While some may find it shocking, there are times when India's parliamentarians do a good job. One such group of MPs has been in the limelight recently: the Parliamentary Standing Committee on Health and Family Welfare, chaired by Uttar Pradesh MP Prof Ram Gopal Yadav. In March the committee presented an important report that called for a complete overhaul of the totally dysfunctional Medical Council of India--a topic highly important for the well-being of every Indian citizen.
(For the more curious, here's detailed information about department-related standing committees.)
On 27 April, this committee submitted another crucial report, regarding Demands for Grants (of the Department of Health and Family Welfare) for 2016-17. The committee's observations and recommendations assume especial significance in the current scenario where the Indian government is being vehemently urged from both national and international quarters to display a much stronger commitment (both in theory and practice) to public health and to universal health coverage for millions of underprivileged citizens.
Following are some significant points from the 170-page report (PDF). It must, however, be remembered that the committee's recommendations are not binding upon the ministry: these reports have "persuasive value" and "shall be treated as considered advice".
(Note: 'the Department' refers to Department of Health and Family Welfare under the Ministry of Health and Family Welfare of India.)
1. Financing of public health
Perhaps the most important observation is something that public health experts have also been repeatedly urging the government for the past several months: allocating more money for health. The report mentions: "India ranks 157 among 190 countries in terms of per capita government expenditure on health (annually only $44 PPP)." (Sri Lanka's government devotes double of what our government does per person, and China's, six times.)
The 'total Plan budget' for the Department of Health and Family Welfare for 2016-17 is ₹31,000 crore. The committee found it grossly inadequate and said:
"A minimum increase of ₹5000 crore would be required for launching (the recently proposed) free drugs, free diagnostics and free dialysis initiatives."
"The Committee also notes that as against the projected demand of ₹2550 crore for 2016-17, NACO (National AIDS Control Organization) has been allocated only ₹1700 crore. In view the good track record of NACO in utilizing the earmarked funds, the Committee lends support to infusing more money, if needed, into NACO at the Revised Estimates 2016-17 stage."
"Though almost three years have elapsed since the launch of the National Urban Health Mission (NUHM), it continues to be plagued with underfunding which is evident from the fact that a meagre allocation of ₹950 crore has been made for NUHM for 2016-17. The Committee observes that the unprecedented urbanization in the country has brought with it rapid growth of populations and a concomitant rise in slum populations and therefore a measly provisioning of Rs. 950 crore is grossly inadequate."
"It is a documented fact that low government expenditure on health leads to high out-of-pocket payments by individual households on healthcare, leading to households incurring catastrophic expenditure which in turn pushes them into indebtedness and poverty. The Committee therefore, recommends that the central government should chalk out a solid fiscal roadmap for generating and allocating more financial resources for Health so that the goal of raising government expenditure on Health to 2.5% of GDP is realised and the vision of moving towards universalization of affordable healthcare is translated into reality." (emphasis added)
2. Healthcare access in tribal areas
"As the tribal areas in the country have the worst health indicators and are plagued with stark inequities in access to healthcare, the Committee recommends that mapping of health facilities in tribal areas be carried out to identify the closest facility which is easily accessible based on geographical conditions (specifically in hard-to-reach areas). These facilities like health sub-centres, PHCs, or satellite centres, should be made functional on a priority basis with necessary backup of referral transport facilities and essential medicines."
3. Infrastructure and human resource deficiencies
"Lack of expansion of public sector hospitals in proportion to population growth and health needs is making healthcare out of the reach of people. Hence the role of the Government in this sector has to be increased substantially to provide adequate healthcare to needy."
"The shortfall for Sub Centres, Primary Health Centres and Community Health Centres (CHCs) is 35,145 (20%), 6,556 (22%) and 2,316 (32%) respectively."
"Overall, there is a shortfall of 81.2% specialists at the CHCs as compared to the requirement for existing CHCs: 83.4% of Surgeons, 76.3% of Obstetricians & Gynaecologists, 83.0% of Physicians and 82.1% of Paediatricians."
4. Addressing the challenge of non-communicable diseases
"India is experiencing a rising burden of Non-Communicable diseases (NCDs). NCDs are estimated to account for about 60% of all deaths in India. The Committee would, therefore, urge upon the Department to adopt a comprehensive strategy to address NCD challenges and also explore the option of mainstreaming AYUSH therapy as part of medical care for effective prevention."
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5. Lack of personnel in central government health institutes
The committee censured the Department for the large number of unfilled posts in Safdarjung Hospital (126 in Group 'A' and 'B' category), AIIMS New Delhi (232 faculty posts) and the six new AIIMS (both faculty and non-faculty vacancies). It expressed its displeasure at "the inertia and indifference of the Department in the matter" and recommended immediate action in filling up the vacancies.
6. Healthcare in the Northeast
"The Committee is also concerned to note that one project in North Eastern Region of India, namely RIMS, Imphal has experienced cost overrun of 10% and time overrun of 4 years while RIPANS, Aizawl has time overrun of 15 months. The Committee's concern in regard to delay in these projects mainly centres on the fact that access to quality health services remains low in the N.E.R"
7. The 'Chhattisgarh sterilization deaths'
The committee made special comments on the tragedy that had happened in Nov 2014: "The Committee is greatly anguished to take note of the revelation that the Sterilization Programme 'still continues to be driven by targets, threats and coercion.'" It asked the Department to apprise it of what 'lessons have been learned' and what measures are being taken to prevent the recurrence of such incidents, including (and this is music to the ears of those working towards a gender-equal India) promoting men's responsibility towards contraception.
8. Retaining health professionals in villages
"Many of the appointments in rural areas are contractual in nature. The absence of good contractual arrangements is a big constraining factor in attracting or retaining good quality manpower. The Committee would, therefore, like to be apprised of the measures taken or contemplated to be taken to overcome the above problem."
"The Committee would recommend that the Department should formulate an appropriate strategy to ensure that the graduate and post-graduate doctors from medical colleges are required compulsorily to join government facilities, especially in rural areas."
(This is an especially controversial recommendation, and one which we hope is not unilaterally implemented by the authorities without extensive consultations with representatives of doctors' associations, public health experts and other stakeholders.)
9. Vaccine manufacturing in the public sector
"The Committee observes that the work of upgradation of the three sera and vaccine manufacturing units (in Kasauli, Conoor and Guindy) has been going on since long and the Committee has been urging upon the Department to expedite completion of work, so as to enable the PSUs to contribute their mite to the country's Universal Immunization Programme, thus insulating it from price and supply uncertainty (through over-reliance on private sector)."
10. Governmental support for thalassemia patients:
"Lakhs of thalassemia patients are there in the country and ignored by the Government because they too belong to small pool of patients. The Committee is of the opinion that intervention of Government becomes very necessary to save the lives of thalessemic patients. The Committee accordingly recommends that thalassemia should also be included in list of various diseases and budgetary allocations should be made for this disease as well."
12. Proper evaluation of Rashtriya Swasthya Bima Yojana (RSBY)
"The Committee would like the Department to evaluate as to what extent the RSBY has been able to promote access to healthcare and provide financial protection to the targeted beneficiaries, and to know whether any mechanism is in place to regulate and oversee the insurers and healthcare providers under the RSBY."
13. Vacancies in Central Government Health Scheme (CGHS)
"The Committee in its 88th report had noted that large number of posts of General Duty Medical Officers and Specialists were lying vacant. Even if UPSC makes selection of doctors, very few join CGHS. The Committee had, therefore, recommended [finding] out the reasons behind doctors not joining CGHS post their selection by UPSC and take remedial measures. The Committee desires to be apprised of the developments in this regard."
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(For the more curious, here's detailed information about department-related standing committees.)
On 27 April, this committee submitted another crucial report, regarding Demands for Grants (of the Department of Health and Family Welfare) for 2016-17. The committee's observations and recommendations assume especial significance in the current scenario where the Indian government is being vehemently urged from both national and international quarters to display a much stronger commitment (both in theory and practice) to public health and to universal health coverage for millions of underprivileged citizens.
A minimum [budgetary] increase of ₹5000 crore would be required for launching (the recently proposed) free drugs, free diagnostics and free dialysis Initiatives.
Following are some significant points from the 170-page report (PDF). It must, however, be remembered that the committee's recommendations are not binding upon the ministry: these reports have "persuasive value" and "shall be treated as considered advice".
(Note: 'the Department' refers to Department of Health and Family Welfare under the Ministry of Health and Family Welfare of India.)
1. Financing of public health
Perhaps the most important observation is something that public health experts have also been repeatedly urging the government for the past several months: allocating more money for health. The report mentions: "India ranks 157 among 190 countries in terms of per capita government expenditure on health (annually only $44 PPP)." (Sri Lanka's government devotes double of what our government does per person, and China's, six times.)
The 'total Plan budget' for the Department of Health and Family Welfare for 2016-17 is ₹31,000 crore. The committee found it grossly inadequate and said:
"A minimum increase of ₹5000 crore would be required for launching (the recently proposed) free drugs, free diagnostics and free dialysis initiatives."
"The Committee also notes that as against the projected demand of ₹2550 crore for 2016-17, NACO (National AIDS Control Organization) has been allocated only ₹1700 crore. In view the good track record of NACO in utilizing the earmarked funds, the Committee lends support to infusing more money, if needed, into NACO at the Revised Estimates 2016-17 stage."
Though almost three years have elapsed since the launch of the National Urban Health Mission (NUHM), it continues to be plagued with underfunding...
"Though almost three years have elapsed since the launch of the National Urban Health Mission (NUHM), it continues to be plagued with underfunding which is evident from the fact that a meagre allocation of ₹950 crore has been made for NUHM for 2016-17. The Committee observes that the unprecedented urbanization in the country has brought with it rapid growth of populations and a concomitant rise in slum populations and therefore a measly provisioning of Rs. 950 crore is grossly inadequate."
"It is a documented fact that low government expenditure on health leads to high out-of-pocket payments by individual households on healthcare, leading to households incurring catastrophic expenditure which in turn pushes them into indebtedness and poverty. The Committee therefore, recommends that the central government should chalk out a solid fiscal roadmap for generating and allocating more financial resources for Health so that the goal of raising government expenditure on Health to 2.5% of GDP is realised and the vision of moving towards universalization of affordable healthcare is translated into reality." (emphasis added)
2. Healthcare access in tribal areas
"As the tribal areas in the country have the worst health indicators and are plagued with stark inequities in access to healthcare, the Committee recommends that mapping of health facilities in tribal areas be carried out to identify the closest facility which is easily accessible based on geographical conditions (specifically in hard-to-reach areas). These facilities like health sub-centres, PHCs, or satellite centres, should be made functional on a priority basis with necessary backup of referral transport facilities and essential medicines."
[L]ow government expenditure on health leads to high out-of-pocket payments by individual households on healthcare, leading to households incurring catastrophic expenditure...
3. Infrastructure and human resource deficiencies
"Lack of expansion of public sector hospitals in proportion to population growth and health needs is making healthcare out of the reach of people. Hence the role of the Government in this sector has to be increased substantially to provide adequate healthcare to needy."
"The shortfall for Sub Centres, Primary Health Centres and Community Health Centres (CHCs) is 35,145 (20%), 6,556 (22%) and 2,316 (32%) respectively."
"Overall, there is a shortfall of 81.2% specialists at the CHCs as compared to the requirement for existing CHCs: 83.4% of Surgeons, 76.3% of Obstetricians & Gynaecologists, 83.0% of Physicians and 82.1% of Paediatricians."
4. Addressing the challenge of non-communicable diseases
"India is experiencing a rising burden of Non-Communicable diseases (NCDs). NCDs are estimated to account for about 60% of all deaths in India. The Committee would, therefore, urge upon the Department to adopt a comprehensive strategy to address NCD challenges and also explore the option of mainstreaming AYUSH therapy as part of medical care for effective prevention."
5. Lack of personnel in central government health institutes
The committee censured the Department for the large number of unfilled posts in Safdarjung Hospital (126 in Group 'A' and 'B' category), AIIMS New Delhi (232 faculty posts) and the six new AIIMS (both faculty and non-faculty vacancies). It expressed its displeasure at "the inertia and indifference of the Department in the matter" and recommended immediate action in filling up the vacancies.
The shortfall for Sub Centres, Primary Health Centres and Community Health Centres (CHCs) is 35,145 (20%), 6,556 (22%) and 2,316 (32%) respectively.
6. Healthcare in the Northeast
"The Committee is also concerned to note that one project in North Eastern Region of India, namely RIMS, Imphal has experienced cost overrun of 10% and time overrun of 4 years while RIPANS, Aizawl has time overrun of 15 months. The Committee's concern in regard to delay in these projects mainly centres on the fact that access to quality health services remains low in the N.E.R"
7. The 'Chhattisgarh sterilization deaths'
The committee made special comments on the tragedy that had happened in Nov 2014: "The Committee is greatly anguished to take note of the revelation that the Sterilization Programme 'still continues to be driven by targets, threats and coercion.'" It asked the Department to apprise it of what 'lessons have been learned' and what measures are being taken to prevent the recurrence of such incidents, including (and this is music to the ears of those working towards a gender-equal India) promoting men's responsibility towards contraception.
8. Retaining health professionals in villages
"Many of the appointments in rural areas are contractual in nature. The absence of good contractual arrangements is a big constraining factor in attracting or retaining good quality manpower. The Committee would, therefore, like to be apprised of the measures taken or contemplated to be taken to overcome the above problem."
[T]he Department should formulate [a] strategy to ensure that graduate and post-graduate doctors from medical colleges are required compulsorily to join government facilities, especially in rural areas.
"The Committee would recommend that the Department should formulate an appropriate strategy to ensure that the graduate and post-graduate doctors from medical colleges are required compulsorily to join government facilities, especially in rural areas."
(This is an especially controversial recommendation, and one which we hope is not unilaterally implemented by the authorities without extensive consultations with representatives of doctors' associations, public health experts and other stakeholders.)
9. Vaccine manufacturing in the public sector
"The Committee observes that the work of upgradation of the three sera and vaccine manufacturing units (in Kasauli, Conoor and Guindy) has been going on since long and the Committee has been urging upon the Department to expedite completion of work, so as to enable the PSUs to contribute their mite to the country's Universal Immunization Programme, thus insulating it from price and supply uncertainty (through over-reliance on private sector)."
10. Governmental support for thalassemia patients:
"Lakhs of thalassemia patients are there in the country and ignored by the Government because they too belong to small pool of patients. The Committee is of the opinion that intervention of Government becomes very necessary to save the lives of thalessemic patients. The Committee accordingly recommends that thalassemia should also be included in list of various diseases and budgetary allocations should be made for this disease as well."
Lakhs of thalassemia patients are there in the country and ignored by the Government because they too belong to small pool of patients.
12. Proper evaluation of Rashtriya Swasthya Bima Yojana (RSBY)
"The Committee would like the Department to evaluate as to what extent the RSBY has been able to promote access to healthcare and provide financial protection to the targeted beneficiaries, and to know whether any mechanism is in place to regulate and oversee the insurers and healthcare providers under the RSBY."
13. Vacancies in Central Government Health Scheme (CGHS)
"The Committee in its 88th report had noted that large number of posts of General Duty Medical Officers and Specialists were lying vacant. Even if UPSC makes selection of doctors, very few join CGHS. The Committee had, therefore, recommended [finding] out the reasons behind doctors not joining CGHS post their selection by UPSC and take remedial measures. The Committee desires to be apprised of the developments in this regard."
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