Topic: Think differently about healthcare
Topic in Syllabus: GS Paper 1: Indian Society
In India, public health and health services have been synonymous. This integration has dwarfed the growth of a comprehensive public health system, which is critical to overcome some of the systemic challenges in healthcare.
- India’s public health workforce come from an estimated 51 colleges that offer a graduate programme in public health. This number is lower at the undergraduate level.
- In stark contrast, 238 universities offer a Master of Public Health (MPH) degree in the U.S.
- In addition to the quantitative problem, India also has a diversity problem.
- A diverse student population is necessary to create an interdisciplinary workforce.
- The 2017 Gorakhpur tragedy in Uttar Pradesh, the 2018 Majerhat bridge collapse in Kolkata, air pollution in Delhi and the Punjab narcotics crisis are all public health tragedies.
- In all these cases, the quality of healthcare services is critical to prevent morbidity and mortality.
- However, a well organised public health system with supporting infrastructure strives to prevent catastrophic events like this.
Healthcare System in India:
- India has a vast health care system, but there remain many differences in quality between rural and urban areas as well as between public and private health care.
- Despite this, India is a popular destination for medical tourists, given the relatively low costs and high quality of its private hospitals.
- International students in India should expect to rely on private hospitals for advanced medical care.
- Studying in India offers a number of health challenges that students from developed countries may be unused to, so it is important to know how the health care system in India operates in the event you need it.
- Health care in India is a vast system and can be much like the rest of the country full of complexity and paradoxes.
History of healthcare in India:
- India’s Ministry of Health was established with independence from Britain in 1947.
- The government has made health a priority in its series of five-year plans, each of which determines state spending priorities for the coming five years.
- The National Health Policy was endorsed by Parliament in 1983. The policy aimed at universal health care coverage by 2000, and the program was updated in 2002.
- The health care system in India is primarily administered by the states.
- India’s Constitution tasks each state with providing health care for its people.
- In order to address lack of medical coverage in rural areas, the national government launched the National Rural Health Mission in 2005.
- This mission focuses resources on rural areas and poor states which have weak health services in the hope of improving health care in India’s poorest regions.
Problem of Health Literacy:
- Legislation is often shaped by public perception.
- While it is ideal for legislation to be informed by research, it is rarely the case.
- It is health literacy through health communication that shapes this perception.
- Health communication, an integral arm of public health, aims to disseminate critical information to improve the health literacy of the population.
- The World Health Organisation calls for efforts to improve health literacy, which is an independent determinant of better health outcome.
- India certainly has a serious problem with health literacy and it is the responsibility of public health professionals to close this gap.
Private and Public Health care:
- The health care system in India is universal. That being said, there is great discrepancy in the quality and coverage of medical treatment in India.
- Healthcare between states and rural and urban areas can be vastly different. Rural areas often suffer from physician shortages, and disparities between states mean that residents of the poorest states, like Bihar, often have less access to adequate healthcare than residents of relatively more affluent states.
- State governments provide healthcare services and health education, while the central government offers administrative and technical services.
- Lack of adequate coverage by the health care system in India means that many Indians turn to private healthcare providers, although this is an option generally inaccessible to the poor.
- To help pay for healthcare costs, insurance is available, often provided by employers, but most Indians lack health insurance, and out-of-pocket costs make up a large portion of the spending on medical treatment in India.
- On the other hand private hospitals in India offer world class quality health care at a fraction of the price of hospitals in developed countries.
- This aspect of health care in India makes it a popular destination for medical tourists.
- India also is a top destination for medical tourists seeking alternative treatments, such as ayurvedic medicine.
- India is also a popular destination for students of alternative medicine.
Challenges in Healthcare Sector:
- Population: India has the world’s second-largest population, rising from 760 million in 1985 to an estimated 1.3 billion in 2015. India added 450 million people over the past 25 years.
- Infrastructure: The existing infrastructure is not enough to serve the needs of the growing population. The public healthcare institutions are under-financed and short staffed. The doctor to patient ratio is dismal at 1:1700. India compares unfavourably with China and US in the number of hospital beds and nurses. The country is 81 percent short of specialists at rural community health centres (CHCs), and the private sector accounts for 63 percent of hospital beds.
- Rural-Urban disparity: Rural India accounts for 70% of the population but accounts for only 30% of the healthcare services. This shows a huge demand-supply gap in the rural areas. Private sector is highly concentrated in urban India while PHCs are short of more than 3,000 doctors. Majority of healthcare professionals are concentrated in urban areas.
- Low government spending: Public expenditure on health accounts for only 1.2% of the total health expenditure which is abysmally low when compared to WHO recommendation of 5%.
- High out of pocket expenditure: Out of pocket expenses account for 62% of the expenditure which is very high when compared to 13.4% in US, 10 percent in UK and 54% in China.
- Insurance: 76% of Indians do not have health insurance. Government contribution to insurance is just 32%. Low insurance penetration forces people to spend out of pocket.
- Dual disease burden: While the problems of Maternal, infant mortality, communicable diseases still exist lifestyle diseases like hypertension, diabetes are on rise. This situation has been termed as Dual disease burden. Lifestyle diseases accounted to half of all deaths in 2015.
- Malpractices in the sector: Selling substandard and counterfeit medicines, unnecessary hospital admissions and exploitation.
- Adequate attention has not been given to alternative healthcare practices like Homeopathy, Ayurveda, Unani.
National Health Policy 2017:
- The National Health Policy of 1983 and the National Health Policy of 2002 have served well in guiding the approach for the health sector in the Five-Year Plans.
- The current context has however changed in four major ways. First, the health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases.
- The second important change is the emergence of a robust health care industry estimated to be growing at double digit.
- The third change is the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty.
- Fourth, a rising economic growth enables enhanced fiscal capacity.
- Therefore, a new health policy responsive to these contextual changes is required.
- The National Health Policy, 2017 (NHP, 2017) seeks to reach everyone in a comprehensive integrated way to move towards wellness.
- It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.
- The policy envisages as its goal the attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence.
- This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.
- Improve health status through concerted policy action in all sectors and expand preventive, promotive, curative, palliative and rehabilitative services provided through the public health sector with focus on quality.
Specific Quantitative Goals and Objectives:
1) Health Status and Programme Impact
Life Expectancy and healthy life:
- Increase Life Expectancy at birth from 67.5 to 70 by 2025.
- Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022.
- Reduction of TFR to 2.1 at national and sub-national level by 2025.
Mortality by Age and/ or cause:
- Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
- Reduce infant mortality rate to 28 by 2019.
- Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
Reduction of disease prevalence/ incidence:
- Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i.e, – 90% of all people living with HIV know their HIV status, – 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
- Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
- To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
- To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels.
- To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.
2) Health Systems Performance
Coverage of Health Services:
- Increase utilization of public health facilities by 50% from current levels by 2025.
- Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by 2025.
- More than 90% of the newborn are fully immunized by one year of age by 2025.
- Meet need of family planning above 90% at national and sub national level by 2025.
- 80% of known hypertensive and diabetic individuals at household level maintain “controlled disease status” by 2025.
Cross Sectoral goals related to health:
- Relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025.
- Reduction of 40% in prevalence of stunting of under-five children by 2025.
- Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).
- Reduction of occupational injury by half from current levels of 334 per lakh agricultural workers by 2020.
- National/ State level tracking of selected health behavior
3) Health Systems strengthening
- Increase health expenditure by Government as a percentage of GDP from the existing 1.1 5 % to 2.5 % by 2025.
- Increase State sector health spending to > 8% of their budget by 2020.
- Decrease in proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.
Health Infrastructure and Human Resource:
- Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts by 2020.
- Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
- Establish primary and secondary care facility as per norm s in high priority districts (population as well as time to reach norms) by 2025.
Health Management Information:
- Ensure district – level electronic database of information on health system components by 2020.
- Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
- Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.
4) Policy thrust
- Ensuring Adequate Investment – The policy proposes a potentially achievable target of raising public health expenditure to 2.5% of the GDP in a time bound manner.
- Preventive and Promotive Health – The policy identifies coordinated action on seven priority areas for improving the environment for health:
- The Swachh Bharat Abhiyan
- Balanced, healthy diets and regular exercises.
- Addressing tobacco, alcohol and substance abuse
- Yatri Suraksha – preventing deaths due to rail an d road traffic accidents
- Nirbhaya Nari – action against gender violence
- Reduced stress and improved safety in the work place
- Reducing indoor and outdoor air pollution
- Organization of Public Health Care Delivery – The policy proposes seven key policy shifts in organizing health care services.
Probable Solutions for healthcare system:
Need an interdisciplinary approach:
- A stark increase in population growth, along with rising life expectancy, provides the burden of chronic diseases.
- Tackling this requires an interdisciplinary approach.
- An individual-centric approach within healthcare centres does little to promote well-being in the community.
- Tight laws, regulations around food and drug safety, and policies for tobacco and substance use as well as climate change and clean energy are all intrinsic to health.
- But they are not necessarily the responsibilities of healthcare services.
- As most nations realise the vitality of a robust public health system, India lacks a comprehensive model that isn’t subservient to healthcare services.
Strong academic programmes are critical for interdisciplinary approach:
- Public health tracks range from research, global health, health communication, urban planning, health policy, environmental science, behavioural sciences, healthcare management, financing, and behavioural economics.
- In the U.S., it is routine for public health graduates to come from engineering, social work, medicine, finance, law, architecture, and anthropology.
- This diversity is further enhanced by a curriculum that enables graduates to become key stakeholders in the health system.
- Hence, strong academic programmes are critical to harness the potential that students from various disciplines will prospectively bring to MPH training.
Investments in health/social services take precedence over public health expenditure:
- While benefits from population-level investments are usually long term but sustained, they tend to accrue much later than the tenure of most politicians.
- This is often cited to be a reason for reluctance in investing in public health as opposed to other health and social services.
- This is not only specific to India; most national health systems struggle with this conundrum.
- A recent systematic review on Return on Investment (ROI) in public health looked at health promotion, legislation, social determinants, and health protection.
- They opine that a $1 investment in the taxation of sugary beverages can yield returns of $55 in the long term.
- Another study showed a $9 ROI for every dollar spent on early childhood health, while tobacco prevention programmes yield a 1,900% ROI for every dollar spent.
- The impact of saving valuable revenue through prevention is indispensable for growing economies like India.
System of evaluating National programmes:
- Equally important is a system of evaluating national programmes.
- While some fail due to the internal validity of the intervention itself, many fail from improper implementation.
- Programme planning, implementation and evaluation matrices will distinguish formative and outcome evaluation, so valuable time and money can be saved.
- A central body along the lines of a council for public health may be envisaged to synergistically work with agencies such as the public works department, the narcotics bureau, water management, food safety, sanitation, urban and rural planning, housing and infrastructure to promote population-level health.
- The proposed council for public health should also work closely with academic institutions to develop curriculum and provide license and accreditation to schools to promote interdisciplinary curriculum in public health.
- As international health systems are combating rising healthcare costs, there is an impending need to systematically make healthcare inclusive to all.
- While the proposed, comprehensive insurance programme Ayushman Bharat caters to a subset of the population, systemic reforms in public health will shift the entire population to better health.
- Regulatory challenges force governments to deploy cost-effective solutions while ethical challenges to create equitable services concerns all of India.
Discuss the systemic challenges in healthcare system and enumerate the suggestions for addressing the challenge?