Question #1. How far did the National Health Policy 2017 succeed in attaining universal health coverage and delivering quality health care services in India? Critically discuss the significance of the National Health Policy as well as the recent transformation held in the health sector.
Contextual introduction of the National Health Policy in India (20-25 words)
Significance of the National Health Policies (25 words)
The National Health Policy 2017
- Goals of the NHP 2017 (15 words)
- Specific Quantitative Goals and Objectives (20 words)
Analysis of the NHP 2017 (20 words)
Recent Governmental Initiatives in the Health-Sector (25 words)
Way forward (25 words)
Conclusion (15 words)
Health is a fundamental human right and that the attainment of the highest possible level of holistic health is a part of the Sustainable Development Goals. In this direction, the Alma-Ata Declaration of 1978 has called on all the governments to formulate National Health Policies according to their own circumstances, as the key to the attainment of the goal of "Health for All" around the globe. India has, so far, formulated three National Health Policies i.e. 1983, 2002, and 2017 with the aim to inform, clarify, strengthen and
prioritize the role of the Government in shaping health systems in all its dimensions.
Significance of the National Health Policies:
The National Health Policy of 1983 and the National Health Policy of 2002 have served well in guiding the approach for the health sector in the Five-Year Plans. The current context has however changed in four major ways:
i) the health priorities are changing. Although maternal and child mortality have rapidly declined, there is a growing burden on account of non-communicable diseases and some infectious diseases;
ii) the emergence of a robust health care industry estimated to be growing at double-digit;
iii) the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty; and
iv) a rising economic growth enables enhanced fiscal capacity. Therefore, a new health policy response to these contextual changes is required.
The National Health Policy, 2017 (hereinafter the NHP 2017) is formulated to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.
The National Health Policy 2017:
Goals of the NHP 2017:
- Attainment of the highest possible level of health and wellbeing for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence.
- This would be achieved through increasing access, improving quality, and lowering the cost of healthcare delivery. The policy recognizes the pivotal importance of Sustainable Development Goals (SDGs).
Specific Quantitative Goals and Objectives:
Following are the major-specific quantitative goals set by the national health policy, 2017:
- Health Status and Programme Impact
a. Life Expectancy and healthy life
- Increase Life Expectancy at birth from 67.5 to 70 by 2025.
- Establish regular tracking of the Disability Adjusted Life Years (DALY) Index as a measure of the burden of disease and its trends by major categories by 2022.
- Reduction of TFR (Total Fertility Rate) to 2.1 at national and sub-national levels by 2025.
b. Mortality by Age and/ or cause
- Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
- Reduce infant mortality rate to 28 by 2019.
- Reduce neonatal mortality to 16 and the stillbirth rate to “single-digit” by 2025.
c. Reduction of disease prevalence/ incidence
- Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS e, - 90% of all people living with HIV know their HIV status, - 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
- To achieve and maintain a cure rate of >85% in new sputum-positive patients for TB and reduce the incidence of new cases, to reach elimination status by 2025.
- To reduce premature mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases by 25% by 2025.
- Health Systems strengthening
a. Health finance
- Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5 % by 2025.
- Increase state sector health spending to > 8% of their budget by 2020
- Decrease in the proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.
b. Health Infrastructure and Human Resource
- Ensure availability of paramedics and doctors as per the Indian Public Health Standard (IPHS) norm in high-priority districts by 2020.
- Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
- Establish primary and secondary care facilities as per norms in high-priority districts (population as well as time to reach norms) by 2025.
c. Health Management Information
- Ensure district-level electronic database of information on health system components by 2020.
- Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
- Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025
Analysis of the NHP 2017:
- Health Finance:
- The National Health Policy of 2017 recommends government expenditure on health to be increased to 2.5% of GDP by 2025, but that seems to be a distant dream still since to reach the set target limit, the country needs to increase its health budget by 0.35% each year from now on. On the contrary, between 2015-16 to 2020-21 there has just been an increase of 0.02% in the health budget in India.
- The National Policy also recommended that expenditure on health by states should be increased to 8% or more of their budget by 2020, but looking at the budget of different states in 2020-21, on average, the state governments in India have just allocated 5.4% of their total budget towards the public health care system.
- States like Andhra Pradesh, Jharkhand, Maharashtra, Karnataka, Haryana, Bihar, and Punjab have allocated less than 5% of their total budget towards public healthcare between the 2015-2021 financial years.
- Health Infrastructure and Human Resource
- In the Healthcare Access and Quality Index released by the medical journal Lancet in 2018, India ranked 145th out of the 195 countries in terms of quality and accessibility to healthcare.
- The foremost lesson that this Covid-19 pandemic teaches us is that a healthcare system that is insufficiently resourced and suboptimal in performance cannot create a strong and swift response when challenged by a public health emergency.
- The commitment to deliver universal health coverage by 2030 is based on fulfilling the promise of rising public funding on health to at least 2.5% of the GDP from the present 1.2% by 2025 as promised by the government, or even earlier as urged by the public health experts. About 70% of this has to be allocated to primary healthcare.
- India’s per capita expenditure on public health has been inadequate for several years. According to the National Health Profile 2019, India’s per capita public expenditure on health in nominal terms is Rs 1,657 (2018-19). This has to be enhanced in a holistic manner.
- The Doctor-Patient Ratio:
- The country has also been battling with shortages of doctors, trained nurses, and paramedics for years now. As of February 2021, India’s doctor-to-population ratio stands at 1:1,404, while the WHO recommends the doctor-to-population ratio to be 1:1000.
- For people in rural India who are completely dependent on government healthcare facilities, the doctor to patient ratio is abysmally low with 1:10,926 doctors, as per the National Health Profile 2019.
Recent Governmental Initiatives in the Health-Sector:
The Significance of the Government’s Role in Healthcare:
- The central government provides a broader framework and direction to all programs to be undertaken like family planning, Swachh Bharat Abhiyan (Clean India Mission), and universal immunization.
- With respect to missions on health, NRHM (National Rural Health Mission) and NUHM (National Urban Health Mission) have had significant achievements.
- The Swachh Bharat Mission (2014–19) aims to achieve sanitation facilities, a cleaner environment, and surroundings for all. One of the main objectives of this nationwide campaign is to eliminate open defecation by the construction of toilets and awareness generation.
- The AMRIT (Affordable Medicines and Reliable Implants for Treatment) Scheme was launched in 2015 aims to reduce the expenditure incurred by patients on treatment of non-communicable diseases like cancer and heart diseases.
- A key announcement in the Union Budget 2018–2019 has been the Ayushman Bharat Programme (ABP).
Ayushman Bharat Program:
- This programme has two objectives:
- delivering comprehensive primary healthcare by establishing 150,000 Health and Wellness Centres (HWCs) by 2022 and
- securing financial cover for secondary and tertiary level hospitalization as part of the National Health Protection Scheme (NHPS).
- The ABP with these two objectives intends to provide citizens an entire range of preventive, diagnostic, curative, and rehabilitative healthcare services across primary, secondary, and tertiary levels.
- The world’s largest health insurance scheme, Ayushman Bharat Yojana (National Health Protection Mission), promises health cover worth Rs. 500,000 to every poor family for treatment of serious ailments.
- Another significant initiative taken by the government is to implement pan-India the Ayushman Bharat Digital Mission (hereinafter the ABDM), which aims to develop the backbone necessary to support the integrated digital health infrastructure of the country. It will bridge the existing gap amongst different stakeholders of the Healthcare ecosystem through digital highways.
ABDM shall create a seamless online platform “through the provision of a wide range of data, information and infrastructure services, duly leveraging open, interoperable, standards-based digital systems” while ensuring the security, confidentiality, and privacy of health-related personal information.
- Mental Health Policy:
- We need to formulate a holistic policy on mental health with simultaneous action on the following fronts:
- Increase the creation of specialists through public financing and develop special rules to give preference to those willing to work in public systems.
- Create a network of community members to provide psycho-social support to strengthen mental health services at primary level facilities and
- Leverage digital technology in a context where access to qualified psychiatrists is difficult.
- Population Stabilization:
- Under the aegis of the NHP 2017, progressive population stabilization initiatives are required with improved access, education, and empowerment.
- The policy imperative is to move away from camp-based services with all its attendant problems of quality, safety, and dignity of women, to the provision for regular services.
- Other policy imperatives are to make accessibility easier pertaining to the modern instruments of family planning.
- Emergency Care and Disaster Preparedness:
- Better response to disasters, both natural and manmade, requires a dispersed and effective capacity for emergency management. It requires an army of community members trained as first responders for accidents and disasters.
- It also requires regular strengthening of their capacities in close collaboration with the local self-government and community-based organizations.
- Mainstreaming the Potential of AYUSH:
- We need to recognize the significance of the AYUSH and incentivize to mainstream the potential of the same through the National AYUSH Mission (NAM).
- The mission recognizes the need to standardize and validate Ayurvedic medicines and establish a robust and effective quality control mechanism for AYUSH drugs.
- The need to nurture the AYUSH system of medicine, through the development of infrastructural facilities of teaching institutions, improving quality control of drugs, capacity building of institutions and professionals is significant in the current scenario.
- Tertiary care Services:
The policy affirmed that the tertiary care services are best organized along lines of regional, zonal, and apex referral centers. In this direction, the Government has set up new Medical Colleges, Nursing Institutions, and AIIMS in the country using this broad principle. However, Regional disparities in the distribution of these institutions must be addressed.
The requirement of the periodic review and standardization of fee structure and quality of clinical training in the private sector medical colleges would play an important role. The core principle of societal obligation on the part of private institutions needs to be followed.
This would include:
- Operationalization of mechanisms for a referral from the public health system to charitable hospitals.
- Ensuring that deserving patients can be admitted on designated free/subsidized beds.
- Attracting and Retaining Doctors in Remote Areas:
- We need to inculcate certain financial and non-financial incentives, creating medical colleges in rural areas; preference to students from under-serviced areas, realigning pedagogy and curriculum to suit rural health needs, mandatory rural postings, etc.
- Measures of compulsion- through mandatory rotational postings dovetailed with clear and transparent career progression guidelines are valuable strategies. A constant effort, therefore, needs to be made to increase the capacity of the public health systems to absorb and retain the manpower.
- The total sanctioned posts of doctors in the public sector should increase to ensure the availability of doctors corresponding to the accepted norms. The exact package of policy measures would vary from State to State and would change over time.
- Public Health Management Cadre:
- The proposal of the creation of the Public Health Management Cadre in the NHP 2017 in all States based on public health or related disciplines, as an entry criterion, should be implemented on an immediate basis.
- An appropriate career structure and recruitment policy to attract young and talented multidisciplinary professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training would also be considered.
- Human Resource Governance and leadership development:
- Human resource management is critical to health system strengthening and healthcare delivery and therefore the policy measures aiming at continuing medical and nursing education and on the job support to providers, especially those working in professional isolation in rural areas using digital tools and other appropriate training resources, should be brought into practice.
- Development of leadership skills, strengthening human resource governance in the public health system, through the establishment of robust recruitment, selection, promotion, and transfer postings policies, etc. are the key areas to be focused on.
- Financing of Health Care:
- The policy advocates allocating a major proportion (up to two-thirds or more) of resources to primary care followed by secondary and tertiary care.
- The inclusion of cost-benefit and cost-effectiveness studies consistently in programme design and evaluation should be prioritized. This would contribute significantly to increasing the efficiency of public expenditure.
- A robust National Health Accounts System should be operationalized to improve public sector efficiency in resource allocation/ payments.
- Collaboration with Non-Government Sector/Engagement with the private sector:
- The policy suggests exploring collaboration for primary care services with ‘not-for-profit organizations’ having a track record of public services where critical gaps exist, as a short-term measure.
- Collaboration can also be done for certain services where a team of specialized human resources and domain-specific organizational experience is required. Private providers, especially those working in rural and remote areas or with under-serviced communities, should be offered encouragement through the provision of appropriate skills to meet public health goals, opportunities for skill up-gradation to serve the community better, participation in disease notification and surveillance efforts, sharing and supporting certain high-value services.
- Corporate Social Responsibility (CSR) is an important area that should be leveraged for filling health infrastructure gaps in public health facilities across the country. The private sector could use the CSR platform to play an active role in the awareness generation through campaigns on occupational health, adolescent health, safe health practices and accident prevention, micronutrient adequacy, antimicrobial resistance, screening of children, etc.
A policy is only as good as its implementation. The National Health Policy envisages that an implementation framework is put in place to deliver on these policy commitments. Such an implementation framework would provide a roadmap with clear deliverables and milestones to achieve the goals of the policy. Moreover, the dynamic programs initiated by the government for provisioning the healthcare services in a subsidized manner, such as Ayushman Bharat, should be audited and modified as per the requirement. And, in this area, well-organized digitized healthcare data is to be formulated for ensuring accountability, transparency, and accessibility.
Question #2. Capacity-building training is needed for the civil servants so they remain entrenched in Indian culture while they learn from best practices across the world. Analyze the statement while discussing the initiative taken by the government to upgrade the training mechanism of the officers.
Contextual Introduction of the Capacity-building Program by the Government (20-25 words)
The Need for the Capacity Building Programs for the Civil Servants (25 words)
Significance of the National Programme for Civil Services Capacity Building the NPCSCB)-Mission Karmyogi
- About the NPCSCB (20 words)
- Salient Features of the NPCSCB (20 words)
- The institutional framework of the NPCSCB (30 words)
Way Forward (20 words)
Conclusion (15-20 words)
The skill-sets and capacity of the civil servants play a vital role in service delivery, program implementation, and performing core governance functions. Recognizing this crucial responsibility, the Union government has embarked upon a major reform drive in the bureaucracy and civil services with the creation of the Capacity Building Commission (CBC) set up under the ambitious project National Programme for Civil Services Capacity Building (NPCSCB), also known as “Mission Karmayogi”.
The focus of NPCSCB is on promoting ease of living and ease of doing business, by considerably enhancing the citizen-government interface. This involves the creation of both functional and behavioral competencies among the civil servants.
The Need for the Capacity Building Programs for the Civil Servants:
- Ensuring Quality: Quality is a journey not a destination with pit stops, as in a marathon, for continuous capacity building and even reskilling, if need be. The Covid-19 pandemic, through the exemplar of corona warriors, has reinforced the concept that exceeding the expectations of the common public is very much the hallmark of excellence in the delivery of public services.
- Holistic Governance: The capacity of Civil Services plays a vital role in rendering a wide variety of services, implementing welfare programs, and performing core governance functions. A transformational change in Civil Service Capacity is proposed to be affected by organically linking the transformation of work culture, strengthening public institutions, and adopting modern technology to build civil service capacity with the overall aim of ensuring efficient delivery of services to citizens.
- Organization and Management (O&M): In developing countries like India the administrative machinery has not been adequate to handle tasks of economic and social development. The idea that the main sort for administrative improvements would flow from each ministry, the function of the O&M Division among civil servants being:
- To supply the leadership drive; and
- by a cooperative effort to build up a common fund of information, experience, and competence in O & M work.
- Building Connections: Since, it is the civil servant, who encounters first with the common public in the administration; for an administration to be effective, it is important to inculcate, sensitivity, empathy among the civil servants, and build up a mechanism to eradicate the materialist barriers, such as language barriers, socio-economic misunderstanding, etc. For the same, the holistic training programs, on-field, and off-field, are a significant requirement.
Significance of the National Programme for Civil Services Capacity Building (hereinafter the NPCSCB)-Mission Karmyogi:-
About the NPCSCB:
- It is a new national architecture for the capacity building of civil services. It is also a comprehensive reform of the capacity-building apparatus at the individual, institutional, and process levels for efficient public service delivery. Apart from domain knowledge, the scheme will focus on functional and behavioral competencies. It proposes to cover approximately 46 lakh, central government employees, at all levels.
- Mission Karmayogi aims to prepare the Indian Civil Servant for the future by making him more creative, constructive, imaginative, innovative, proactive, professional, progressive, energetic, enabling, transparent, and technology-enabled. Empowered with specific role-competencies, the civil servant will be able to ensure efficient service delivery of the highest quality standards.
Salient Features of the NPCSCB:
The NPCSCB has been carefully designed to lay the foundations for capacity building for Civil Servants so that they remain entrenched in Indian Culture and sensibilities and remain connected, with their roots, while they learn from the best institutions and practices across the world. The Programme will be delivered by setting up an Integrated Government Online Training-iGOT Karmayogi Platform. The core guiding principles of the Programme will be:
- Supporting Transition from ‘Rules-based’ to ‘Roles-based’ HR Management.
- To provide for ‘on-site learning’ to complement the ‘off-site’ learning.
- To create an ecosystem of shared training infrastructure including that of learning materials, institutions, and personnel.
- To calibrate all Civil Service positions to a Framework of Roles, Activities, and Competencies (FRACs) approach and to create and deliver learning content relevant to the identified FRACs in every Government entity.
- To make available to all civil servants, an opportunity to continuously build and strengthen their Behavioural, Functional, and Domain Competencies in their self-driven and mandated learning paths.
- To enable all the Central Ministries and Departments and their attached and subordinate organizations to directly invest their resources towards co-creation and sharing the collaborative and common ecosystem of learning through an annual financial subscription for every employee.
- To encourage and partner with the best-in-class learning content creators, including public training institutions, universities, and individual experts.
- To undertake data analytics in respect of data provided by iGOT- Karmayogi pertaining to various aspects of capacity building, content creation, user feedback, and mapping of competencies and identify areas for policy reforms.
The institutional framework of the NPCSCB:-
- PM led Human Resource Council
- A Public Human Resources Council comprising of select Union Ministers, Chief Ministers, eminent public HR practitioners, thinkers, global thought leaders, and Public Service functionaries under the Chairmanship of Hon'ble Prime Minister will serve as the apex body for providing strategic direction to the task of Civil Services Reform and capacity building.
- This council will act as an apex body:
- To drive, and provide strategic direction to the Programme;
- To approve & Monitor Civil Service Capacity Building plan; and
- To review the reports submitted by Capacity Building Commission.
- Cabinet Secretary Coordination Unit
- It comprises of select secretaries and cadre controlling authorities, headed by Cabinet Secretary
- The primary function of this body is to monitor the progress, and execution of plans.
- Capacity Building Commission
- It is proposed to set up a Capacity Building Commission, with a view to ensuring a uniform approach in managing and regulating the capacity building ecosystem on a collaborative and co-sharing basis, which will include experts in related fields and global professionals.
- The mandate of the commission are:
- To assist the PM Public Human Resources Council in approving the Annual Capacity Building Plans.
- To exercise functional supervision over all Central Training Institutions dealing with civil services capacity building.
- To create shared learning resources, including internal and external faculty and resource centers.
- To coordinate and supervise the implementation of the Capacity Building Plans with the stakeholder Departments.
- To make recommendations on standardization of training and capacity building, pedagogy, and methodology
- To set norms for common mid-career training programs across all civil services.
- To suggest policy interventions required in the areas of HR Management and Capacity Building to the Government, and prepare the Annual HR Report on the health of Civil Services and Target Achievements.
- To audit human resources available in the government, and undertake analysis of data from iGOT-Karmayogi.
- Special Purpose Vehicle
- A wholly owned Special Purpose Vehicle (SPV) for NPCSCB will be set up under Section 8 of the Companies Act, 2013. The SPV will be a "not-for-profit" company and will own and manage the iGOT-Karmayogi platform.
- The SPV will create and operationalize the content, market place and manage key business services of the iGOT-Karmayogi platform, relating to content validation, independent proctored assessments, and telemetry data availability.
- The SPV will own all Intellectual Property Rights on behalf of the Government of India.
- An appropriate monitoring and evaluation framework will also be put in place for performance evaluation of all users of the iGOT-Karmayogi platform so as to generate a dashboard view of Key Performance Indicators.
- iGOT-Karmayogi Platform:
- The Karmyogi Programme will be delivered by setting up an Integrated Government Online Training (iGOT) Karmayogi Platform.
- The platform brings the scale and state-of-the-art infrastructure to augment the capacities of over two crore officials in India. It is a continuous online training platform, which would allow all government servants from assistant secretary to secretary level to undergo continuous training, depending on their domain areas.
- The platform is expected to evolve into a vibrant and world-class marketplace for content, carefully curated and vetted digital e-learning materials from international universities will be made available.
- Besides capacity building, service matters like confirmation after probation period, deployment, work assignment, and notification of vacancies, etc. would eventually be integrated with the proposed competency framework.
- Monitoring and Evaluation
- The monitoring and evaluation of the performance of all users of the iGOT-Karmayogi platform will be undertaken on certain Key Performance Indicators (KPIs), including the individual learner, the supervisor, the organization, the peer group, the content provider, the content creator, the technology service provider among others.
- A dashboard and an Annual State of the Civil Services Report are proposed to capture the KPIs for all the departments, organizations, and agencies of the government and document the outcome of the current initiatives, the targets against goals along with the roadmap for future Public HR Management and Capacity Building.
- The larger significance of the program is, that it aims to prepare the Indian Civil Servant for the future, by making him more creative, constructive, imaginative, innovative, proactive, professional, progressive, energetic, enabling, transparent, and technology-enabled.
- Empowered with specific role-competencies, the civil servant will be able to ensure efficient service delivery of the highest quality standards.
- Eventually, all service matters such as recruitment (National Recruitment Agency), confirmation after probation, deployment, work assignment, and notification of vacancies will all be integrated into the proposed framework.
Having said so, we need to evaluate and prepare ourselves for the challenges that may arise in our way forward: -
- Estimation of the knowledge, skill, and attitude (KSA):
- Mission Karmayogi is a very ambitious program and for that reason faces the prospect of losing its way in mid-course if not steered with caution. The imparting of knowledge, skill, and attitude (KSA) begins with a training needs assessment (TNA).
- If the mission is to succeed, careful and precise estimation of existing KSA, in a decentralized environment, would hold the key to its implementation.
- Strong System of Feedback:
- For distance self-learning to build core competencies among frontline workers, a strong system of feedback, mentorship, and peer-learning has to be put in place. Further, incentive-linked training, if poorly executed, runs the risk of becoming a source of demotivation.
- Individual Behavioral Training with Cultural Inculcation:
While individual-level professional and behavioral training is important for improving organizational performance, the culture in which those competencies are deployed is equally important. A learning organization thrives on practices of a shared vision of development, commitment to capacity building at all levels, and empowerment of the employees.
Civil Servants are now playing a major role with the gradual expansion of state activities in modern times. The increased complexity of social change and administrative arrangements make the tasks of their administration more challenging. The future civil servant has to have the knowledge of as much management, economics, and sociology, history, law, and politics to cope with the rising volatile situation. In this sense, the government’s Karmyogi program will pave the way for the holistic reformation of the civil servants, and rejuvenation of the notion of civil services in India.