The practice of public health care has been dynamic in India, and has witnessed many challenges in its attempt to affect the lives of the people of this country. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus (HIV) have been addressed through a concerted action of the government. Social development coupled with scientific advances and health care has led to a decrease in the mortality rates and birth rates. India added 450 million people over the 25 years to 2016, a period during which the proportion of people living in poverty fell by half.
Budget spending and Insurance Levels
• The public expenditure on health sector remains a dismal show of only around 1.4% of the GDP.
• The investment in health research has been low with a modest rate of 1% of the total public health expenditure.
• Insurance coverage remains low, over 80% of India’s population remains uncovered by any health insurance scheme.
• There has been a stark rise in the out-of-pocket expenditure on health issues. This led to an increasing number of households facing catastrophic expenditures due to health costs.
IMR, MMR, Hunger, Non-Communicable diseases, and Mental Diseases
• India missed by close margins in achieving the millennium development goals of maternal mortality (India – 167, MDG – 139) and under 5 child mortality rate (India 49, MDG – 42). The rate of decrements in stillbirths and neonatal death cases has been slow.
• Nutrition status has been dismal and is one of the causes of child mortality and morbidity. As per the global hunger index (by IFPRI), India ranks 97th in 2016
• India ironically has “dual-disease burden”, a continuing rise in disease arising out of exclusions (out of poverty or lack of proper healthcare facilities), while the other as lifestyle diseases like diabetes and cardiac related problems, which accounted for half of all deaths in 2015, from 42% in 2001-03.
• There has been a steady rise in mental illnesses in the country. One in every four women and 10% men suffer from depression in India.
• At the same time progress has been marked in the field of communicable diseases as such. Polio has been eradicated, leprosy has been curtailed and HIV – AIDS cases have met the MDG target of being reduced by half in number.
• Health workforce density in India remains low.
• India’s ratio of 7 doctors and 1.5 nurses per 1,000 people is dramatically lower than the WHO average of 2.5 doctors and nurses per 1,000 people.
• The majority of the health workforce is concentrated in urban areas.
• Acute shortage of paramedical and administrative professionals.
The targets for Public Health in India includes the epidemiological transition (rising burden of chronic non-communicable diseases), demographic transition (increasing elderly population) and environmental changes. The unfinished agenda of maternal and child mortality, HIV/AIDS pandemic and other communicable diseases still exerts immense strain on the overstretched health systems.
The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender and race or ethnicity. Lack of adequate progress on these underlying social determinants of health has been acknowledged as a glaring failure of public health.
Inadequate financial resources for the health sector and inefficient utilization result in inequalities in health. Public healthcare under-financed, short-staffed; rural areas particularly affected
India has the lowest government spend and public spend, as a proportion of gross domestic product (GDP) and the lowest per capita health spend, Indians met more than 62% of their health expenses from their personal savings, called “out-of-pocket expenses”, compared with 13.4% in the US, 10% in the UK and 54% in China.
India’s existing infrastructure is just not enough to cater to the growing demand. Rising population, inadequate resources and meagre health insurance penetration
A majority of the population living below the poverty line (BPL) continues to rely on the under-financed and short-staffed public sector for its healthcare needs, as a result of which their healthcare needs remain unmet.
Majority of healthcare professionals happen to be concentrated around urban areas where consumers have higher paying power, leaving rural areas underserved. 74% of India’s doctors cater to a third of the urban population, or no more than 442 million people.
The country is 81% short of specialists at rural community health centres (CHCs), and the private sector accounts for 63% of hospital beds, according to Indian government health and family welfare statistics.
ADDRESSING THE ISSUE: Strategy & Stakeholders
ROLE of GOVERNMENT
The role of government is crucial for addressing these challenges and achieving health equity. The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India's public health system. The role of government in influencing population health is not limited within the health sector but also by various sectors outside the health systems.
Health system strengthening: Important issues must confront are lack of financial and material resources, health workforce issues and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The National Rural Health Mission (NRHM) launched by the Government of India is a leap forward in establishing effective integration and convergence of health services and affecting architectural correction in the health care delivery system in India.
There is an urgent call for revitalizing primary health cares across the country in the attempts to achieve “Health For All”.
Health information system: The Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector. Mechanisms to monitor epidemiological challenges like mental health, occupational health and other environment risks are yet to be put in place.
Health research system: There is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.
Regulation and enforcement in public health: A good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes. Wide gaps exist in the enforcement, monitoring and evaluation, partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and lack of community involvement. Revival of public health regulation through updation and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and procedures.
Health promotion: Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened. Much can be done to improve the effectiveness of health promotion by extending it to rural areas as well.
Human resource development and capacity building: There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. Pre-service training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. In-service training for medical officers is essential for imparting management skills and leadership qualities.
Urgent need to increase the number of paramedical workers and training institutes in India.
Public health policy: Identification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector. National Health Policy 2017 can be used by states, communities, professional organizations and all sectors.
Focus on Social determinants of health: Kerala is often quoted as an example in international forums for achieving a good status of public health by addressing the fundamental determinants of health: Investments in basic education, public health and primary care.
Improve Living conditions: Safe drinking water and sanitation are critical determinants of health, which would directly contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of drinking water supply and sanitation through existing programs, in both rural and urban areas, is achievable and affordable.
Urban planning: Provision of urban basic services like water supply, sewerage and solid waste management needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works to develop financially sustainable cities in line with the Millenium Development Goals, which needs to be expanded to cover the entire country. Other issues to be addressed are housing and urban poverty alleviation.
Revival of rural infrastructure and livelihood: Action is required in the areas of Promotion of agricultural mechanization, improving efficiency of investments, rationalizing subsidies and diversifying and providing better access to land, credit and skills.
Nutrition and early child development: Recent innovations like universalization of Integrated Child Development Services (ICDS) and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive growth under the eleventh 5-year plan. Micronutrient deficiency control measures like dietary diversification, horticultural intervention, food fortification, nutritional supplementation and other public health measures need intersectional coordination with various departments, e.g., Women and Child Development, Health, Agriculture, Rural and Urban development.
Social security measures: The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee Scheme (MREGS) has the potential to change the complexion of rural India. It differs from other poverty-alleviation projects in the concept of citizenship and entitlement. However, employment opportunities and wages have taken the center stage, while development of infrastructure and community assets is neglected.
Other social assistance programs
The Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security measures for the unorganized sector (91% of India's workforce). The National Old Age Pension scheme has provided social and income security to the growing elderly population in India.
Population stabilization: There is all round realization that population stabilization is a must for ensuring quality of life for all citizens. Formulation of a National Policy and setting up of a National Commission on Population and Janasankhya Sthiratha Kosh reflect the deep commitment of the government. However, parallel developments in women empowerment, increasing institutional deliveries and strengthening health services and infrastructure hold the key to population control in the future.
Private sectors, civil societies and global partnerships: Effective addressing of public health challenges necessitates new forms of cooperation with private sectors (public-private partnership), civil societies, national health leaders, health workers, communities, other relevant sectors and international health agencies (WHO, UNICEF, Bill and Melinda Gates foundation, World Bank).
1. Population growth: India has the world’s second-largest population, rising from 760 million in 1985 to an estimated 1.3 billion in 2015. Migrants from rural areas continue to flock to urban settlements; roughly 32% of them inhabiting cities–although estimates of this migration vary–that are already bursting at the seams.
2. Infrastructure: India’s existing healthcare infrastructure is just not enough to meet the needs of the population. The central and state governments do offer universal healthcare services and free treatment and essential drugs at government hospitals. However, the hospitals are, as we said, understaffed and under-financed, forcing patients to visit private medical practitioners and hospitals
3. Insurance: India has one of the lowest per capita healthcare expenditures in the world. Government contribution to insurance stands at roughly 32%, as opposed to 83.5% in the UK. The high out-of-pocket expenses in India, as we detailed earlier, stem from the fact that 76% of Indians do not have health insurance, according to data from the Insurance Regulatory and Development Authority.
4. Rural-urban disparity: The rural healthcare infrastructure is three-tiered and includes a sub-center, primary health center (PHC) and CHC. Indian PHCs are short of more than 3,000 doctors, with the shortage up by 200% over the last 10 years to 27,421, as IndiaSpend reported in 2016.
Potential Opportunities to Improve Healthcare in India
The Union Budget 2017–18 includes measures to boost rural development, infrastructure and macroeconomic stability, and although the health budget has been increased 27%, allocations could have been matched more holistically with the government’s ambitions, particularly when considering adjustment against inflation and new health-program announcements.
The national insurance scheme (the Rashtriya Swasthya Suraksha Yojana) is a minor improvement on the existing one, with the annual limit per family increased from Rs 30,000 to Rs 100,000, with an additional “top-up” of Rs 30,000 for senior citizens.
Information Technology (IT) is set to play a big role with IT applications being used for social- sector schemes on a large scale. Beneficiaries are issued a biometric-enabled smart card containing their fingerprints and photographs. Hospitals empaneled under the government insurance scheme are IT enabled and connected to servers in districts. Beneficiaries can use a smart card that allows them to access health services in any empaneled hospital across India.
The ministry of health and family welfare launched several new computer and mobile-phone based e-health and m-health initiatives like the Swastha Bharat mobile application for information on diseases, symptoms, treatment, health alerts and tips; ANMOL-ANM online tablet application for health workers, e-RaktKosh (a blood-bank management information system) and India Fights Dengue.
Individual states are adopting technology to support health-insurance schemes. Eg. Remedinet Technology (India’s first completely electronic cashless health insurance claims processing network) has been signed on as the technology partner for the Karnataka Government’s recently announced cashless health insurance schemes.
The government’s National Innovation Council, which is mandated to provide a platform for collaboration amongst healthcare domain experts, stakeholders and key participants, should encourage a culture of innovation in India and help develop policy on innovations that will focus on an Indian model for inclusive growth.
Emergence of “frugal innovation” in the private sector — products and business models that offer quality diagnostics and care at a much more affordable price.
Tele-medicine, mobile clinic and mobile testing labs can help in proving basic facility to the remote places.
Making available Generic Medicines to the masses will help the poor people and also help maintain India as a major produce of generic medicines. Eg. Jan Aushadi pharmacy.
Healthcare delivery in India is now uniquely poised to undergo a change at all its stages – prevention, diagnosis, and treatment. No single entity in the healthcare sector can work in isolation.
The evolution of the sector calls for involvement from all stakeholders and the use of innovation to bridge intent and execution. India has the opportunity to leap-frog a lot of the healthcare problems that developed nations are grappling with, such as unlinked electronic medical records and overspending.
Social determinants of health and economic issues must be dealt with a consensus on ethical principles – universalism, justice, dignity, security and human rights. This approach will be of valuable service to humanity in realizing the dream of Right to Health.
It is true that a lot has been achieved in the past: The milestones in the history of public health that have had a telling effect on millions of lives – launch of Expanded Program of Immunisation in 1974, Primary Health Care enunciated at Alma Ata in 1978, eradication of Smallpox in 1979, launch of polio eradication in 1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few.
School health, mental health, referral system and urban health remain as weak links in India's health system, despite featuring in the national health policy. Mental health has remained elusive even after implementing the National Mental Health Program.
With unique challenges that threaten the health and well-being of the population, for a future of healthy India, it is imperative that the government and community collectively rise to the occasion and face these challenges together, in a sustainable way.