Dr. Nomal Chandra Borah
CMD, GNRC Hospitals, Guwahati

Federal approach missing, regional imbalances remain unaddressed in National Health Policy 2015

An evidence-based prescription from the North-East  relevant to North, East, West and South to rectify the inadequacies of centrally-formulated, nationally-imposed and regional lyirrelevant policy formulation and implementation process.

Let us first consider pieces of evidence that illuminates aspects of the state of health of the nation and its care that the Draft Policy attempts to address. Life expectancy in India has risen by five years in the past decade, according to the Union ministry of health and family welfare. This is due to better immunization and nutrition, coupled with prevention and treatment of infectious diseases. Though India will remain a young country overall, the population of the elderly will touch 12-13 percent by 2025 and 17 percent by 2050, according to the World Health Organization (WHO).

The longer lives of our people today, however, are often being led under the debilitating shadow of health conditions resulting from our present lifestyles and longer life-spans. The causes of fatality, and often, disability, today are lifestyle-triggered conditions such as hypertension which leads to coronary artery disease and stroke.

Our lives are longer, but not healthier. A prosperous nation cannot be built by unfit, unproductive people. Apart from primary, preventive and promotive healthcare, India must cater well for secondary and tertiary healthcare, if we have to pursue a brighter destiny for this country and her population.

Given this situation, one would have expected the draft policy to be farsighted and pay significant attention to the emerging burden of healthcare due to demographic and lifestyle changes, and the consequential importance of secondary and tertiary care all the more so as Section 2.7 explicitly acknowledges that non-communicable diseases and injuries now account for 50.9 percent of the nation burden of disease and that National Health Programmes offer very limited coverage and scope of treatment for non-communicable diseases.

To address this emerging burden, the nation must be prepared to provide affordable, accessible specialist care to our population. Let us allow statistics to further illuminate how inadequately prepared we are to provide care in the present situation, leave alone the future due to lack of skilled manpower the foremost requirement for healthcare. The statistical construct below also highlights how acute the regional imbalance is.

Let us take a condition, say, epilepsy and the specialists who treat it neurologists. If diagnosed early and treated, 80 percent epilepsy patients can lead a productive life. Lack of treatment, however, results in arrested intellectual growth, rendering individuals incapable of contributing significantly to society for the rest of their lives. The population of approximately 55 million people in North-East India carries a burden of prence of epilepsy greater than 300,000 individuals and annual new incidences numbering over 27,500. Now, nearly 99 percent of these individuals do not receive proper medical attention. This is not surprising, considering that there are just 12 (yes, twelve) neurologists catering to the entire population of 55 million in North-East India a ratio of 1:45,83,333. In developed nations, this ratio is around 1:18,000 more than 255 times higher. Similar is the situation in specialisation after specialisation cardiology, oncology, nephrology, hepatology, pulmonology, and the like. Considering that our population-todoctor ratio or patients-to-bed ratio is typically one-fourth those found in the developed world, the situation in specializations is literally more than 60 times worse!

Even if we accept a ratio far lower than the developed countries, the gap remains formidable, though surmountable if we innovate. Even if we wish to have, say, three specialists for 25-odd key specialisations for every one-million of population, this would mean a requirement of around 3,750 specialists, of whom 150-odd would be neurologists. Given that we have 12 neurologists at present in the North-East, this means a required increase of 138 neurologists almost twelve times over what is available at present. But here is the catch: the entire country today is producing just 50 neurologists, approximately, annually of which only two are produced in the North-East. Typically, at least one of them is from outside the North-East and will not be available to serve the people of the region once he or she qualifies. This means that at this rate of addition of skilled manpower one specialist per year it will take 138 years to bridge the gap (on the basis of the entirely unrealistic assumption that there is no further growth of the population!). Do note that neurologists are required to not only treat epilepsy but several other conditions in people of all age groups. Ominously, the prence of such conditions in the population is multiplying rapidly on account to present-day lifestyles; and, the above situation repeats itself in specialty after specialty. Policy to deliver healthcare to the country must address this ironic, tragic situation.

The situation has manifested itself in such an acute form due to lack of region-focused, innovative, visionary, locally-relevant health policies for creation of skilled manpower pools in the regions. This is hindering the process of creation of a resource pool comprising adequately trained manpower – without which availability, accessibility and affordability of necessary healthcare for the people will forever remain a mirage and never become a reality.

While the National Health Policy has expressed the intent to address the issue of creation of qualified manpower pool, it fails to acknowledge the scale of the gap, the consequent dimensions of the challenge and the urgency to respond. Regional realities, requirements and methods to cater to these requirements can best be understood and addressed by regional drivers of innovation in public interest. In the absence of such platforms and mechanisms, a centrally-driven agenda will only perpetuate the scarcity of skilled manpower, continuing the economic benefits enjoyed by some vested interests today, from the shortage of skilled manpower.

Considering the scale of the challenge as demonstrated by the statistical formulation above, the speed with which the challenge must be addressed is significantly higher than possible through the methods outlined in the draft national health policy which ascribes no role to the states in the creation of pool of skilled manpower. The challenge can only be addressed by adopting what may be termed as the federal method of formulation of policy to create skilled manpower pool, implementation and regulation of such policy. The federal method of policy formulation and implementation would entail providing adequate role for state governments, state universities, state specific social entrepreneurs and public- private partnerships. State representatives public and private should be given their seats and their say at the policy-making table specifically regarding creation of the pool of trained manpower, and provided the freedom and authority to formulate state-specific policies in pursuit of locally-relevant objectives in accordance with the federal mode of transforming India espoused by our Prime Minister Narendra Modi.

The state governments, universities and other stakeholders should be empowered to design and develop curriculum and the mechanism to monitor its quality to create the required number of specialist clinicians who can take care of the conditions that are responsible for 50.9 percent of the healthcare burden as identified by the draft policy itself.

In the absence of the above, we Indians from the North-East, and perhaps many others from the North, East, West and South, will need several lifetimes before we can benefit from the outcomes that the policy proposes to deliver. Meanwhile, the region will continue to lag behind in health and Human Development Index parameters, remain economically backward, a hotbed for militancy and a burden on the nation, which is attempting to soar towards its destiny. Is that the overall outcome national policymakers are seeking from the Draft National Health Policy 2015, and other such policies being centrally formulated and nationally-imposed?.

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