National Health Policy-2017 Excoriated

The Swacch Bharat Sweep-stake

The National Health Policy-2017 (NHP-2017), approved by the Union Cabinet in its meeting on 15.03.2017, has raised more doubts than satisfaction about the aim, intent and priority of the Modi government in achieving universal health coverage and delivering quality health care services to all at affordable cost. The policy has been in the drafting stage for more than two years since it was placed in the public domain on 31 December, 2014 for comments, suggestion and feedback. However, NHP-2017 is actually a step down of the Modi Government from the policy’s original draft that had proposed health be considered as a Fundamental Right. The policy repeatedly emphasized on “health assurance” instead of adequate availability of healthcare as a constitutional right. The policy further marginalized the government’s role as a “strategic purchaser” of secondary and tertiary healthcare from the private sector in lieu of an essential provider of healthcare services to its fellow citizens. In India, private facilities in healthcare sector barely exist in underserved areas and the gap in healthcare services is also the worst in those areas. Moreover, the policy proposes to increase government spending in healthcare from the existing 1.15% to 2.5 % of GDP by 2025. But, the draft of the policy had promised the timeframe of 2020. Thus, within a little more than two years of time the government has extended the number of years necessary to increase public spending on health to 2.5% of GDP. Even if achieved, it would be half of what the World Health Organisation (WHO) recommends as minimum. Ironically, there has been a gap between the claims and actual public expenditure on health for last three years. And, the healthcare budget for the financial year 2017-18 is less than that of the 2011-12 allocation if inflation is adjusted. Under this background, the “policy thrust” of NHP-2017 has to be scrutinized and questioned. The new National Health Policy asserts to institutionalize inter-sectoral coordination at national and sub-national levels to optimize health outcomes. For this, the policy identifies coordinated action on seven priority areas for improving the environment for health. These are:

• The Swachh Bharat Abhiyan
• Balanced, healthy diets and regular exercises.
• Addressing tobacco, alcohol and substance abuse
• Yatri Suraksha – preventing deaths due to rail and road traffic accidents
• Nirbhaya Nari –action against gender violence
• Reduced stress and improved safety in the work place
• Reducing indoor and outdoor air pollution

All these “seven priority areas” must be examined at length to understand the government’s policy perspective on healthcare. Let us begin with the Swacch Bharat Abhiyan (Clean India Movement).

Swacch Bharat is not a new initiative of Modi government

Swacch Bharat Abhiyan, in contrary to the truth, has been touted as the most indigenous and innovative project of Modi government. Since NHP-2017 is supposedly aimed at pre-empting the occurrence of diseases, therefore, it seems logical to identify the Swachh Bharat Abhiyan as the top most priority for healthcare. But, such initiative was taken much earlier. In fact, on 1 April 1999, the Government of India restructured the Comprehensive Rural Sanitation Programme and launched the Total Sanitation Campaign. The scheme was later renamed as Nirmal Bharat Abhiyan (NBA) on 1 April, 2012 by the then Prime Minister Manmohan Singh. The Narendra Modi Cabinet just renamed the NBA as Swachh Bharat Abhiyan on 24 September, 2014. Probably, the utter failure of “Nirmal Gujarat Campaign” faced by Narendra Modi as the Chief Minister of the state feared the Prime Minister Modi to search for a name that does not contain the word “Nirmal” in it.

Nirmal Gujarat campaign – 2007

Amidst pomp and show, Nirmal Gujarat campaign was launched by Chief Minister Narendra Modi on 30 December, 2007 from Gandhinagar calling upon the people of the state to maintain cleanliness so that the state becomes healthy and attractive. He also noted that clean cities and villages have been achieved only by people's awareness. In fact, Modi had 12 years to clean up Gujarat but no substance was achieved except relying only on people’s awareness. This is because of inadequate government funding and improper administrative reform w hichdid not yield any significant success for the campaign. On Nirmal Gujarat Mission’s request, a survey was jointly conducted by the Planning and Resources on Urban Development Affairs (PRUDA) and the All India Institute of Local Self Government (AIILSG) during February – May, 2009 to evaluate the success rate of ‘Nirmal Gujarat’ campaign particularly, its impact on sanitation standards in slums including the effects of the campaign on eradicating open defecation and the impact on the level of cleanliness in urban areas and its report “Nirmal Gujarat Rapid Impact Assessment” was published in June, 2009. Few excerpts from the report would suggest the ‘success story’ of Nirmal Gujarat campaign after two years of its launch:

Ø  74.5% slum dwellers did not have immediate access to Pay & Use toilet. These were mainly because of higher cost of Pay & Use toilets and their unavailability in the immediate areas around the slums.

Ø  41.6% of survey participants chose open defecation over toilets.

Ø  A little over 10% used toilets.

Ø  In absence of waste collection service, citizens disposed off their garbage on streets and such phenomenon was common within lower income groups.

Ø  Generally richer people were more satisfied than poorer ones.

Nirmal Gujarat had more critically polluted cities

During 2010, three years after the launch of Nirmal Gujarat campaign, six areas of the state namely Ankleshwar, Vapi, Ahmedabad, Vatva, Bhavnagar and Junagadh were declared as the critically polluted by the Ministry of Environment and Forests (MoEF), Government of India, based on the Comprehensive Environment Pollution Index (CEPI). CEPI is a score sheet on pollution developed by IIT-Delhi and central pollution control board (CPCB). CEPI scores of 70 and above were considered as critically polluted industrial clusters. Vapi was found to be 88.09 in the year 2010. Gujarat Pollution Control Board (GPCB), in its report “Comprehensive Environmental Pollution Abatement Action Plan, Vapi Industrial Cluster– Gujarat” published from Gandhinagar during 2010 acknowledged the fact and assured the MoEF that it would implement its action plan to improve environment quality of the region. This action plan is known as the Vapi Action Plan.

The details of Vapi Action Plan

Vapi Action Plan had various management and mitigation measures like safe disposal of industrial waste and treated water; strengthening air quality monitoring etc. The plan also recognized that the non-compliance by industries mainly caused environmental pollution in the region. Earlier in 1989, Vapi was declared as critically polluted. Therefore, in 2010, a moratorium was imposed on the expansion of industries and the setting up of new ones at Vapi. Despite all its action plan, CEPI index score in 2013 showed that Vapi still topped the pollution charts with a score of 85.31. Considering the impact on human health and very high level of exposure of humans to the pollution, MoEF re-imposed the ban on any permission to any new or expansion of project in Vapi.

Environment plunged into corporate plunder

Despite hazardous pollution issues, the plutocracy of Gujarat was continuously pushing to lift the moratorium. In 2016, Modi government revised the CEPI to do away with the parameters like the impact on human health and environmental degradation. The new CEPI index has ensured that the areas like Vapi would no longer be classified as critically polluted and, hence, to allow for an inflow of industrial activities. As a result, in November 2016 MoEF lifted the moratorium on expansions and new investments in three industrial clusters in Gujarat namely Ankleshwar; Vapi and Vatva. This clearly shows Modi government’s unquestionable commitment towards corporate profit over environment’s safety and people’s health.

Consequences of Modi’s Nirmal Gujarat Campaign

Nirmal Gujarat Campaign was all about a cosmetic programme. It was needed to bring fundamental changes in policies and to reform the system. But, the trusted corporate watchman Narendra Modi, even as the Chief Minister, was never interested in doing something that could affect the corporate profit. With money from the government exchequer to run the campaign; with more and more focus on media propaganda and much of fanfare, the over publicized Nirmal Gujarat Campaign ended up with lack of sewerage facilities in colonies after colonies, water logging resulting into mosquito outbreak, no garbage lifting vehicles in many municipal areas, no Panchayat Safai Kamdars (sweepers) etc. Beyond the showcase super highways; shopping malls and the famed Sabarmati riverfront, overall Gujarat remains unclean.

An insight of Modi’s Swacch Bharat Abhiyan

India is committed to achieve the Sustainable Development Goals and, hence, it has to achieve universal access to safe drinking water, adequate sanitation and hygiene to all its citizens. With sanitation as a key priority, Swacch Bharat Abhiyan (SBA) was introduced by restructuring the erstwhile Nirmal Bharat Abhiyan (NBA) for raising the standards in sanitation. The completion of SBA is targeted in the year 2019 which is the 150^th birth anniversary year of Mahatma Gandhi. But, after two and half years of SBA’s introduction, the question remains, “Can India become clean, as Swachh Bharat hopes, by 2019”?

The Ministry of Drinking Water and Sanitation (MDWS), the nodal body that implements the SBA has been allocated Rs 20,011 crore in the Union Budget-2017. There is an upward trend in budgetary allocations from 2012 to 2017. According to MDWS, sanitation coverage has gone up from 42 percent in October, 2014 to 60 percent in 2017. But, is that sufficient? Moreover, beyond sanitation SBA includes supply of drinking water, solid waste management, sewerage, storm water drains etc. Swacch Bharat Abhiyan fails to fulfill its promises in every count.

Toilet plan behind schedule

Following a Swacch Bharat cess, levied from November 2015, nationwide toilet construction gained momentum. According to the government statistics, nearly 16 million toilets have been constructed in rural India during these two years. The Centre has set a target of construction of 100 million toilets in five years time by 2019 to make India open-defecation free which means the construction of 20 million toilets per year. If the rate of construction is just an average of 8 million for first two years, will it be able to construct rest 84 million toilets in next three years? Moreover, we need to look beyond just in terms of toilet construction but also into issues of sustainability of toilets. There are important issues like lack of acceptability and proper usage of the toilets built in remote rural areas particularly in populous states like Uttar Pradesh.

Sewage systems

Sewage systems are equally important as toilet construction. According to the Central Pollution Control Board report, India has only 522 working sewage treatment plants. Only around 37 percent of wards in urban areas reported to have a proper liquid-waste disposal system for community and public toilets as reported by the National Sample Survey Organization.

Solid waste management

With rapid urbanization, solid-waste management remains as a key challenge in India. 377 million people in urban India generate 62 million tons of garbage daily, making the country as the world’s third-largest garbage generator, after China and the USA. Out of these, more than 45 million tons of garbage is left untreated and disposed off by municipal authorities daily in an unhygienic manner. At the national level, around 35 percent of India does not even have waste dumps, let alone processing ability. Against a target of 30 percent, only around 17 percent of urban solid-waste (garbage) was processed as of March 2016. Even door-to-door trash collection in urban areas was around 42 percent against a target of 50 percent.

What about water

The Union Budget for the financial year 2017-18 has witnessed an increase of only Rs 50 crores in the allocation for rural water. There was an expectation for higher allocations considering the recent drought situation in the country which has further worsened the drinking water crisis. In his Budget speech, the finance minister assured that the open-defecation free villages would be prioritized for piped water supply under the SBA though such meager budgetary allocations have raised doubts about the intent. Earlier, in May, 2016 the Parliamentary Standing Committee on Rural Development expressed its concern over the fallout of the decrease in budgetary allocation for the rural drinking water programme. There are also concerns regarding the quality of water. Despite the proposals to provide safe drinking water to over 28,000 arsenic and fluoride affected areas in the next four years, how the mission would get the success is anybody’s guess. The government must take the stock of its progress in providing with safe drinking water across social categories, gender and culture.

Conclusion

Do we still need to believe that the Swacch Bharat Abhiyan is all about cleanliness all around and for the improvement of the living conditions of the common citizens? To promote Swachh Bharat widely across India, Modi government spent tax payers’ money to the tune of Rs 212.57 crore in 2014-15 and, in 2015-16, the expenses rose to Rs 293.14 crore. Though India is lagging behind on Swacch Bharat plan and its effective execution, but its advertisement expenditure does not fall short of being on the higher side. Until the Swacch Bharat Mission would comply with the popular expectation rather than the over ambition of the government, its inclusion in the priority list for National Health Mission remains invalid.

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