Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?


The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Santitation: Behavioural change critical

That high toilet coverage without concomitant utilisation of the facilities at a very high level and washing hands with soap will not bring about a reduction in diarrhoeal episodes and worm infestation, or any improvement in nutrition and growth, has been clearly brought out in a study undertaken in rural Odisha. The study involved about 4,600 households from 50 villages grouped in an intervention arm and about 4,900 households from 50 villages in a control group; there were nearly 25,000 individuals in each group. The coverage of toilets shot up from 9 per cent to 63 per cent among those in the intervention arm within 18 months, compared with an increase from 8 to 12 per cent in the control villages. Eleven of the 50 villages in the intervention arm had toilet coverage of 50 per cent and above; only two villages in the control group had coverage that was this high. Despite usage at the household level in the intervention arm being 84 per cent for women and 79 for men and children, it translated to only about 50 per cent at the community level. As a result, in both the arms the number of children below five years who were affected by diarrhoea was nearly the same. There was no difference in worm infestation rates or any improvement in nutrition or growth rates, either. There was no decrease in faecal contamination of water or any significant drop in contamination of the hands of individuals.

The results of the trial should serve as a painful reminder that emphasis on high toilet coverage without ensuring very high usage will not lead to improvement in health indicators. After all, the only way to reduce the overwhelming load of diarrhoeal and other pathogenic bacteria in the environment and improve health indicators is to refrain from shedding such bacteria in the environment. The timing of the results is perfect. The government recently rolled out its ambitious Swachh Bharat Mission with the aim of ensuring a toilet in every Indian household by the end of 2019; an earlier programme primarily targeted families that were below the poverty line. Building toilets is the necessary but easier part; bringing about behavioural change is the more daunting challenge. This is amply reflected in the study, done in accordance with the government’s earlier programme. The Mission should not remain a mere infrastructure-centred programme but should give equal priority to creating awareness of the benefits of toilet usage through a massive campaign. On paper, the “top priority” of the Mission is to improve toilet usage by bringing about behavioural change. There is also a provision to “monitor usage”. It is important that such ideals get translated into discernible actions and results on the ground.

Published in The Hindu on October 16, 2014

Editorial: Commendable initiative on open defecation

At a time when open defecation remains something of a taboo subject and is seldom discussed in public, it is commendable that Prime Minister Narendra Modi turned the spotlight on the practice while addressing the nation on August 15 and brought the discourse straight into lakhs of drawing rooms. Soon after he urged the corporate sector to “prioritise the provision of toilets in schools” under corporate social responsibility programmes, the social movement is slowly gaining traction. Two companies — Tata Consultancy Services and Bharti Enterprises — have committed themselves to playing their part in achieving the monumental task of ensuring that all schools in the country have toilets for boys and girls in a year’s time. Hindustan Zinc Limited has increased by 10,000 the number of toilets it would build in villages in three districts of Rajasthan; its earlier target number was 30,000. There is an urgent need for many more companies to follow suit quickly. But building toilets alone would achieve next to nothing if providing access to water does not go hand in hand with it. That over 620 million people in India still defecate in the open is at once a shameful and disgusting statistic. The ignominy becomes all the more striking as India has the most number of people in the world continuing with this abhorrent practice; Indonesia is a far second with 54 million people doing that. That Bangladesh reduced the prevalence from 34 per cent in 1990 to 3 per cent in 2012 is a potent reminder that the war against open defecation has to be won in double quick time. This can be achieved only if building toilets, both in schools and in households, continues to be a priority for the government and every other sector in the country.

The ramifications of open defecation are too grim to be ignored. Many of the water-borne diseases — cholera, diarrhoea, dysentery, Hepatitis A, typhoid and polio — are linked to open defecation. Hence, it is no coincidence that nearly 14 per cent (over 300,000) of deaths among children in India under five years of age are caused by diarrhoea-related diseases; diarrhoea is the second biggest killer in this age group. Also, frequent diarrhoeal events result in malnutrition and, in turn, stunting in children under five. The absence of toilets in schools is one of the reasons why girls drop out of the system at an early age. There is a huge economic cost, too. According to a document of the World Bank’s Water and Sanitation Programme, the economic impact of poor sanitation is about Rs.2.4 trillion (which represented 6.4 per cent of India’s GDP in 2006). It is important to remember that building toilets without building awareness and changing the mindset, would still yield poor results.

Published in The Hindu on September 1, 2014



New approach needed to curb open defecation?

At over 620 million, India has the most number of people in the world defecating in the open. Open defecation and lack of sanitation are the leading causes for water-borne diseases like diarrhoea and stunted growth in children. Over 300,000 children aged below five years in India die each year due to diarrhoeal diseases.

Hence, curbing open defecation is central to cutting the number of child deaths. But increasing the number of households with toilets and reducing the practice of open defecation to bring about any significant improvement in health outcomes in children aged below five years appears quite challenging according to a study published recently in PLOS Medicine .

The results of the first of its kind, large-scale, randomised, control study involving about 5,200 children below five years of age from 3,039 households amply demonstrates that the government has to revisit its current strategy of increasing the number of households that have toilets to reduce open defecation and thereby improve the health outcomes in young children. The study took place between May 2009 and April 2011 in 80 rural villages from two districts of Madhya Pradesh.

The households were divided into an intervention arm and a control arm. The households that were below the poverty line were provided Rs.4,200 to construct toilets. The funds were provided by the Total Sanitation Campaign (Rs.2,200) and Nirmal Vatika (Rs.2,000). The households in the intervention arm received messages on open defecation and the need to end it. There were community follow-ups and personal visits, as well. Toilets were also constructed in these households.

Despite all these, the intervention led to only 19 per cent increase in households that went in for toilets; there was just 10 per cent decrease in open defecation. Finally, there was insignificant improvement in child health outcomes (diarrhoea, anaemia, parasite infection and growth).

“We caution the readers that we are not saying that sanitation does not work but may be much high level of toilet coverage and their use are needed for health impacts,” Sumeet R. Patil, the corresponding author from the Network for Engineering and Economics Research and Management (NEERMAN), Mumbai, and School of Public Health, University of California, Berkeley, told this Correspondent in an email.

Can the modest decline (10 per cent) in open defecation in a matter of 21 months not be considered significant? “That should be a matter of interpretation. We report that among households [that] had a toilet, approximately 40 per cent reported daily open defecation by men or women. You can interpret this also as 60 per cent did not defecate in the open regularly when they had a toilet. One may say the glass is half full! Therefore, my inference would be that large reductions in open defecation in such a short amount of time were “conditional” on having a toilet. When toilets were increased by 20 per cent, open defecation decreased by 10 per cent,” he said.

The debriefing of people who did not have toilets helped in understanding why people did not construct toilets. The key reason was the lack of money/affordability. Lack of water supply and other constraints followed affordability. “As some quasi-experimental evidence to this, we find that the BPL households who got more subsidy built more toilets than non-BPL households (about 30 per cent effect), which suggests the effect of higher subsidy. We do believe (based on our analysis) that subsidy is needed and more subsidies do result in higher toilet coverage/more reductions in open defecation,” Dr. Patil said.

Besides subsidy, a big factor is addressing the habit, cultural, and mindset of people to bring about a real effect. “Household debriefing identified habit-related reasons for continuing with open defecation despite having a toilet,” Dr. Patil noted. “Whether the behaviour change would be sustained or slowly taper off over time remains an open question.”

But can health indicators, particularly diarrhoea, be seen within a short period of 21 months, especially when the entire community has not become free of open defecation? “There are two questions here. First, can diarrhoea be reduced in short amount of exposure to improved sanitation at household level or at village level? Yes! Diarrhoea is expected to be a sensitive disease and we can see reduction in a matter of a few months. The more distal outcomes such as [reduction in] parasite infections and [improvement in] child growth may take several months or even years,” he said.

“Second, can we see diarrhoea impacts when the entire community is not free of open defecation? There is a consensus that level of diarrhoea (infectious diseases) should go down in the entire community so that community-household-community transmission of diseases is reduced. With only few households using a toilet, the pathogenic load in the environment may not go down enough for even the toilet-using household to realise health effects. This is the externality of communicable diseases.”

The study has several limitations — the duration of the study was short, it relied totally on recall of details by participants, relying on them on toilet usage etc.

Despite these limitations, the study highlights the compulsion to take a hard look at the strategy of fighting open defecation.

Trials with intense awareness programmes bring about the most positive changes. In spite of this, the current study did not register significant improvements.

From a public health perspective, the strategy adopted has been unable to improve child health. “We recommended that first efficacy of approaches should be proven at the pilot scale to know what works, and then scale up the intervention to the entire country,” he stressed.

“Governments and international donors need to know whether large-scale rural sanitation programs improve child health before expending further resources on these interventions or to identify an urgency to improve the existing program design or implementation so that they deliver the health impact,” the Editor’s summary notes.

Published in The Hindu on August 28, 2014

‘India is drowning in its own excreta’

Published in The Hindu on June 14, 2012

Sixty per cent of the “global total” who do not have access to toilets live in India, and hence are forced to defecate in the open. In actual numbers, sixty per cent translates to 626 million. This makes India the number one country in the world where open defecation is practised. Indonesia with 63 million is a far second!

At 949 million in 2010 worldwide, vast majority of people practising open defecation live in rural areas. Though the number of rural people practising open defecation has reduced by 234 million in 2010 than in 1990, “those that continue to do so tend to be concentrated in a few countries, including India,” notes the 2012 update report of UNICEF and the World Health Organisation (WHO).

For instance, of the 2.4 lakh gram panchayats in the country, only a mere 24,000 are completely free of open defecation.

More than half of the 2.5 billion people without improved sanitation live in India or China. The high figure prevails even as four out of 10 people who have gained access to improved sanitation since 1990 live in these two countries.

“Rapidly-modernising India is drowning in its own excreta,” notes the New Delhi-based Sunita Narain, Director General of the Centre for Science and Environment in a Comment piece published on June 14 in Nature.

The only silver lining is the determination with which Rural Development Minister Jairam Ramesh intends to rid the country of open defecation within a decade. His endeavour got a shot in the arm recently when the Cabinet Committee on Economic Affairs increased the amount of money to be spent for household toilets in rural areas from Rs. 4,600 to Rs.10,000.

But increased spending alone will in no way turn out to be a magic bullet in solving the malaise of open defecation. Numerous examples from other countries serve as testimony to this. Bringing about a change in mindset is the paramount need.

Awareness of the link between open defection and diseases like diarrhoea will in one way change the way people defecate. After all, almost 10 per cent of all communicable diseases are linked to unsafe water and poor sanitation. According to WHO, open defecation is the “riskiest sanitation practice of all.”

According to the global health body, compared with 1990, more than two billion people have access to improved drinking water sources. Thus the Millennium Development Goal’s drinking water target has been reached — “over 2 billion people have gained access to improved water sources from 1990 to 2010, and the proportion of the global population still using unimproved sources is estimated at only 11 per cent.”

The fine print

But the fine print reveals the rider. WHO does not have the critical information about the safety of the drinking water, though. Since testing for microbial and chemical parameters to designate drinking waters as safe is expensive, WHO used a proxy indicator — measuring the proportion of the population using drinking water sources that supposedly are protected from contamination, particularly from faecal matter.

But access to drinking sources can hardly be a true indicator, as is the case in India. “Leaking and incomplete sewage systems contaminate rivers and lakes, causing diseases like cholera,” notes Nature. “Around 97 million Indians do not have access to clean drinking water.” The problem arises due to contamination of drinking water by leaked sewage. Sewage inevitably pollutes water bodies, both surface and aquifers.

According to the Comment, only a few facilities exist in the country to treat waste water. “Officially, the country has the capacity to treat 30 per cent of its waste water.” But in reality it is far less at “20 per cent.”

While ridding open defecation will go a long way in improving sanitation and reducing disease outbreaks, Sunita Narain makes a strong case for larger investments in sewage systems and effective use of water. The need for newer technologies cannot be ignored.

Current technologies use “large amounts of water to transport small amounts of excreta through expensive pipes to costly treatment plants, she states. This is “unworkable and unaffordable,” especially considering the fact that cities are growing at a rapid pace and infrastructure is always lagging behind.