|Year : 2017 | Volume
| Issue : 2 | Page : 65-68
Challenging times for public health towards attaining sustainable development goals
K Sujatha Rao
Former Union Secretary MOHFW, Govt of India and author of “Do We Care? India's Health System”
|Date of Web Publication||26-Apr-2017|
K Sujatha Rao
Former Union Secretary MOHFW, Govt of India and author of “Do We Care? India's Health System”
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rao K S. Challenging times for public health towards attaining sustainable development goals. Indian J Community Med 2017;42:65-8
|How to cite this URL:|
Rao K S. Challenging times for public health towards attaining sustainable development goals. Indian J Community Med [serial online] 2017 [cited 2017 Nov 20];42:65-8. Available from: http://www.ijcm.org.in/text.asp?2017/42/2/65/205210
| Introduction|| |
Despite 7 decades of development resulting in the trebling of incomes and improved access to good-quality care, yet India has been unable to make a decisive epidemiological transition. Unlike China or Sri Lanka that too had an impoverishing colonial past, India still has a substantial burden of communicable diseases that accounts for 36% of the country's and almost a fifth of the global disease burden. India is yet to eliminate leprosy and kala azar. While in the initial decades, we did well in bringing down caseloads due to malaria from an estimated 75 million in 1947 to about 2 million by 1976, we still have substantial mortality and morbidity. Dhingra et al. in 2010 estimated that India has over 120,000 deaths (15-69 years age) due to malaria that were halved by a specially constituted Committee of Experts. Though of late, deaths are falling, yet we still have a long way to go compared with Sri Lanka that has not reported a single death in the recent past. In addition, new variants of vector-borne diseases, such as dengue and chikungunya seem to be crowding our landscape further, in the midst of rising apprehensions of resurgent tuberculosis. It is feared that if unchecked, India could account for substantial percentile of global multidrug-resistant tuberculosis cases by 2022.
This inability to cross the epidemiological threshold is reflective of a weak capacity to deal with infectious diseases and a failure of the health system. This is worrisome as like never before, the world is becoming a less secure place if we go by the rash of global epidemics that we witnessed in the last decade–SARS, H1N1, H5N1, avian flu, Ebola, and Zika, forcing WHO to announce public health emergency on two occasions. The point that no armies or border controls can ensure health security have heightened concerns of our vulnerability, shifting focus to building country's capacities to face challenges of global health in an increasingly interdependent world.
| Public health and noncommunicable diseases|| |
Since noncommunicable diseases (NCDs) are triggered largely on account of lifestyles, such as unhealthy diets and lack of exercise or overconsumption of tobacco and alcohol, it is normally assumed that the poor are not affected. Evidence not only shows that the poor too suffer from these diseases, undoubtedly to a lesser extent than the better off sections, but also face disproportionately greater financial hardship. Simplistic notions then resulted in the delayed response of the government in crafting a comprehensive policy of prevention and early diagnosis of NCDs, such as hypertension, diabetes, cancer, or asthma and mental disorders alongside our efforts to handle communicable diseases. And just as communicable diseases can be averted and effectively treated at an incredibly low cost; NCDs too can be prevented and if detected early, managed.
Need for primary care: Lesson for India
Tackling India's dual burden would require an understanding of India's history. The decision to abandon comprehensive primary care as envisioned in Alma Ata in 1978 and elaborated in the first National Health Policy of 1983 was unfortunate. In addition, four other factors contributed to achieving less than expected outcomes: one, the infirmities in the design of our disease control policies, focusing more on technology than paying attention to behavior change. Reasons for less than expected outcomes include low attention to underlying social determinants, failure to develop appropriate institutional mechanisms to implement strategies, chronic underfunding resulting in large vacancies and the disbandment of public health cadres. As the examples of malaria, TB and HIV/AIDS control show, a people and community centered primary care has to be the foundation of the country's health system. Community participation is essential, be it in effecting behavior change for the use of long lasting insecticide bed nets or good adherence to treatment. In other words, it is argued that given the limitation of vertical disease control program approaches, what is needed is reconstructing the battered primary health care system.
| Public health and the National Health Policy 2017|| |
The recently released National Health Policy (NHP) of the Government of India then needs to be examined within the backdrop detailed above.
The NHP 2017 has reiterated Government's serious commitment to public health. Embedded within the overarching ambition to achieving Universal Health Coverage by 2025 is the assurance to comprehensive primary care to all. Quantifiable and measurable goals have been laid down. The foundation for the primary care system is to be the chain of subcenters upgraded as health and wellness centers, endowed with capacity to provide the full range of preventive and promotive services to avert diseases and enhance well-being. The need to improve information and strengthen disease surveillance has been recognized. For addressing the serious shortage of human resources, the NHP has proposed a three-pronged approach consisting of reviving the multipurpose male worker cadre, empowerment of ASHA's to undertake preventive education at the community level and training AYUSH doctors, nurses and paramedics for six months on public health to position them in the wellness centers.
While the NHP does strongly assert that primary health care will be provided by the public sector, it also provides for private, nongovernment actors to participate. While access to urban primary care is to be assured by incentivizing social enterprises and the private sector, in the underserved rural areas, the policy seeks to closely collaborate with the private sector for gap filling. Such collaboration also envisages training the private sector providers and partnering with them for obtaining reports on infectious diseases treated by them.
The fault lines
The NHP 2017 has four major fault lines. First is the mismatch between the ambition in the text and the amounts being allocated. India is one of the 15 countries in the world that has public spending as low as 1.15% of gross domestic product (GDP). On primary care, public investment is barely $17 per capita. International estimates prepared for the Sustainable Development Goal 3's target of universal health coverage to essential care by 2030 is about $85 per capita. Because of such low public investment, India's primary health care infrastructure is poorly developed and where available, underutilized, for example, providing a bare 15% of the services to under-5 children.
Second is the lack of clarity on the role of the state. The policy states that the primary provider of primary care services will be government, but elsewhere also provides room for nongovernment actors. Primary care markets are highly competitive and there is enough evidence to show how the public and private sectors cannot coexist in the same space. Invariably, the public sector is undermined, also because of the provision for government doctors being permitted private practice, creating conflicts of interest. Besides, no mention has been made to ensure that by law, the private sector has to follow the treatment protocols and submit periodic reports on the patients being treated for infectious diseases. Such weak oversight is reason for the growing multidrug resistance on the one hand and the outbreak of wild polio traces in Hyderabad and Gujarat on the other.
Third is the weak commitment made to building the required infrastructure in urban and rural areas for delivering primary health care services. Though the NHP does reaffirm the desire to achieve the Indian Public Health Standards (IPHS), it fails to assess the fiscal implications in doing so. As per the data furnished by the Ministry, bridging the infrastructure gaps to achieve IPHS would need Rs 1.5 lakh crores of which about Rs 1 lakh crore is only toward capital expenditures. Against such a substantial requirement, government over the years under the National Rural Health Mission has barely spent 15%.
Finally, the NHP seeks to focus on the community health worker for prevention and diagnosis of NCDs including mental health counseling. The enormities of the logistics involved, the social implications, and over all feasibility are daunting. Clearly, there is some amount of simplification as the NHP does not offer any institutional mechanisms to address the needs of training, supervision, procurement, and timely supply of diagnostic kits, accounting, reporting, and oversight for quality over a million units.The approach also appears to be ahistorical as reasons why the 2010 model of equipping and enhancing capacity at the community health centers by a team consisting of a medical doctor, health workers, physiotherapists, and so on to screen, identify, and diagnose NCDs did not really take off have not been examined.
The choice to neglect primary care or infectious diseases control and public health is getting narrow by the day. Any further neglect will entail adverse implications. There is considerable evidence to demonstrate the devastating economic impact of infectious disease epidemics as seen in SARS in China and Ebola in Sierra Leone, Guinea, and Liberia.
Unlike common perception, primary care is neither low cost nor easy to implement. Primary care has been defined by Starfield as “that aspect of a health services system that assures person focused care over time to a defined population, accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only rare or unusual manifestations of ill health are referred elsewhere, and coordination of care such that all facets of care (wherever received) are integrated.”
On the face of it, this definition sounds simple, logical, and reasonable. But in implementation, it is far more challenging and complex than running a nursing home. Primary care deals with a large amount of uncertainty and a wide set of variables and possibilities that may range from genetic, behavioral, and environmental to cultural, calling for alertness, and timely referrals. This is why primary care is neither low cost nor is it something that paramedics can do all by themselves without the support of the qualified medical doctors. Infact, primary care requires expertise in disease surveillance, family health, linkages with social determinants, communication with communities and marginalized sections of society, home nursing, and so on requiring laboratories and a range of skills-a multidisciplinary team consisting of public health physicians, epidemiologists, nurses, counselors, physiotherapists, laboratory technicians, entomologists, ophthalmic assistants, community, and social psychology etc. India has to take a long-term perspective and steadily and seriously work toward building this system brick by brick rather than waste time with short-term solutions that have failed repeatedly.
While there is little evidence to empirically demonstrate the effectiveness of primary care deserving of resources and policy attention, data from other countries show how critical and effective it is in promoting good health and reducing disease and the attendant costs. For example, US data shows that over a decade of focusing on primary care, there was a 36% reduction in hospital days, 42% reduction in emergency, and a 25% increase in childhood immunizations. Similarly, the Family Health Program of Brazil implemented during the decade 2000-2010 showed that for every 100,000 population in the age group 24-74 years, there was a reduction in number of cardiovascular disease cases from 40 to 27, heart diseases from 23.3 to 12.4, and a reduction in hospitalization from 3.32 to 2.83. Since high costs are making hospital care unsustainable, comprehensive primary care to prevent, avert, and manage disease at the early stages is emerging as a global priority.
Clearly, the evidence points toward the need for India with its low-resource base to prioritize primary care and infectious disease control in the first instance. Second, there is a need to restructure the institutional framework for public health. Reports prepared in 1995 had suggested that there should be a Director General for Public Health, recruited from the open market and a whole directorate for Public Health. There is also the long pending demand for a Department for Public Health. It is only when such focus is provided that a systematic and emphatic approach to the multidimensional nature of public health can and will be possible. The Ministry of Health needs to get out of the comfort zone of denial and squarely assess the needs and demands of the public health discipline.
Third is the need for laws-a public health law to regulate and make all stakeholders, including citizens, accountable. The recently drafted public health law is more in the mould of the old colonial law where the citizen's privacy in the name of disease control can be violated with impunity. Such an approach failed under the British, it will fail now. Instead, clear line of accountability on communities, local bodies, related departments, health workers, providers of care, pharmacists, and so on is needed so as to achieve the required comprehensive approach to primary health care.
| Conclusion|| |
Public health measures do help avert disease and reduce mortality. Prevention, promotion, and early diagnosis of disease is the only cost-effective option left for India that is unable to spend more than 1-1.5% of its GDP on health in the near future. With such low resources, having a system that is based on treatment and hospitalization is neither affordable nor feasible. It is an imperative, not choice, for India to single-mindedly focus on achieving the challenging goal of assured comprehensive primary health care to all. This is the prerequisite for making the epidemiological transition. As the implications of neglect can be severe, it is hoped that the long-pending issues related to public health will get the attention they deserve.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dhingra N, Jha P, Sharma VP, Cohen AA, Jotkar RM, Rodriguez PS, et al
. Adult and child malaria mortality in India: a nationally represented mortality survey. Lancet 2010;376:1768-84.
Ministry of Health and Family Welfare, Government of India. National Health Policy 2017.
Chatham House. The Royal Institute of International Affairs, London “Shared Responsibility for Health: A Coherent Global Frameworkfor Health Financing. Final Report of the Centre in Global Health Security. Working Group on Health Financing; May 2014.
Prinja S, Bahuguna P, Mohan P, Mazumder S, Taneja S, Bhandari N, et al
. Cost Effectiveness of Implementing Integrated Management of Neonatal and Childhood Illnesses Program in District Faridabad, India. PLoS One 2016;11:e0145043.
World Bank, 2014 Ebola: Economic Impact Could be Devastating. Washington, USA; 2014.
Starfield B, Basic concepts in population health and health care. J Epidemiol Community Health 2001;55:452-4.
Sugarman JR, Presentation on primary care. The Global Partners' Forum. Seattle, USA; 2016.
Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML, Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014;349:g4014.
Ministry of Health and Family Welfare on Restructuring of the DGHS-A Report by the Administrative Staff College of India. 1995.