Indian Medical Association (HQs.)



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Indian Medical Association (HQs.)ima logo colour-small

(Registered under the Societies Act XXI of 1860)

Mutually Affiliated with the British & Nepal Medical Associations

I.M.A. House, Indraprastha Marg, New Delhi-110 002

Telephones : +91-11-2337 0009 (10 lines), 2337 8680, 2337 8053, 2337 0352

Fax : +91-11-23379470, 23370375, 23379178

Website: www.ima-india.org ; Email: hsg@ima-india.org

National President Honorary Secretary General

Prof (Dr) A Marthanda Pillai Dr K K Aggarwal
Padma Shri Awardee Padma Shri, National Science Communication &
9847062019 Dr B C Roy National Awardee

9811090206

dramp2014@gmail.com hsgima@gmail.com



THEME OF THE YEAR: DEDICATED TO A HEALTHY INDIA


Draft National Health Policy: Views of Indian Medical Association
Executive Summary

Thirteen years after the last National Health Policy, the Ministry of Health has brought out a new draft National Health Policy, which is already in the public domain. Indian Medical Association place on record its appreciation for immediately bringing out a National Health Policy soon after assuming power. The National Health Policy of 1983 and that of 2002 have served us well, in guiding the approach for the health sector in the Five-Year Plans. Development of a more robust, effective and credible new National Health Policy will give direction and coherence to our efforts further to improve health of the nation.


The importance given to urban health, addressing social determinants of health, suggestions to harness newer technologies like tele-medicine, recognizing the role of private sector through health strategic purchasing, newer strategies for resource generation like health cess etc. are appreciable.
Indian Medical Association (IMA) feels that the policy, should give greater focus for preventive and rehabilitative care in the context of rising burden of non-communicable diseases. However the IMA is of the view that greater contribution in terms of GDP will be required to attain the set goals in the present policy. The association feels that at least around 5% of GDP needs to be earmarked for health
The policy recommends setting up of task forces for developing indicators and targets and mechanisms for achievement. While task force for implementation of programme makes sense, it is mandatory that the policy clearly spells out indicators and targets. For any task force the scope and target should be predefined, if not the task force will come out with its own indicators and targets, which could be contrary to the philosophy of the policy.
Strengthening the family planning program, improving medical education, school health education, programmes for health of the elderly, mental health, four tier system of health care, family doctor concept, health manpower assessment, improving overall efficiency of health management, addressing intra state and inter state disparities and system for monitoring and expenditure tracking, IMA feels, are all important areas where the health policy needs to focus more.
A large part of allocation of funds are usually spent on pay and allowances, pensions, transport and establishments, hence funds for actual expenditure on health and medical care needs to be increased and specified. There should be a permanent mechanism to monitor the utilization of funds and to ensure that funds reach the targeted population for whom it is intended. There is need for inculcating better managerial skills for which an Indian Medical Service like IAS and IRS is required.
The private health providers cannot be bracketed together the small and medium level health institutions play a distinct role in supplementing the government health sector by serving in rural and remote areas, making health care accessible and affordable to the weaker sections of the society. In fact, these small players move the national health indices. The presence of corporate sector is largely in major cities and contributes to tertiary care. The policy needs to give special importance and consideration to the small and medium level institutions for its complementary role, while giving due importance to the corporate sector with adequate scope for independent existence and growth of both the sectors.
Health and Education are fundamental rights of the citizen. Just as the Government is promoting education through aided schools, health needs to be promoted by introducing the novel concept of aided hospitals. If not, the policy will become more beneficial to people who can afford even otherwise.

The concept of comparative efficiency as proposed in the policy, needs to be closely examined. Value for money is a myth since even those who seek health care from public sector do spend from Out Of Pocket, the same amount as in private sector.


The policy, which is silent on Health Human Resource Development, needs to spell out clear cut directions to curb the uncontrolled, unregulated expansion of these sectors as has happened so far; and to ensure more uniform and even distribution of institutions with emphasis on needy and backward areas. The medical council should be made more strong and autonomous by incorporating provisions for accreditation medical grants commission and mechanisms for facility augmentation and staff promotion activities. There is a need for proportionate production of all streams of health manpower personal on the basis of manpower requirement so that the pyramidal structure of health delivery is retained.
Quality assured drugs should be made available through the public distribution system to make them affordable. The drug quality control mechanism should be strengthened. The apprehensions following the recent amendments in the drug patent laws need to be addressed and the escalation of cost of drugs consequent on these legislations need to be prevented. The government should invest more resources in research on development of new drugs and devices. Just like techno parks, common facilities for drug research and quality assurance need to be established. ‘Make In India policy’ should be extended to manufacturing of Drugs, life saving equipments and devices.
Since the private sector provides care for 70 percent of the population due consideration needs to be given to it. Income tax, luxury tax and service tax in hospitals and VAT on drugs goes contrary to this. Government policy should influence and encourage private health care establishments by exempting them from the purview of income tax and providing subsidies. Government also should provide water, electricity and basic amenities at reduced rates for private hospitals. Government in turn can demand a major role for these institutions in public health and curative services. Poor needs to be provided free or subsidized health care in these institutions. This will reduce the cost of care eventually avoiding catastrophic health expenses. This model will be cost effective compared to heavy investments required in health insurance systems. Failure of American model insurance - driven health care provisioning should be a lesson while framing the policy

Considering private hospitals as pure industry is entirely misleading and it contradicts the Government policy of making health as a fundamental right. Private health care is a service sector governed by medical ethics. When the Government demands that medical ethics need to be followed and considers it as a service sector, branding clinical establishments in private sector as an industry exposes a contradiction. The pre-conceived notion that private sector is profit-driven and ignoring it in the overall structure of health delivery, allowing it to run parallel to the Government sector rather than promoting them to compliment, goes against the spirit of this policy.

The need for standardization and quality health care services is understandable, but the mechanism to ensure it through Clinical Establishment Act will be counter-productive. A process of voluntary and incentive driven accreditation is the best practical option where professional organizations like IMA can play a pivotal role.

The integrated medicine concept is again a misplaced thought process, which is not based on ground reality or evidence. When different systems of medicine are available, public always would like to try a different system when one system fails. Through the integration of systems, the Government is denying the right of the public to choose a pure alternate system. It is not their desire to opt for a different system when the process of integration has already diluted it. Integrating different systems of medicine, which have diametrically opposite basic principles, will only lead to destruction of these systems. Modern medical degree should be made the basic qualification to practice medicine. All other systems of medicine should be learned only after acquiring basic modern medicine degree, that is MBBS and not in the reverse order. In all other countries including Germany where Homeopathy took origin, a modern medical degree is a prerequisite to learn any other system of medicine.

IMA feels that the new policy document does not make a strong case for moving towards our objective of universal access to affordable health-care. There are innumerable challenges to be overcome before its stated objectives become a reality.  IMA demands serious deliberations and consultations with all stakeholders including professional associations before the policy is finalized. IMA being the biggest stakeholder in health scenario in India, our views should be seriously considered before finalizing the policy


(Prof (Dr) A Marthanda Pillai) (Dr K K Aggarwal)

Padma Shri Awardee, Padma Shri, National Science Communication &

National President, Dr B C Roy National Awardee

Indian Medical Association Honorary Secretary General,

Indian Medical Association

President, Heart Care Foundation of India



Draft National Health Policy: Views of Indian Medical Association


  1. Introduction, Context, need and scope

Thirteen years after the last National Health Policy, the Ministry of Health has brought out a draft new national health policy, which is in the public domain for discussions.  The National Health Policy of 1983 and the National Health Policy of 2002 have served us well, in guiding the approach for the health sector in the Five-Year Plans and for different schemes. Development of a more robust, effective and credible new national health policy will give direction and coherence to our efforts further to improve health of the nation. IMA congratulate the government in bringing out a policy within few months of assuming power.

The importance given to urban health, addressing social determinants of health, suggestions to harness newer technologies like tele-medicine, recognizing the role of private sector through health strategic purchasing, newer strategies for resource generation like health cess etc. are appreciable.

The policy is put forwarded as‘a declaration of the determination of the Government to leverage economic growth to achieve health outcomes’, in the ‘global context of all nations committed to moving towards universal health coverage’. Given the two-way linkage between economic growth and health status, and considering the fact that India being the third largest economy, the policy acknowledges that the promise of Health Assurance by the new Government is an important catalyst for the framing of this new Policy.

With a 15% compound annual growth rate, the policy describes the health care industry as a robust one. However the policy fails to recognize that this high growth rate is at the cost of people of this country getting pushed below poverty line. Also, as the policy itself rightfully acknowledges later, the major growth is in the Pharmaceutical industry and corporate hospital sector and not in small and medium hospital level. Infact small and medium sized clinical establishments in the country are getting closed down due to misguided policies of successive governments.

When it comes to the review of achievements so far, the policy tries to take ‘all is well’ position by showcasing extrapolated figures. This is a dangerous position since complacency in achieving the targets can set in which can further slow down the progress towards achieving better maternal and child health indicators. International development agencies have carefully analyzed the progress and have predicted that most of the MDG targets are not achievable at the rate of decline of these rates so far, except may be in the case of TB.

In population stabilization, the policy identifies declining sex ratio as the only major problem, but fails to even mention any specific intervention to address it, the least. While agreeing that there is widespread inequity in health outcomes between geographical areas and between social groups, the policy, sadly, does not put forward any concrete plans to address this disparity later.




  1. Situation Analysis

The entire existing National Health Programs together covers only about 15% of disease morbidity. No sustained effort is seen in improving the national programs- both in technical aspects and in increasing financial support. Financial support is cut down in the pretext of having controlled the disease, e.g. AIDS control program. In a welfare economy, disease control programs should get priority over tertiary care services. Newer treatment and combination therapies are still to find mention in national programs. Emerging evidence suggest that burden of diseases like TB are underestimated in the country and hence calls for increased investment from the Government. National Health Programmes for non-communicable diseases are very limited in coverage and scope, except perhaps in the case of the Blindness control programme. However the policy does not put across any visible solutions. Even though the policy says that all drugs and diagnostics are free under most national programs, the fact remains that many services under these programs are incurring substantial out-of-pocket expenses. Experience shows that whenever the funding for existing national programmes are reduced in areas where disease control has been supposedly achieved, there is reemergence of these diseases. This could even happen with the AIDS control programme, if the fund is reduced. The national disease control programmes should include more diseases like cancer, Cardio vascular diseases, diabetes, and all other communicable diseases so far not included in the national programmes.

There is complete lack of professionalism in health care management with no mechanism to ensure accountability and financial discipline. A proper auditing to make sure that the sparse fund available reaches the targeted population is lacking. The policy should come out with solution to address these issues.Even though National Rural Health Mission (NRHM) led to a ‘significant strengthening of public health systems’, the policy accepts that states with better capacity at baseline were able to take advantage of NRHM than weaker ones. ASHAs could bring the community closer to public services and it is true that deployment of volunteers like ASHA may contribute to improvement; and not creation of half-baked Doctors through bridge courses. No system building was done as part of NRHM even though it was envisaged. It In fact damaged the existing system at state level. It has not acted complimentary to system but went parallel. However capacity building to absorb and utilize the fund was not built into the existing system. There should be some permanent mechanism to monitor the utilization of funds and to ensure that funds reach the targeted population with the intended purpose. There is need for inculcating better managerial skills in the health system; one option is to have Indian Medical Service just like IAS, IRS etc.Revised NHM should address system issues and control of NCDs trauma and other emerging communicable diseases. Public private partnership model, which has been successful in TB, can be used for all disease control programs.

It is an innocent misinterpretation of statistics, when the policy claims that in terms of comparative efficiency, public sector is value for money as it accounts because even those who depend on public health sector do have heavy OOP expenses, which has been missed out in this assessment. If it is also considered, the efficiency figures will not stand. Even those who utilize public facilities, expenses are incurred OOP, particularly diagnostics and drugs. Value for money is a myth since even those who seek health care from public sector do equally spend OOP, same amount as in private due to sheer non-availability of diagnostics and essential drugs. It is widely known that VIPs, Government bureaucrats and people who can afford to pay, utilize the lion share of the public sector facility and deserving poor public are kept away and forced to seek health care from private sector or even quacks.

Considering private hospitals as pure industry is entirely misleading and contradicts the Government policy of making health as a fundamental right. When the Government demands that medical ethics need to be followed and considers it as a service sector, branding clinical establishments in private sector as an industry exposes the contradiction in Government policy. The need for standardization and quality healthcare services is understandable, but the mechanism to ensure it through CEA will be counterproductive. A process of voluntary and incentive driven accreditation is the best practical option. Professional organizations like IMA can play a pivotal role in this process. The pre-conceived notion that private sector always is profit-driven and ignoring it in the overall structure of health delivery and allowing it to run parallel to the Government sector rather than promoting them to compliment is unbecoming of a health policy.

Policy should aim to improve the access and affordability of secondary and tertiary Care by increasingly involving private institutions, through encouragements and incentives. Influence and encourage private health care establishments by exempting them from the purview of income tax, providing subsidies to these institutionsThe Government should even think of the concept of ‘aided hospitals’ in the lines of ‘aided schools’. Government in turn can demand at least 15% free care in these institutions for poor patients. In the preventive and primary health care also role of private sector needs to be strengthened to a process of retainership and by defining a role for the family doctor. This model will be cost effective compared to heavy investments required in health insurance systems. Failure of American model insurance driven health care provisioning should be a lesson while framing the policy

The integrated medicine concept is again a misplaced thought process, which is not based on ground reality or evidence. In the process of strengthening alternate systems, the integrated system will only destroy the alternate systems of medicine. By the integration of systems, the Government is denying the right of the public to choose an alternate system, which is pure. Public always would like to prefer an alternate system of medicine when one system fails. It is not their desire to opt for a different system when the process of integration already has diluted it. This in itself is denying right to health

When it comes to human resources, it is a major omission that the policy is unaware of the number of existing modern medical institutions and number of students passing out every year. At present we have 1 Doctor for 1500 population when the developed country average is 1 per 650. The Government view that modern medical doctors are not adequate and it has to be increased to 1 for 1000 population is a misconceived one. In western countries when a Doctor sees hardly 25 patients per day, they may need a ratio of 1:650. But when our Doctors are used to seeing 100 to 300 patients per day and equally serving these populations, to achieve a ratio as in advanced countries is un-necessary and waste of resources. This can be only considered as a lame excuse to introduce half-baked Doctors through bridge courses and short-term courses. The non-availability of Doctors in many parts of the country is mainly because the Government has not revised the staff pattern in the health Department even though the population has increased over the years and number of people availing health care has also gone up. The staff pattern is still that of 1961 in many states. Also to be remembered that in some states, no regular appointments of General Duty Medical Officers have taken place in last 10 -15 years. The staff pattern has to be revised immediately. Doctors in public sector are not available as per population norms; inter state and intra state disparities are there, with certain PHCs even catering up to 100,000 population. When the ideal doctor nurse ratio is 1:3, the current ratio is 1:2. Instead of the Government taking steps to produce more nurses, the Government is thinking of Nurse Practitioners which will make the shortage of nurses even graver and make the health delivery structure an inverted pyramid and this will destabilize the health delivery.

There is no scientific assessment of HR requirement in health sector, which is an absolute necessary for planning manpower requirement. The fact that the paramedical work force including Nurses, ANM, GNM, JPHN, pharmacist and Laboratory Technicians, are much more deficient (40 to 60%) compared to Doctors (14- 24%) is not taken into consideration when human resource planning is done. When the Government is showing an unnecessary haste in increasing the number of Doctors through short term and bridge courses, what the health delivery system really wants is an increase in all the categories of paramedical personal. That is what requires urgent addressing.


  1. Goals, Key Principles and Objectives

The policy says that ‘the attainment of the highest possible level of good health and well-being, 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’ as it’s goal, which is a vision statement or rather a wish and not a goal, which should be a time-bound one with defined parameters to achieve

The Key principles laid down by the policy are Equity, Universality, Patient Centered Care andQuality of Care, Inclusive Partnerships, Pluralism, Subsidiarity, Accountability, Professionalism, Integrity and Ethics, Learning and Adaptive System and Affordability. Integrity and ethics needs to be discussed separately from Professionalism and efficiency, which may go together. To ensure the highest level of professionalism and efficiency particularly in the Government sector, a new cadre of managers like Indian Medical Services in the line of IAS, IPS is the need of the hour.



The policy recommends setting up of task forces for developing indicators and targets and mechanisms for achievement. While task force for implementation of programme makes sense, it is mandatory that the policy clearly spells out indicators and targets. For any task force the scope and target should be predefined, if not the task force will come out with its own indicators and targets, which could be contrary to the philosophy of the policy.The objectives stated in the policy are not measurable ones, but only mere statements.

Presently national disease control programs address only 15% of morbidity in the country, like TB, VBDs, and maternal and child mortality. Government should design and implement national programs to address at least 50% of morbidity in the country by 2020.The programs should aim to bring down morbidity by at least 25% by the year 2025. Priority programs include those to address NCDs, Cancer, occupational diseases, mental disorders, problems of the elderly and road traffic accidents

Government should invest more in health care whereby the out of pocket expenses is brought down aiming to reverse the ratio of public vs OOP expenses to 70:30 and should aim at achieving 50:50 central state share in public health expenditure in the place of the present ratio of 30:70. Public spending on health should be at-least 2.5% of GDP by 2019 and at least 5% by 2025. Major source of financing should be tax based. The Government should be explicit in spelling out in creation of health cess and taxes rather than saying it will explore. Government should raise more revenue by introducing 0.5% health cess in VAT and through additional tax of 2% in tobacco, alcohol, luxury vehicles and packaged food. Government should aim to mobilize two hundred thousand Crores if the proposed expenditure has to be achieved.

It should be kept in mind that private health care establishments are major job providers, much higher than any other sector. No other sector is able to offer employment proportionate to the investment as is done in health sector. Therefore Government should consider all support to private health care investment like land lease, as indirect contribution to employment generation which will in-turn lead to economic prosperity, in comparison with other sectors like automobile or factories or IT where Government is giving support in terms of lease land , free electricity water, tax exemption etc. This in-turn will lead to improved health as well.





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