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India's basic services very weak, it's time we promote health equity

Unfortunately, we have arrived at a very lopsided stage of development in health: our basic services are very weak but we can boast of several strengths in advanced health care.

india Updated: Oct 06, 2014 15:32 IST

Political will is even more important than professional skill for addressing India's health in the next decade. There should be political will to elevate health to the top tier of the national development agenda. Economy, equity and electability together will constitute the will. Recognition that it is necessary to invest in health for accelerating economic growth has finally become an axiom of global development. It is now influencing our national development agenda.

The imperative of promoting health equity, to bridge huge gaps in major health indicators across different social, geographic and gender groups, is a call to conscience that politicians recognise and respond to, whether on their own or through pressure exerted by civil society. Health is also now becoming an important electoral issue, with provision of essential health services generating political popularity and electoral gains. The recent election of Joko Widodo as President of Indonesia has been mostly attributed to the popularity of the universal health coverage (UHC) he introduced as Governor of Jakarta. In India, we are seeing the stirrings of a similar response to health policies that please the people.

Even as health begins to take its rightful place in the framework of national development, we need to critically identify the fault lines in our previous policies and reassign priorities for resource allocation to health programmes. Now is the time to do so, since the government has announced its intent to develop a new health policy. The Prime Minister's Independence Day address did not include major initiatives on health (other than sanitation), despite his known commitment to increased investment in health. This suggests that careful thought is being given to setting down priorities before unveiling new initiatives in health. This is the right time, therefore, to debate key issues of our health policy.

Let us first look at the health pyramid, the mismatch of needs and gains, and the state of development at different levels of the structure since Independence. At the very base are the social and environmental determinants of health such as water, sanitation, nutrition and clean environment. Policies in other sectors influence these determinants which constitute the foundations of public health in any society.

Then come the layers of promotive, preventive and basic clinical services provided by well-designed and efficiently-delivered primary health care. Higher up the pyramid, but with smaller contributions to societal health, are secondary care services (such as those provided in district hospitals) and tertiary care services (such as those provided by well-equipped medical college hospitals and corporate hospitals). Paradoxically, the nation's gains in health diminish as we ascend the pyramid while the cost spirals up. There is no dispute that all of these layers are needed, each serving its purpose, but the big question is how we should prioritise our investments among those.

Unfortunately, we have arrived at a very lopsided stage of development in health: our basic services are very weak but we can boast of several strengths in advanced health care. This reflects a malaise in planning and implementation since Independence. While rural primary health care was prominently positioned as a design feature in health policy, low levels of resource allocation and poor governance led to people being deprived of basic health services, even as tertiary care capacity expanded in both public and private sectors.

Just as excitement about new centres of higher education masked the neglect of basic primary education in the eyes of policymakers, basic health care too receded from the radar screen of political attention as bright specks of gleaming new hospitals came in to view. Poor population health indicators, across the life course, now stare at us as the price of that neglect.

We need to provide correctives, by implementing pro-health policies in all sectors that have a vital impact on health at the wider population level and reinforcing basic health services as the keystone of a strengthened health care system. The emphasis on clean water and improved sanitation is entirely appropriate - it now needs effective implementation across the country.

Nutrition calls for a multi-sectoral response, to assure all Indians of diverse diets which not only provide adequate calories (energy) but also an appropriate balance of key nutrients, to meet differing needs at each stage of life. From water and sanitation to agriculture, food systems and trade, polices must ensure nutrition security so that we remove the shame of child under-nutrition and curb the rising burden of diabetes, heart diseases and cancers. Political will has also to be exerted to eliminate tobacco consumption in all forms and minimise harm from alcohol.

In revamping health services, primary health care in rural and urban areas must become the thrust area of the National Health Mission. This way, we can create a delivery system which optimally utilizes modern technologies while inviting communities to become informed and empowered participants. Technology-enabled Accredited Social Health Activist (ASHAs), nurses and community health workers can transform India's neglected primary health care by increasing outreach and effectiveness of service delivery. Hand-held tablets with point-of-care diagnostics and decision support systems as well as mobile phone applications can empower frontline health workers. This will also create huge employment opportunities for young people, especially women from rural areas.

While primary health care needs to be substantially strengthened, from sub-centres to community health centres, higher levels of care need to be provided at district hospitals. These should be upgraded and linked with both primary care and advanced tertiary care. This requires improvement of infrastructure, equipment and staffing at district hospitals. In states which have less than needed number of medical and nursing colleges, new colleges should be attached to the revamped district hospitals. Indian systems of medicine such as AYUSH need to be integrated into the health services, at all levels of care.

All citizens must be provided financial protection against the impoverishing effects of health care through a combination of financing mechanisms: increased public expenditure on health (especially primary health care); mandatory employer-provided insurance in the organised sector and a single nationally portable scheme. This national scheme should be a progressive integration of central and state funded health insurance schemes designed to deliver an essential health package in both out-patient and in-hospital care. Integrated primary, secondary and tertiary care should be delivered through district level networks. In this, public and private health care providers can be combined under a government-managed universal health care framework.

All public health facilities must provide people with prioritised drugs that are in the National List of Essential Medicines (NLEM), in a generic form. They should also be assured of free point of care or essential diagnostic services. This will have an immediate benefit of lowering Out Of Pocket Spending (OOPS) which is presently very high, around 70%, and is largely driven by expenditure on medicines. Basic diagnostic services can now be performed through portable diagnostic devices which can be provided to frontline health workers.

A national commission on human resources for health must be created. Its mandate should be to reform and govern the standards and accreditation of medical, dental, nursing and allied health professional education, while also providing opportunities for innovative models of inter-professional education. This is the only hope for revitalising fossilised and poorly-governed health training programmes. India needs more specialist doctors, basic doctors, specialist nurses, general nurses, several categories of allied health professionals and community health workers. The promised national health assurance programme will succeed only if a multi-layered, multi-skilled and motivated workforce is created to deliver the health services. Robust systems must be created for gathering and processing health information as also for regulation of drugs, devices and clinical establishments.

There are about 6.4 million jobs that are even now potentially available to different categories of allied health professionals ranging from optometrists and laboratory technicians to physiotherapists and mental health counsellors. These opportunities, in both private and public sectors, will only grow over the next 10 years. India has the youth power to train this workforce not only for itself but also for the rest of the world. The proposed national institute of allied health sciences and regional institutes of allied health sciences should be quickly established, with state-of-the-art training skill labs and simulation centres.

India's health planning as well as the design, delivery and evaluation of health programmes has suffered because of minimal investment in training and development of public health professionals. Tamil Nadu, the only state with a designated Public Health Cadre in its health services, has the best functioning health system. Public health training institutions have to be strengthened and expanded to create professionals who can be effectively utilised in central and state level public health cadres across the country.

Can we radically transform India's health system and improve our health indicators by 2022, when independent India turns 75? Some of the initiatives proposed above can be implemented soon, such as the provision of essential drugs and diagnostics. Others will take time, like enough doctors and nurses to meet the needs of an expanding health system. However, much can be achieved over the next 8 years, for the Prime Minister to proudly proclaim from the Red Fort that India's progress in health matches its economic development.

All it needs is political will, across the spectrum of governance at the centre and in the states.

(K Srinath Reddy, president of Public Health Foundation of India (PHFI), has been advisor or consultant at the World Health Organisation, among other institutions. He has taught at Harvard School of Public Health)

First Published: Oct 06, 2014 15:27 IST