference of sources. Shifting the health goal is without any basis, and the objectives defined for the policy change are incongruous with the introduction. A detailed description does not give a clear picture but rather confuses the reader as it talks of comprehensive universal health-care services to be provided with a holistic concept but maximum emphasis is made in the implementation of a national program. Private health-care services are an area to reckon but except for mere references on the involvement in private-public mode, nothing concrete is observed, especially in the primary care level. Involvement envisaged in the secondary and tertiary levels is nebulous. The implementation health insurance program as well as regulatory mechanISM with the existing is also not defined exclusively in the context of a newer health policy.
Keywords: Alternative health manpower, convergence and continuum in health care delivery, cost of health care and health-care financing, graded referral service, health care delivery system, health-care needs, health policy analysis, personal health care and public health care, public and private mix in health care delivery, regionalization of health care delivery, social and environmental determinants of health
|How to cite this article:|
Ahmed FU. Draft national health policy 2015: A critical appraisal. Indian J Public Health 2016;60:40-50
| Introduction|| |
The draft of the "National Health Policy (NHP) 2015" is the third in the series of NHPs of India. In the backdrop of the global consensus on the goal of "Health for All" (HFA) to be achieved through "primary health care" strategy,  the first NHP was formulated in 1983. During the initiation of the economic liberalization policy of India and adoption of the millennium development goals (MDGs) as a target of achieving the HFA by all the countries of the world in 2002, India formulated its 2 nd NHP. In the recent years, to achieve the MDGs the United Nations and other world bodies reviewed the progress made so far and suggested two strategies of "Health in All" - a concept implying "health as an integral part of development"  and "universal health coverage."  This is the backdrop of the draft of NHP 2015. The objective of the article is to critically review the draft of NHP 15.
A. Context, Need and Scope: The context, need, and scope answer three basic queries required for a policy change, viz., Why a new policy (context)? What are the changes envisaged (need and scope)? How will it be achieved?
- Why a new Policy and the draft policy highlights the queries in the following words: Governments realization of facts that being "the world's third largest economy in terms of Gross National Income (in PPP terms)" possessing as never before "a sophisticated arsenal of interventions, technologies and knowledge required for providing health care to her people yet the gaps in health outcomes continue to widen". "The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way and on an adequate scale". And the "Global context of all nations committed to wards universal health coverage" as stated in the Introduction of the draft clearly justifies the need for a policy change. 
- What are the changes envisaged? It envisages improvement of "the performance of the health care system" and the four areas identified for consideration are:
- Addressing the "changing health priorities," which include shortcomings in the attainment of MDGs, deficiencies in the preventive programs, access to treatment, and "unfulfilled expectation of many other health needs," viz., emerging and re-emerging infectious diseases and increasing noncommunicable diseases.
- Utilization of the "emergence of a robust health care industry".
- Reducing the "ever increasing catastrophic expenditure due to health care".
- More resource allocation due to "increased fiscal capacity available" in the country.
- How it will be achieved? "The political will to ensure universal access to affordable health-care service in an assured mode" would be the driving force and the universal access to health care would be achieved by making changes under "investments in health, organization, and financing of health-care service, prevention of diseases and promotion of good health through cross-sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies, and regulation and legislation for health."
B. Situation analysis: Desegregated data on demography and disease prevalence (current and trend) according to the socioeconomic status, available health care infrastructure in rural and urban areas both formal and informal, public and private, available trained/untrained health manpower as per the norms of the Indian Public Health Standards, quality and cost of (especially private) services provided, and their geographical distribution and utilization pattern are some of the most important information needed for formulating any health policy. But the information provided in the chapter of situation analysis is poor in this regard and the data provided in the draft are not authenticated with references. Some important observations on situation analysis are:
- Achievements of Millennium Development Goal in population stabilization, disease control program, and inequities in health outcomes and quality of care4: On performance of MDGs, it is stated that infant mortality rate (IMR), maternal mortality ratio (MMR), and under-5 mortality rate (U5MR) are below the international average and the rate of decline of still births and neonatal mortality rate are less than the U5MR. On the population stabilization front, "the national total fertility rate (TFR) has declined from 2.9 to 2.4" but with a persistent declining sex ratio. The inadequacy of the existing disease control program is evidenced with the statement that current programs only cover "10% of all mortalities and about 15% of all morbidities" but "over 75% of communicable diseases are not covered under any program." Multidrug resistance of Mycobacterium and drug resistance of malaria parasite against available drugs are emerging problems. "Subcritical human resource deployment, weak logistics, and inadequate infrastructure" are some of the deficiencies attributed to the inadequacy of the program. On the topic "Inequities in health outcome," the draft is selective for only some reproductive and child healths (RCH) parameters but not inequities of performance of other national health programs. Under the head "Quality of care," it only mentions the status on the health care related to RCH services excluding the other types of health-care services rendered by the public and private health care institutions at three levels and the quality of care of services rendered through extension clinics and at domiciliary level rendered by the public health care system. The data are essential for policy change.
- Failure of the National Rural Health Mission (NRHM) as an instrument for strengthening the state health care system was attributed to the strategy of "selective facility development" and the nonavailability of "higher levels of investment and resources" required for providing comprehensive care. The nonavailability of a comprehensive range of health care packages, the requirement to address the whole spectrum of current health problems, and the social and environmental determinants of health are major deficiencies of NRHM.
- Basic information necessary as a resource to policy formulation, e.g., urban health care infrastructure (public and private), availability of different health care providers, and type of services rendered and its adequacy, cost, and utilization pattern are missing in the draft.
- Nonavailability of high quality, timely, and reliable data on demography, disease prevalence, and mortality disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location, its trend, and other characteristics relevant in national contexts necessary to identify where and why inequalities exist is a major deficiency, which is necessary to frame policies and programs to reach the most vulnerable are missing in the draft policy. Information related to the prevalence of different types of diseases and utilization pattern services for different morbidities the other two essential information is also insufficient in the draft. 
- Cost of care and efforts at financial protection and public finance health insurance: The nonavailability of free services in the public sector except for selective services under the National Health Program as well the charges levied for diagnostic services, nonavailability of many essential drugs to treat most of the noncommunicable diseases (NCDs) and injuries, and overcrowding and long waiting time in public hospitals are the reasons for "funneling" of patients to private institutions. The reason for overcrowding and long waiting time in the public secondary and tertiary level hospitals is due to the nonperforming primary health centers situated in rural areas, nonavailability of primary health care institutions in the urban area, and lack of a regionalized graded referral in the public health care system. As there is no regulatory mechanism to control the prices of services provided by private health care system, patients are literally fleeced. Support from the state to ameliorate the financial burden is restricted to maternity care, newborn care, and infant care. To contain the out-of-pocket expenses on treatment, eight states introduced a different scheme, viz., health insurance program, direct purchasing of care through trusts, and initially reserving some services only through public hospitals later extended to limited private hospitals. "Rashtriya Swastha Bimayojna" (RSBY) was initially started by the Ministry of Labor and later shifted to the Ministry of Health to reduce the financial burden of treatment in the population below the poverty line. Evaluation of such programs reveals that schemes such as the RSBY have improved the utilization of hospital services, especially in the private sector and among the poorest 20% of the households and scheduled castes (SC)/scheduled tribes (ST) households. The reported loopholes are "denial of services by private hospitals for many categories of illness," "oversupply of some services," and adoption of "various fraudulent measures including charging informal payments." It is also observed that the schemes managed by independent bodies or when managed by insurance companies are better.
- Government proactive policy to encourage the growth of the health care industry by measures such as tax exemption on rural hospitals and health insurance, duty exemption for life-saving equipment have contributed to a robust health care industry worth $40 billion that is projected to grow to $280 billion by 2020 with a growth rate of 14%, projected to increase to 21% in the next decade. The service sector, viz., hospitals, clinics, and diagnostic centers constitutes the major component (about 60%) followed by pharmaceutical (25%) and insurance (15%) sectors. As the health care industry touches the lives and health of the population, the policymakers are happy about its growth but at the same time concerned about excessive capitalization and overcrowding in a few cities unduly influenced by the requirements and perceptions of the industry. They are also apprehensive about the demands on public financing and flouting the basic policy structure, especially with regard to the cost, standards, and regulations. 
- Human resource development, research and challenges, and AYUSH doctors: Information on health manpower is sketchy and does not contain the actual requirement and deficiencies thereof with future projection as well as the training capacity available in India to train the required health manpower. The ubiquitous participation of unqualified private health care providers in health care delivery is also missing. NHP cites "modest funding of less than 1% of all public health expenditure" for research as the major cause of underperformance in research but is silent on the strengths and weakness of current research to improve the health-care services. "Emergence of integrative medicine" by a meaningful, phased integration of indigenous system of medicine (ISM) with the existing health delivery system is a welcome step. But details regarding the number of AYUSH doctors, available infrastructure of training, its quality and capacity, and the service utilization pattern are missing.
- In 2011, India invested 4.1% of the gross domestic product (GDP) on health care, which varied from 3.3% in Sri Lanka to 17.7% in the USA. On personal health expenditure, the Government of India's contribution is less than 1.04% of GDP. In real terms, the government's contribution for the treatment of an individual is only 30% and the remaining 70% is spent by the individual out of his/her own pocket. The government's contribution on personal health care in 2011 in Denmark was 85.3%, in the UK was 82.2%, in Thailand was 77.7%, in the USA was 47.7%, and in China was 55.9%. Disaggregated data on "core health expenditure" and "broad health expenditure" (BHE) as mentioned in the 12th plan document,  which is necessary to understand the implication of the different types of investment on health and its outcome, are also missing. It is also not known whether the investment on improving the physical, social, and biological environments necessary for reducing the major disease causing factors spent by nonhealth departments/ministry is included as a health investment and how is it audited and accounted for.
- Regulatory role of government: Information related to the existing state and central acts regulating the health care delivery systems, services, its pricing, and their strength and weakness is also not available. Nonavailability of the current status and loopholes in the implementation of the existing rules such as the Clinical Establishment Act, the Indian Public Health Standards is another major deficiency to formulate new policies.
C. Goal: India in its first NHP (1983) set the goal of HFA in conformation with Alma Ata Declaration at International Conference on Primary Health Care in 1978 in which India was a signatory.  Though India has progressed mostly in achieving the MDGs and increase in life expectancy, it is still lacking in improving the status of health of the newborns and infants as well as reducing disabilities due to current and emerging morbidities and breaking the vicious cycle of disease and poverty so that the population is not able to attain "a level of health that will permit them to work productively and to participate actively in the social life of the community in which they live." So the refined goal should read as: "To increase the Active life expectancy at birth."
D. Objectives: The objectives stated in the draft do not corroborate with the goals set. But the goal has been changed to achieve the following proposed objectives:
- To reduce the disease burden in the community by utilizing the concept "Health in All" by addressing all social and environmental determinants of health.
- To ensure universal availability of comprehensive and continued health-care services for the prevalent types of morbidities in a graded referral mode from the primary and secondary levels to the tertiary level maintaining equity and accessibility.
- To make the available health-care services (public/private) affordable with an objective of reducing out-of-pocket expenses on treatment and thereby preventing impoverishment due to catastrophic treatment expenditure on the family.
- To ensure alignment of the growth of the health care industry and medical technology with public health goals.
E. Policy direction
1. Ensuring adequate investment: The draft policy's proposal of a "potentially achievable target of raising public health expenditure to 2.5% of the GDP" needs clarification. Expenditure on which health activity is being referred to? Is it the expenditure on the "personal care component," i.e., treatment of diseases and prevention at the individual and family levels? Or is it expenditure on other community-based public health-care services and expenditure made on addressing the social and environmental determinants of health? If the government accepts the concept of "Health in All" than the expenditure made on improving the social and environmental determinants and other expenditure contributing to health, nutrition, and welfare of the mother, child, the elderly, the unemployed, and other underprivileged groups its effective use should be accounted for in improving health. This may be grouped as "public health expenditure." At present, the health outcome of such expenditure is lacking and one is not sure how it is accounted for.  As health is lower on the priority list of the national needs, the current system of allocation on health from the general taxation fund will always be less. So a separate health fund has to be generated to be spent under both the heads "Core Health Expenditure" (CHE) and "Broad Health Expenditure" (BHE) and the amount is to be appropriated accordingly for specific public health programs. The following suggestions are made for generating additional revenues for health:
1. Imposing "health cess" on different industries and developmental agencies affecting the social and environmental determinants of health.
2. Imposing health tax on products such as tobacco, saturated fat, and other harmful agents and activities that lead to health hazards.
3. The third source is universalization of personal health insurance by public or private initiatives. For the organized and unorganized laborers, the existing ESI scheme may be strengthened by including the unorganized labor sector. This should include all government employees - central and state, organized public and private sector employees as well as workers in the agriculture sector and daily wage earners of any kind. The labor department should be strict in enforcing this. All senior citizens should be covered by a health insurance scheme sponsored by the state. For others, the health insurance options are: a) self; b) those who are economically and socially disadvantaged through government support, or by employers and by philanthropic individuals, organization or as an activity of corporate social responsibility. We should take the advantage of the "Pradhan Mantri Jan Dhan Yojana" - the Prime Minister's universal bank account program, which can be linked to the health insurance scheme covering life, disease, and disability. There should be only one agency that looks after health insurance and its implementation. The Government's role will be regulatory so as to set the standards of treatment, quality of care, and sound pricing as well prevention of any fraudulent practice. It should also ensure protection of the public from exploitation. A "Health Services Regulatory Authority" such as the "Telecom Regulatory Authority of India" (TRAI) may be constituted at the central as well as state levels for regulating the public and private personal health-care services in India.
4. Comments on preventive and promotive health: Addressing the wider social and environmental determinants of health
There is an intricate relationship of all developmental programs and services such as basic infrastructure, economic, social, and human resources existing with the health status of the population. Hence, a policy directive by making "health an integral part of all development policies" is appropriate. This will make positive health outcome one of the obligatory responsibilities of all the development departments and make them accountable for the same. Most of the service packages for community development are inherently meant for mitigating the effects of the social and environmental "determinants of health" and to get the best result, the strategy of convergence of the development package and health outcome should be initiated. In the above context, the development of health care infrastructure should be made coterminus with the development of other infrastructures, viz., roads, electricity, and health care institutions, which will improve the quality and utilization of services.
Currently, the delivery of social, economic, nutritional, and other social security and welfare packages to mitigate the health consequences of different critical periods of the human life cycle (pregnancy, lactation, infancy, childhood, adolescent, geriatrics, and illness or disability due to injuries), and different occupational groups is provided under different programs of different ministries as a unitary package for a specific "episode" according to the specific modality. The selection criteria to find out the beneficiaries of each program as well as the different parameters adopted for evaluation of each program make it difficult to link it to health outcome.
Health status/condition is seldom the leading criterion except for those programs directly linked to health. If health status/condition is used as a major criterion for selection of beneficiaries of the social security/welfare program and the service delivery strategy is changed to "convergence" and "continuum care," the resultant health as well as the socioeconomic outcomes of this "integrated and continuum health and social welfare package" will be the best indicator of the efficacy and will help in attaining the goal of such programs. As pointed out in the situation analysis, 100% of the services to address the social determinants in the form of preventive and promotive services are provided by the public health care system, and "convergence" of health and health-related social and welfare packages targeting the identified individuals/families/communities as per health needs will be most effective.
5. Organization of public health care delivery: For universal health coverage, India must have a flexible architecture to deal with the regional diversities and differential health-care needs of rural and urban areas. Considerable gaps exist with respect to disease morbidity and mortality between urban and rural areas. While the combined problems of undernutrition and inappropriate nutrition account for almost equal proportions of the population in rural (48%) as well as urban areas (49%), undernutrition is a dominant problem in the former while overweight and obesity account for half the burden of "malnutrition" in the latter. Urban areas have four times more health care workers in a population of 10,000 than rural areas, and 42% of health care workers identifying themselves as "allopathic doctors" in rural areas have no medical training compared to 15% in urban areas. 
6. The current situation of the health care delivery system can be described as a skewed distribution of services, both public and private, with the preponderance of secondary and tertiary care facilities mainly concentrated in the existing and emerging urban locations. Secondary private hospitals providing single or multiple specialty services owned by individual specialists is a common feature all over India, especially in smaller towns. Hospitals run by trusts, nongovernmental organizations (NGOs), and other collective enterprises are less but are emerging. A skewed distribution of health care facilities in urban areas and unregulated pricing of services have affected the equity, accessibility, and affordability of the available services. The absence of a functioning graded referral system between primary, secondary, and tertiary health care institutions under the public health care system is affecting the continuity of care necessary for a comprehensive care for NCD and other life cycle specific Diseases. As the health care package available in public health care institutions is morbidity specific and episodic as per the service protocol defined under different national health programs including the NRHM, the services are provided not only to the targeted beneficiaries belonging to the families of the community residing in the designated catchment area but also to anyone who attends the public health care institution of any part of the country. This is one of the reasons why there is an overcrowding in those health centers where the functioning is better. To provide "assured comprehensive care that has continuity with higher levels," NHP envisages the establishment of a graded referral system to provide services as per the needs of the targeted beneficiaries in all the public health care institutions starting from subcenter to tertiary level institutions. But how this will be translated to action is not clear from the document. Universal coverage of health-care services can only be attained through an efficient "regionalized graded referral system" with public-private partnership (PPP) covering all the areas - urban and rural, supported by an effective and efficient monitoring system. The following suggestions are made in this regard.
a. Districtwise health care infrastructure with health manpower resource mapping: Mapping should include both public and private health care institutions at the primary, secondary, and tertiary levels as well as health care providers, specialists, generalists, AYUSH doctors, and unqualified practitioners.
b. Regionalization of health-care services against the available health care infrastructure at various levels: Designating functional primary health care institutions (public or private) with designated villages as a catchment area is the first step in making the primary network. Each institution will have a population of a specific number to be served by a team of health care workers led by a qualified doctor. To improve the coverage as well as quality of clinical and public health-care services instead of increasing the number of existing multiskilled workers, two different cadres of health care workers, viz., personal care health care workers and public health care workers will be effective as suggested by Ahmed et al.  Each of the licensed practitioners, along with their clinical assistants, will be allocated specific families for providing institutional as well extended clinical services organized by public health care cadres. They will work as a team and individual health care workers on their own will not be allowed to practice solo without any qualified supervisor/mentor. The pharmacy should only serve medicines on the prescription of a licensed qualified medical practitioner.
c. Each state has to make rules for issuing license to all health care providers, viz., allopathic and AYUSH doctors, nurses, and all other members engaged in health care delivery. Licensing should be periodic. For reissuing license, certificates of the successful completion of compulsory periodic training through continuing education program as well as no adverse report in practice will be necessary. Each of the health care providers will practice his/her own system of medicine/specialty/trade but not in a laissez-faire manner.
d. It has been observed that a secret network of mutual convenience between qualified practicing allopathic doctors, even specialists and unqualified rural medical practitioners (RMPs) on a fee-sharing basis exists in several cities and urban areas of India. Each privately owned health care institution has its own marketing strategy as well as patient funneling mechanism.  The network is extensive with monetary incentives. This type of network can be modified to cover the "hard-to-reach and unreached areas" in rural as well as urban settings. Modification includes auctioning of services for specific delineated areas to private health care providers and individuals or groups with a trained and licensed personal care health team under a capitation fee system as exists in the UK under NHS.
e. Each of the primary health care institutions managed either by the public or private sector should have referral linkage with the next higher levels of care and the referral will be two-way in nature. Except for cases of emergency, there should be incentives and disincentives for maintaining the referral protocol. The referral should be a two-way referral. Permission for establishing any new health care institution including practice irrespective of the level should be given as per the actual requirement of the services as felt by the local authority and not on the preference of any individual, public, or polity.
f. Monitoring the quality of services, pricing as well adherence to the code of conduct of the practitioner and his/her team will be essential for effective functioning of this scheme at the state and district levels.
g. Strict enforcement of the antiquackery legislation against the unlicensed health care providers who violate the code as well as increasing the punishment for such offences equivalent to "attempt to murder" should be made.
h. In view of the ubiquitous availability of unqualified "public health care providers"/rural medical practitioners/jhola chap doctors and extensive utilization of their services by the local people throughout India for various reasons, their inclusion in the delivery of primary health care will be a pragmatic step. As the traditional public health care provider (PHCP) is age-old and accepted by the community at large, most of the measures taken for abolishing it from the society through legal and other measures have failed. It is a sensitive social and political issue, which should be handled cautiously. A sensible way is to take advantage of the existing system as suggested below:
- PHC-wise data mapping on the availability of the different categories of practicing unqualified PHCPs/RMPs.
- For keeping up the quality of treatment as well as maintaining ethical practice, the public health care system must organize continuing medical education (CME) programs for all the doctors and assistants. Undergoing a specific number of CME programs should be made mandatory for renewal and continuation of the service license.
- Special incentives for clinical practitioner teams for their involvement in all national health care programs and other socially desirable services, viz., epidemic control, disaster management, directly observed treatment short course (DOTS), and reproductive and child health (RCH) may be introduced.
i. Awareness campaigns to educate consumers about health-care services, the available services and their cost, type, and quality of care, and the local approved team, the grievance redressal mechanism, and whom to contact are also necessary for the existing public health care system.
j. A good surveillance system consists of recording each defined health event and health-care service availed by an individual of a delineated geographical area covered by a health care institution and analyzing the same to find out the health-care needs and the performances of the existing health-care services. A health event includes disease, disability episodes, life cycle events, viz., marriage, pregnancy, births, and deaths among the individuals of a defined geographical area in a defined period of time. If all the events for an individual are recorded in real time while he/she avails any service from any health care institution - public or private, it will be the best database of any surveillance system, which may be augmented by active- and community-based surveillance activities. Compulsory registration of all the attendances/admissions and briefs of diagnoses based on which services were provided by the health care institution - public and private against the unique identity available from any commonly used address-proof document, e.g., Aadhaar card, voter's ID card, and PAN card will be a strategy to capture the health events. The services provided should also include preventive, curative, or any other personal care services both at the community and institution levels during illness or at different periods of the life cycle. An "electronic health card" (EHC) with a unique number based on the Aadhaar card/PAN card/voter's ID card may be introduced. The Prime Minister's policy of linking Aadhaar card with basic services such as Public Distribution System (PDS) and other social security services may include the health package provided by the health care institutions or extension services. The services provided by health care workers should also be reflected in the EHC. The EHC format will have the following basic information: Unique identity data, health condition, and/or morbidity data service data including pricing. This will constitute the primary data source of the "Community-based Health Information and Management System" (CHIMS), which will also include the integrated disease surveillance data. The entry point in the integrated health care system is the family level through an accredited social health activist (ASHA). The entry of the family for services may be either through an ASHA for "community-based services" or the attending institutions from subcenters or any other primary, secondary, or tertiary health care institutions (public or private). The data so collected can be converted to a customizable data tools such as "Sortable Stats" that allow one to view, sort, and analyze the health data at the block, district, state, and national levels. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA has introduced the same as a strategy tool to control major health problems. 
7. Secondary care and tertiary care: The bed density in a population of 1,000 in the year 2005 was 0.90, whereas the World Health Organization (WHO) guideline is 3.5. The global average in 2002 was 2.6. The compound annual growth rate (CAGR) of bed density in India in 2002-2010 was 9%. During this period, the CAGR of the bed density in the private sector was 13% against 5% in the public sector, resulting in the increase of its share of beds in the private sector to 63% against 49% in the public sector.  As per the above statement, no planner can ignore the growth in secondary and tertiary care institutions in the private sector. It will be outrageous not to utilize the vast available resources in the private sector in the process of universalization of health-care services. For utilizing the services of these existing secondary and tertiary care services, a "PPP model" can be developed on bed-sharing between the management of private medical college hospitals and state government medical college hospitals, which can serve as the forerunner of other PPP services.
8. Human resource development: The suggested strategy of Health manpower development "from normative approaches in their development to targeted approaches to reach underserviced areas" are procrustean in nature. Apart from the health care infrastructure and other resources, human resource for health is of primordial importance to create universal access. Ahmed et al. described two types of health care packages - one that is institution-based and the other that is family/community-based. To deliver health-care services effectively and efficiently, two distinct cadres of health manpower - "public health" cadres and "personal health care" cadres are essential. These cadres should be at all levels from the community to the district, state, and central levels. The public health cadre should be responsible for providing public health-care services including health management information systems (HMIS) as well as organize the delivery of community-based comprehensive personal care services.  As the intricacy in patient care is increasing day by day, we need to have more trained paramedical manpower apart from nurses, laboratory technicians, and pharmacist. For running a health care delivery system from the primary level to the tertiary level, we need 35 types of paramedical personnel. The current situation of training infrastructure in India is dismal. Out of 35 categories, we have facilities for training only 20 types of paramedical personnel. It is reported that 1,597 institutions are available for training in General Nursing and Midwifery (GNM), 312 institutions for Auxiliary Nursing Midwifery (ANM), 11 institutions for Lady Health Visitor (LHV), and 461 institutions for training pharmacists.  Unfortunately, all these training centers except for state-run health and family welfare training centers (HFWTCs) are unorganized and not supervised by any regulatory body. The estimated cumulative annual growth rate of such private institutions is substantial.
a. Unregulated and unsupervised paramedical training conducted by private training institutions is a major deficiency in our paramedical training program. In a democracy, everyone has the right to establish institutions to train various types of paramedical personnel but common sense dictates that training of such a vital group must be strictly monitored. The report "From Paramedics to Allied Health Professionals: Landscaping the Journey and Way Ahead" is one of the right steps taken by the Ministry of Health and Family Welfare (FW)-Government of India to standardize the unregulated training programs. 
b. To maintain uniformity in training, an accreditation mechanism by an approved body is essential. The existing State Institute of Health and Family Welfare (SIHFW) may be made the regulatory body of all sorts of paramedical training, which will be guided by the National Institute of Health and Family Welfare (NIHFW). Only those who pass a licensing test should be allowed to practice his/her trade.
c. The role played by existing professional bodies such as the Medical Council of India, Dental Council of India, Nursing Council of India, and Pharmacy Council of India are three-dimensional. All these bodies set the competencies necessary to practice the profession, ethical standards of practice, minimum standard requirements (MSRs) on infrastructure, manpower, resources, and other requirements for starting a course as well as act as the accrediting bodies and advice the government on continuation or withdrawal of permission of training on the basis of periodic inspections conducted by them as per their terms of reference by appointing ad hoc assessors. These bodies are also responsible for developing the curriculum for training. One wonders whether a democratically elected professional body is the right organization to develop the curriculum! The Ministry of Health and FW-Government of India should form an expert group to look into the existing curriculum. The Deans of different medical colleges, medical educationists, public health experts, and even representatives from different professional councils and bodies may be the members of such a group. There is an urgent need of such an endeavor as the professional bodies have utterly failed in this regard. For supervision and control of professional practice, higher educational agencies such as the University Grants Commission and state-owned boards such as the National Board of Examination should oversee the implementation of different training programs and evaluation systems. The University Grant Commission's National Assessment and Accreditation Council (NAAC) system of accrediting different deanery of the university may be extended to the medical and other professional deanery to oversee the quality of infrastructure, training facilities, etc., by utilizing the MSRs of the Medical Council of India (MCI) as the gold standard. Accreditation of the hospital should be bestowed on the national accrediting bodies by using the professional bodies' MSRs and evaluation conducted by trained professional evaluators.
d. Introduction of "bridge course": At this moment, there is a "gold rush" for taking admission in the Bachelor of Medicine, Bachelor of Surgery (MBBS) course after passing Higher Secondary/+2 examination. The parents go to any extent, even using any sort of unfair means to admit their wards. A provision of a "bridge course" of MBBS, specifically for those who are qualified graduates as nurses, dentists, pharmacists, laboratory technicians, and other paramedicals may reduce the rush for MBBS seats. It is high time to provide an opportunity to those who missed the first chance through a system of lateral entry. In advanced countries, there are instances of people changing their professional courses after practicing for certain years at a lower level or at the same level. The modalities of admission and the curriculum designing may be done accordingly. Introduction of such bridge course will lower the unnecessary haste for availing a single window in the career progression of a youth.
9. Regulatory framework: It is a settled legal position that the right to health is integral to the fundamental right to life as enshrined in Article 21 of the Indian Constitution, which has been upheld by the Supreme Court of India in a catena of decisions. In the light of the other constitutional provisions in the form of the Directive Principles of State Policy, it is evident that the Government is under a constitutional obligation to provide health care and social welfare facilities to all of them in its population who are in need. The Government of India's decision to adopt the concept of "Health in All" in all government development policies is also a welcome one to oversee the implementation of the commitment of "Health in All." But till date, the government has been slow to take any concrete step even to address the social and environmental determinants of health. But due to the proactive campaign of social activists and citizens, the judiciary has already taken essential steps in the matter of "environmental pollution" as well as "right to food" by setting special committees to oversee the people's health interest. We apprehend that the judicial process on such issues takes a long time and in view of the adoption of the policy of universal health coverage for its population by the Government of India, it will bring forth many more public litigation issues to the judicial institution. But delay in the judicial decision will harm the evolving detrimental health determinants as well as cause a burden to the population for addressing its illnesses. In the above context, to oversee the interest of public health a quasi-judicial body known as "Health Commission of India" has been proposed to be established. This proposed body through interministerial and interagency coordination will monitor the implementation of "Health in All" to address the social and environmental determinants of health and all aspects related to universal health coverage including compliance with all legal provisions to improve the health of the nation at the state and central levels. This will also take steps and prevent any discrimination made in providing health care and welfare so that each citizen can lead a healthy and productive life.
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