National Health Policy 2017: What’s in it for sexual and reproductive health?

After a gap of 14 years since the National Health Policy of 2002, the cabinet approved the National Health Policy 2017 in March 2017. As an organisation working in sexual and reproductive health, Hidden Pockets has attempted to look at the policy from the lens of sexual and reproductive health of the population in the country. The policy has set targets for several parameters relating to sexual and reproductive health including family planning, HIV/AIDS, antenatal care coverage, newborn immunization, neo-natal mortality, infant mortality, among others. In a way to achieve these targets, several programmes and steps have been outlined in the policy. Some of the key highlights in the policy affecting sexual and reproductive health are:

National Health Programmes

In terms of National Health Programmes with respect to sexual and reproductive health, the policy includes:

• RMNCH+A (Reproductive, Maternal, Newborn, Child, and Adolescent Health) services would address factors affecting maternal health and child survival by addressing – “the social determinants through developmental action in all sectors.”
• With respect to children and adolescent health, it acknowledges the need to expand the scope of reproductive and sexual health in order to address issues like

“inadequate calorie intake, nutrition status and psychological problems interalia linked to misuse of technology, etc.”

• Increase the proportion of male sterilization from less than 5% currently, to at least 30% and if possible much higher.
• Focused interventions on the high risk communities like MSM (Men who have Sex with Men), Transgender, FSW (Female Sex workers), etc. and prioritized geographies for control of HIV/AIDS

Our take on National Health Policy 2017

• It is progressive that the government acknowledges the need for expansion of reproductive and sexual health for adolescents and the need to address social determinants for maternal health. However, how it intends to implement these measures has to be seen.
• Linking of psychological problems due to misuse of technology to sexual and reproductive health, could also lead to curbing of access to technology, especially for girls. It is already happening in some parts of India. How does the government intend to balance between gender equality with respect to access to technology/opportunity and healthcare?
• It is also interesting that the policy includes MSM as a high-risk community. Sec 377 criminalizes carnal intercourse against the order of nature (which includes homosexuality). It would be interesting to see the government’s initiatives to target this group.

Primary, secondary and tertiary healthcare

• The government will be introducing Health and Wellness Centres to provide “larger package of comprehensive primary health care.” To access these services, every family would be given a health card linking them to these facilities and making them eligible for a “defined package of services anywhere in the country”. The government intends to do this by using digital health to link primary, secondary and tertiary levels of healthcare.
• At the secondary care services, even “caesarian section and neonatal care would be made available at least at the sub-divisional level in a cluster of few blocks.”
• At the tertiary level, referral mechanisms will be operationalized to private institutions with deserving patients being admitted at a designated fee/subsidized beds.
• Also, select tertiary services will be purchased from non-government sector hospitals to assist the poor

Gender based violence:

The section on Gender based violence notes that public hospitals need to be made women-friendly and the staff need orientation to gender sensitivity issues. It also states that healthcare to survivors and victims of gender based violence needs to be provided free and with dignity in the public and private sector.

Our take:

• Gender violence also affects the transgender community, going beyond just women. However, the policy limits the scope to women.
• Even with respect to women, the policy does not qualify or define gender violence or gender sensitivity issues.

Women’s health and gender mainstreaming:

The policy notes,

“There will be enhanced provisions for reproductive morbidities and health needs of women beyond the reproductive age group (40+) This would be in addition to package of services covered in the previous paragraphs.”

Healthcare for transgender:

Apart from control of HIV, there is mention of transgenders only with respect to research –

“Research on social determinants of health along with neglected health issues such as disability and transgender health will be promoted.”

There is no mention of transgender community in the list of vulnerable groups that the government intends to target with the new policy.

Our take: Apart from being vulnerable to sexually transmitted diseases, the transgender community continues to face discrimination in terms of access to basic healthcare. This is often due to lack of clarity regarding the hospital-ward of admission for members of the third gender. This continues to be the case even with provisions in the Transgender Persons (Protection of Rights) Bill and the NALSA judgement  that criminalizes denying of services to them.

The government recently issued a guideline to the SwachhBharath Mission (Gramin) stating that the third-gender community may be allowed to use public toilets of their choice.  Can we expect more such guidelines to make healthcare inclusive for the transgender community?

Some of the other highlights in the policy that could also have an effect on sexual and reproductive health are:

Partnerships with non-governmental/private organisations:

• There is heavy emphasis on government-private partnerships in the policy including capacity building, skill development, disaster management, mental health programmes, disease surveillance, health information system, Corporate Social Responsibility (CSR), among others.
• The policy also suggests government collaboration with the private sector for ‘Health and Wellness centres’ to set up fully functional primary healthcare facilities.
• Private organisations have not been defined properly. In some cases, the term ‘non-government’ has been used for both ‘profit’ and ‘not-for-profit’ organizations. Two senior bureaucrats have clarified that non-governmental organisations meant both NGOs as commonly understood as charitable organisations – as well as private for-profit organisations as indicated by a Wire report.
• The policy recommends a Health Information Exchange involving the private sector also pooling in data. With such high involvement of the private sector in healthcare, will they also be subjected to the regulations of the Right to Information Act? What guarantees accountability?

Financing and cost of healthcare:

• The government intends to finance its health policy by increasing health expenditure from the existing 1.5% of GDP to 2.5% by 2025 and increase state sector health spending to >8% of state budgets by 2020.
• The policy also notes that finance will be allocated by targeting specific population sub groups, geographical areas, health care services and gender related issues.
• It also suggests timely revision of National List of Essential Medicines (NLEM) along with appropriate price control mechanisms for generic drugs in a way to decrease cost for patients seeking healthcare in the private sector.
• The policy recommends the setting up of a medical tribunal to address disputes/complaints regarding different issues including prices of services.
• The policy states that only few states have adopted the Clinical Establishment Act of 2010: Advocacy for adoption of this Act by other states will be undertaken.
• Primary healthcare in urban areas would involve a cost for the middle class as against vulnerable groups.They will also be privatized.
• It states that at the tertiary level, in the geriatric and chronic care segments, both for in & out-patients, most drugs and diagnostics would be free or subsidized with “some co-payments for well-to-do”.
• It also notes that to encourage private sector participation, private sector would be incentivized through reimbursement/fees

Our take:

• Would 2.5% of GDP for health expenditure by 2025 be sufficient to cover all plans mentioned in the policy? Sujatha Rao, former Union Health Secretary explains why this allocation could be too little too late
• Which are the population sub groups, geographical areas and gender related issues? How will they be prioritized? On what basis? There seems to be a lack of clarity.
• The policy has mentioned cost control measures only for medicines in the private sector. Though the policy talks about a medical tribunal with respect to pricing of services, it is not clear if services provided by the private sector would fall within the ambit of this tribunal. According to the data released by the Health Ministry for the year 2013-14, Indians spend 8 times more on private hospitals compared to government hospitals.

Health Information Exchange:

The government intends to establish integrated health information architecture to strengthen health surveillance, establish registries for diseases of public health importance by 2020. It intends to set up a Health Information Exchanges and National Health Information Network by 2025. This includes exchange of information even from private hospitals and non-government hospitals.

“The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture.”

The government also intends for private sector participation in developing and linking systems into a common network/grid, which can be accessed by both public and private healthcare providers.

Our take: The National Health Policy 2017 mentions that the medical tribunal will also be responsible for resolution of disputes related healthcare and also the need for protection of patients including right to information, access to medical records, confidentiality, privacy, among others. Information related to health is of sensitive nature especially sexual and reproductive health. This could include details about HIV and AIDS patients, abortion data, among others. What happens if there is a data leak? The government recently admitted to Aadhaar data leak.  Note that the government is already running a pilot to link PLHIV to Aadhaar number in Delhi. There is no privacy law in India yet.

In case of vulnerable groups (as mentioned in the policy) like sex workers, the government intends to provide them with better healthcare. With linking of phone numbers to Aadhaar number being mandatory, the phone numbers and biometrics of sex workers could be susceptible to misuse. What is the protection assured to them against harassment, once their Aadhaar biometrics and phone numbers are entered into the system to access healthcare?

Right to Health as a fundamental right:

Right to Health is not a fundamental right promised by the constitution of India. National Health Policy 2017 has reiterated the same. It advocates an “incremental assurance based approach”. The policy tries to understand Right to Health from two perspectives.

“Questions that need to be addressed are manifold, namely, (a) whether when health care is a State subject, is it desirable or useful to make a Central law, (b) whether such a law should mainly focus on the enforcement of public health standards on water, sanitation, food safety, air pollution etc, or whether it should focus on health rights- access to health care and quality of health care – i.e whether focus should be on what the State enforces on citizens or on what the citizen demands of the State?”

Our take: Focus on public health standards (sanitation, water, food safety etc) alone may not be sufficient in terms of ensuring sexual and reproductive health standards in the country. Considering the cost involved in privatized healthcare especially in sexual and reproductive healthcare, it already is quite difficult for all to access good and affordable healthcare. Even without Right to Health as a fundamental right, access to healthcare could become a problem with (mandatory) Aadhaar integration if authentication failures continue to persist, as has been the case with several states in the country. There is also the concern regarding deactivation of Aadhaar number without any recourse for the Aadhaar holder. How will this affect a person’s access to primary healthcare or health and wellness centres, as the policy calls it? How does the government intend to tackle this? It is appreciable that the policy highlights the need to improve the healthcare standards in the country before Right to Health is made a fundamental right. However, it does not mention a timeline for the implementation of this “incremental assurance based approach”. What is the vision for Right to Health as a fundamental right?

Implementation Framework:

The policy also envisages an implementation framework to be put in place to deliver on the policy commitments.

“A policy is only as good as its implementation.”