Seven Health Secretaries in Seven Years – Where Is the Accountability?

The government should keep the secretary of the health department unchanged for three years for him/her to be able to show results. But that has not been happening.

A health worker (R) weighs a child under a government program in New Delhi, India

A health worker (R) weighs a child under a government programme in New Delhi. Credit: Reuters

The NDA government had promised good governance and policy stability. Yet we have a fourth secretary in the health department in the last three years – the seventh in the last seven years. Since both the outgoing and the incoming officers have sterling reputations, the reason for this mid-course change is unclear.

Why it matters

Health is a complex sector, and a highly contentious one, with several stakeholders working at cross purposes, requiring focused leadership, undistracted by the noise – something similar to the journey of Odysseus when he was tied to the ship’s mast to keep himself from being distracted by the lovely music of the sirens and in the process wreck the ship on the rocks. But such focused leadership requires knowledge of the purpose of the journey, the direction to take, the end to reach. And such clarity comes with years of engagement, absorbing the nuances, developing an intuitive grasp of matters and most importantly, building a team and assessing the political environment within which to steer policy. It is for this reason that the Second Administrative Commission suggested that the tenure of Secretary should be three years. Every change at the top then means a loss of a few months till new equations are formed, trust developed, and understanding gained.

Also read: Why India’s Poor Are Still Paying for Healthcare Despite the National Health Insurance Scheme

Matters of importance

In line with predecessor governments, the NDA too accorded lukewarm priority to health. It sacked a knowledgeable minister, wound up the National AIDS Control Organisation, that had a global reputation of being a best practice, stopped the reform process of the Rashtriya Swasthya Bima Yojna, shifting it instead to the already overburdened Ministry of Health, and reduced central funding to states in real terms. Instead of swift action to reform the Medical Council of India, in response to the scathing report of the Parliamentary Standing Committee on Health, a Committee was constituted. Two years later, the draft bill is still awaiting action.

On the positive side, the NDA articulated a bold health policy framework that is significant for adopting a more comprehensive health system approach. Rather than being coy about the participation of the private sector for achieving welfare goals, the policy makes its cooperation vital to the achievement of Universal Health Coverage through a National Health Assurance Programme. Undoubtedly, the National Health Policy, 2017, notwithstanding its several loopholes, flaws, gaps and contradictions, provided a way forward. But not without the risk of the health system being hijacked by corporate sector lobbies to the detriment of the poor, as seen in the cluttered policy framework that the NITI Aayog came up with – and was met with nation wide criticism – including state governments. Likewise, the NDA introduced the NEET that have some lessons to build upon. The government also sought to make drugs and diagnostics more affordable by capping prices – this is likely to provoke a reaction from vested interests.

India at crossroads

As can be seen, India is clearly standing at crossroads. Even as the agenda of unfinished tasks grows long, new challenges are emerging from the shadows. Inadequate budgets and the non-availability of well trained human resources are two problems that need to be addressed without further prevarication. Medical and paramedical education has been brazenly commercialised. In the race for profits, quality has been severely compromised. This needs to be rectified. And solutions are available.

Likewise, through dialogue, reforms to remove bottlenecks, and facilitate partnering with the private sector to achieve national goals, needs to be carefully put into place. As a process, this requires patience and negotiation skills, but is more sustainable than the lazy option of selling off government assets.

Also read: India’s New National Health Policy is Ambitious on Paper But Lacks Clarity

Finally, the scope for exploring non budgetary financing to meet the huge capex needs of the primary health system needs to be looked at to bring about the architectural correction. Conclusive evidence shows that a cost effective and sustainable health system is possible only when built on the foundations of an accessible and free at the point of use, primary care. India’s health system is based on the more expensive model of specialist-led hospital treatment. The various government sponsored health insurance schemes cover only surgeries. This needs to be expanded to cover other services, and with time the out patient treatment as well.

The government, like Odysseus, needs to be tied to the mast to focus, uncompromisingly, on eliminating and effectively containing the load of infectious diseases that still accounts for a third of the disease burden and hurts the poor disproportionately. Universal access to nutrition, tap water, sanitation and clean air are the vital ingredients of such a strategy. This basket of public goods then must be made universally available to all without discrimination as the first charge on government finances.

The list of what needs to be done is endless, posing a challenge to the most well meaning of governments. A beginning needs to be made by keeping the Secretary unchanged for three years and making him/her accountable to results – the precedent for the wisdom of such a policy being Tamil Nadu.

K. Sujatha Rao is a former union secretary of the Ministry of Health and Family Welfare, government of India, and the author of Do We Care: India’s Health System.