When the Prime Minister announced, in his Independence Day address of 2011, that health would be among the foremost priorities of the 12th Five-Year Plan (2012-17), it was both an admission that health has been hitherto an area of great neglect and a promise that policy would now accord it the priority it deserved. Are we now on that path?
With an infant mortality rate (IMR) of 44 per 1,000 live births, we now appear to be on track to reach close to, though not attaining, the 12th Plan goal of 25 per 1,000 live births by 2017. While the National Rural Health Mission (NRHM) has accelerated the decline in overall IMR, the relatively intransigent neo-natal mortality rate needs a focused effort. Maternal mortality ratio is still too high, at 212 per 100,000 births, to bring the 12th Plan goal of 100 within easy reach.
While NRHM has markedly increased the number of institutional deliveries through a series of incentives, the quality of care at public health facilities where women deliver needs to be improved. This calls for more and better trained professionals, improved infrastructure and drug supply, and measures of accountability assessed through technical and social audits.
The 12th Plan proposes to expand the NRHM into the National Health Mission (NHM) by adding an urban component. This recognises the vulnerability of the urban poor, many of whom are rural migrants carrying the health problems of their past and acquiring the disorders of their present locale. The NHM also provides for progressive integration of many vertical health programmes. It will also influence determinants like water, sanitation, nutrition, and environment.
The appalling spectre of childhood malnutrition and anaemia among women and children will have to be tackled through convergence of health and developmental programmes which range from food security and clean drinking water to a revamped Integrated Child Development Scheme that assures good nutrition during the first 1,000 days of life (conception to two years of age), in addition to the existing schemes for the children.
The mounting menace of non-communicable diseases (cardiovascular disorders, cancers, mental illness etc) should also receive greater attention. These diseases now threaten persons in all socio-economic strata and impose high health and economic burdens due to untimely death or prolonged disability. Prevention of these diseases needs more than a mere medical response, calling for policies that decrease tobacco consumption, promote healthy food and enable physical activity even in crowded environments.
Public financing of health, pitifully small so far, will rise from 1.05% to 1.85% of GDP during the 12th Plan. While still insufficient, the rise should be used to strengthen the public health care system and provide financial protection to people who are presently crushed by a high out-of-pocket expenditure (71% of all health care). Primary health care should be prioritised, since that is the greatest need of the vast majority and, if effectively delivered, will substantially reduce the demand for secondary and tertiary care. District hospitals too should be strengthened and linked to medical and nursing colleges.
The proposal to provide essential drugs, in their generic form, free of cost at all public facilities, is most welcome, since expenditure on drugs is a major component of unaffordable health cost borne by individuals. The existing centre or state funded health insurance schemes should be integrated into the broad framework of Universal Health Coverage (UHC) which provides an entitlement to a range of essential health services, including both in-hospital and out-patient care.
A multi-layered health workforce is needed to deliver these services across the country. Non-physician health care providers (community health workers, paramedics and nurses) will have to be deployed in large numbers to strengthen primary and secondary care, even as specialist doctors are produced to meet the needs of tertiary care.
Family medicine has to grow as a specialty geared to the needs of primary care. Public health and health management cadres should be created, to improve the design and delivery of health programmes. India’s strength in IT should be harnessed to bridge geographical and skill gaps and extend primary health services to underserved areas.
We do not need to look far for inspiration or to believe that this dream can be realised. Kerala (with its strong action on social determinants) and Tamil Nadu (with its efficient public health system) are role models within India. Even in our immediate neighbourhood, Sri Lanka, Bangladesh and now Nepal are demonstrating how robust public health systems can improve health in many dimensions. With political will, backed by professional skill, India’s health can be transformed over the next decade.
K Srinath Reddy heads the Public Health Foundation of India. He is the President-Designate, World Heart Federation and chairs the Planning Commission’s high level expert group on Universal Health Coverage.