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 Table of Contents    
EDITORIAL COMMENTARY  
Year : 2019  |  Volume : 44  |  Issue : 3  |  Page : 185-187
 

Why investing in public health is so critical


Former Regional Adviser and Director at World Health Organisation, Regional Office for South-East Asia, New Delhi, India

Date of Submission28-Jun-2019
Date of Acceptance26-Jul-2019
Date of Web Publication20-Sep-2019

Correspondence Address:
Dr. Jai Prakash Narain
F-20A, Hauz Khas Enclave, New Delhi - 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_271_19

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How to cite this article:
Narain JP. Why investing in public health is so critical. Indian J Community Med 2019;44:185-7

How to cite this URL:
Narain JP. Why investing in public health is so critical. Indian J Community Med [serial online] 2019 [cited 2019 Oct 18];44:185-7. Available from: http://www.ijcm.org.in/text.asp?2019/44/3/185/267348




Today, public health in India is at the crossroads. This fact is widely recognized by all stakeholders including those dealing with policy- as well as lawmakers. In fact, a former minister in the central government famously stated in 2012 that India's public health system has collapsed.[1] More unfortunate situation, however, is that in spite of this prevailing knowledge and understanding of the importance of public health, not much has been done to alter or improve the situation.

Not only public health remains neglected from policy and resource point of view, even the concept of public health is not understood properly by the decision makers nor by the public at large. It is not surprising, therefore, that public health infrastructure remains woefully weak and overstretched to the limit. The most critical bottleneck being the lack of human resource or public health workforce, especially in rural areas where the majority of India's population lives.

What exactly is public health and why is it important? Often defined as the science and art of preventing disease and promoting the health of people, public health is fundamental for prolonging and improving quality of life including of those at the bottom of the population pyramid.[2],[3] The three overarching principles of public health as described are protecting populations from risks and dangers to health by addressing modifiable determinants of health such as ensuring safety of food, water, physical, and social environment; addressing equity meaning that no one is denied life-saving health interventions or services of quality on the basis of his/her social, economic status or geographic location; and focusing on wellness or disease prevention in a population or a community. Clinical medicine, on the other hand, focuses on a patient already suffering from a disease condition.

As defined by the World Health Organization (WHO), health means the attainment of physical, mental, and social well-being and not merely the absence of disease or infirmity,[4] and like the WHO, the core functions of public health include providing leadership on matters critical to health; shaping research agenda and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical- and evidence-based policy options; and monitoring the health situation and assessing health trend.[5] Public health is, in fact, a public good. For example, strong public health capacity prevents or contains outbreaks of communicable diseases. These outbreaks have a potential to amplify into epidemics or pandemics and destroy the fragile economies of the developing countries. It goes without saying that economic development can be the result of improvements in the public health, and hence, investing in public health shall not only improve the quality of health but also boost the economy.[6] In that sense, a strong public health is a facilitator of human development.[7]

Challenges facing public health today

In spite of much progress made over the past decades in life expectancy and gradual reduction in infant mortality, numerous health challenges still confront India. The country is experiencing demographic, environmental, and an epidemiological transition, where along with unfinished agenda of infectious diseases, populations are also faced with the effects of chronic noncommunicable diseases such as cardiovascular diseases, diabetes, cancer, and chronic pulmonary diseases which are now the leading causes of death.

The fear of impending pandemics of influenza or any new and emerging infections which mostly are of zoonotic in origin is real which requires us to remain alert and stand by ready to detect and respond rapidly to such situations. Globalization, rapid and unplanned urbanization, and climate change will continue to challenge public health in the 21st century.

While India is the fastest-growing major economy in the world, there is enormous inequality and disparities in distribution of wealth, and the gap between the rich and poor is widening. Although universal health coverage (UHC)[8] or the national health protection concept [9] is being promoted and implemented in the country, the infrastructure and capacity to provide quality health services equitably, be it promotive, preventive or curative, to those who need it the most, remain weak and lackluster.

As a result, the vast populations, especially those living in rural and geographically remote areas, do not have access even to basic health care, with the poor and marginalized in the society as worst sufferers. Given that ill health is driven by social, economic, behavioral, and environmental factors which lie outside of health sector, public health action requires a broad multisectoral engagement.

In 2015, India and other 194 countries of the world agreed on the UN Sustainable Development Goals (SDGs) covering all aspects of human development.[10] One relates specifically to health and well-being, while many other goals too indirectly impact and address aspects of health. The link between SDGs and public health thus is well established.

In this regard, the public health of today is expected to take a lead role in formulating and advocating for policies that are inclusive and that help in improving health conditions in an equitable and sustainable manner, as outlined in UHC. Without inclusive growth and equitable distribution of health services, a country cannot develop and occupy its rightful position in the high table among nations of the world. SDGs in fact underpin the concept of UHC.

To address the above challenges, we need a public health in the country which is robust and battle ready, on a sustainable basis.

Myths and misconceptions

In spite of the obvious importance of public health, there are even today many misconceptions regarding public health which result is it not being given the priority it deserves.

Some of these are as follows:

Myth# 1: Public health is synonymous with medical or clinical care provided in a public sector setting.

As described above, public health has to do with preventing disease and promoting health and well-being of people and community. In the medical field on the other hand, clinicians focus on diagnosing and treating diseases in one patient at a time. However, a public health physician preventsdiseases by working with people and communities, identifying the causes of disease and disability, and providing evidence-based solutions as well as implementing large-scale prevention programs to bring diseases under control.

Myth# 2: Health of the people can be improved only by building many big hospitals.

Hospitals are indeed important for providing secondary and tertiary level health care for patients who are ill and need treatment. The tendency among policymakers often is to advocate for building large hospitals in the false perception that building hospitals are akin to imparting health and well-being. However, health has everything to do with prevention, health promotion, and early detection even before one becomes ill and requires hospitalization. For this, focus must shift to strengthening primary health care so that quality health services are accessible to people at a site closer to their home.

Myth# 3: Only doctors can improve public health and paramedical or other staff do not have an important role to play.

Today, public health encompasses as wide-ranging areas as vaccine-preventable diseases, communicable disease outbreaks, chronic disease, healthy aging, mental health, disaster preparedness and response, injury prevention, and tobacco control. Addressing such diverse activities need support not only of epidemiologists but also microbiologists, behavioral scientists, communication experts as well as nurses and paramedical staff. Public health, therefore, is a work of a team, cutting across many disciplines well beyond the health sector.

Myth# 4: Disease prevention and health promotion is cheap and hence require fewer resources.

In India, health receives a small proportion of the overall government budget – a mere 1.3% of the gross domestic product. This is among the lowest of all countries in Asia. The comparatively small investment gives a false impression that public health interventions, although cost-effective, are “cheap” and should require fewer resources. Based on the available evidence, it is clear that public health interventions can benefit greatly from significant and sustained government funding increase. After all, expenditure on public health must be considered a good investment with high returns!

The way forward

To address the situation going forward, the policymakers must first of all recognize the centrality of public health and its critical role in nation building. The lack of understanding of the role of public health leads to it being ignored and not given its due importance. In the name of health, politicians often announce opening of new hospital buildings, at considerable cost. Creation of tertiary hospitals or expenditure on sophisticated medical devices is, of course, important for providing diagnosis and treatment facilities, but this should not happen at the expense of investing on public health infrastructure and primary health care or addressing social determinants of health.

In fact, much greater investment is urgently needed to augment efforts to promote a healthy lifestyle to prevent diseases, strengthen disease surveillance programs, and enhance research capabilities in the country.

There is, therefore, a great need to advocate for greater policy support and financial investments for public health. Health is indeed essential to boost growth; a nation cannot hope to develop and prosper unless its population is healthy. India with a disproportionately high global burden of disease cannot develop economically to its fullest potential until its population is healthy and productive. Therefore, the government must invest more on public health! Of the meager current allocation for health, only 15% is spent on primary health care. This means that most of the health budget is going to build large hospitals for clinical care at the expense of health promotion and disease prevention. Isn't prevention better than cure?

The entire country as a nation must as a priority strengthen public health institutions along with the human resource in the overall context of the existing health system. The health system in the country is fragile and overstretched to the limit. The government health facilities are of poor quality plagued with lack of staff and facilities forcing poor to cater to private providers incurring high out-of-pocket expenditure. Lack of staff contributes not only in undermining quality but also equitable access to basic health care by the poor and most vulnerable populations. In fact, the primary responsibility of any government is to help the poorest of the poor and most marginalized in the society. The governments at the state level must formulate appropriate policies including provision of incentives and creation of an enabling environment that can help ensure that doctors, especially specialists, go and serve in the rural and remote tribal areas.

This issue is also pertinent as India is committed to achieving global goals such as UHC as a part of SDGs and has launched many path-breaking policy initiatives such as Ayushman Bharat including strengthening primary care by transforming subcenters and primary health centers into “health and wellness” centers, antimicrobial resistance policy, and digital health. Success of these ambitious policies and reforms is dependent entirely on the availability of adequate health workforce, especially public health professionals. Given the shortfall and inequitable distribution, the situation is extremely worrisome, especially at the primary care level, where the health workforce are needed the most. The decision-makers must carefully examine the issue and find sustainable solutions such as placing public health experts in and every community health center and district hospital.

The June 2019 acute encephalitis syndrome episode in Bihar demonstrates the health and political ramifications that can follow outbreaks associated with emerging and re-emerging infectious diseases. The ever-present threat of Ebola, SARS, influenza pandemics, and dengue outbreak year after year necessitate strengthening of epidemiological and laboratory core capacities in the country. The competency-based epidemiology training such as the India Epidemic Intelligence Service runs by the National Centre for Disease Control (NCDC) since 2012,[11] and other field epidemiology training programs are an excellent example which must be expanded so that ability to detect unusual events such as outbreaks early and respond rapidly is enhanced in all districts on a priority basis. Given the size and technical expertise available in the country, the government must strive to establish a world-class laboratory for each emerging infection, linked with other public health laboratories as a part of laboratory network. To bring about great efficiency and quality, NCDC will have to be made an autonomous body along the line of the Indian Council of Medical Research and free it from red tape so that it has freedom and leadership to make its own decisions and to collaborate with public health institutes in the country as well as in the Southeast Asia Regions.

Finally, public health needs to heal thyself. It is at present at best a divided and fragmented house; as the public health professionals have managed to create many disparate associations with their own office bearers working in silos, with little convergence or collaboration with other sister associations. Unless all these associations come under a common umbrella or a consortium and agree to work on a common cause of public health albeit keeping their identities intact, a united public health remains a pipe dream. Ideally, there should be one umbrella association, one overall identity or nomenclature, and one program of work. A uniform collective professional approach is the need of the hour.

In addition, the preventive and social medicine (or community medicine) departments in medical colleges and the national public health institutions presently working in isolation need to create a network. Such a network could facilitate the sharing of research findings and evidence generated for national policy making.

No wonder that the health domain in the government sector today is largely dominated by bureaucracy or administrators with little or no background of the field, pushing the public health experts or subject matter experts to the sidelines. The role of the Directorate General of Health Services – historically responsible for all public health programs in the country – too has diminished remarkably vis a vis the Ministry of Health. Such a duality is contributing to the demoralization of the entire public health cadre in the country.

In conclusion, health challenges facing the country are enormous. A robust public health system is, therefore, needed to protect populations from risks and dangers to health, ensure equity and social justice so that everyone everywhere can have equitable access to good quality health services, and to address the underlying causes of ill health in ways that provides population-wide protection and prevention. It is also clear that without a strong public health system, the SDGs can neither be achieved nor the national policy initiatives implemented effectively. Investing in public health is, therefore, not only a programmatic necessity but also an ethical imperative!



 
   References Top

1.
India's Public Health System has Collapsed. Jairam Ramesh on NDTV, 2012. Available from: https://www.ndtv.com/india-news/indias-public-health-system-has-collapsed-jairam-ramesh-504746. [Last accessed on 2019 Jun 25].  Back to cited text no. 1
    
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What is Public Health. Centers for Disease Control Foundation. Atlanta, GA: Centers for Disease Control. Available from: https://www.cdcfoundation.org/what-public-health. [Last accessed on 2019 Jun 27].  Back to cited text no. 3
    
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Constitution of the World Health Organization as Adopted by the International Health Conference, 1946. In World Health Organization Basic Documents. 48th ed; 2014. Available from: http://apps.who.int/gb/bd/PDF/bd48/basic-documents-48th-edition-en.pdf#page=7. [Last accessed on 2019 Jun 24].  Back to cited text no. 4
    
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World Health Organization. The Role of WHO in Public Health. World Health Organization. Available from: https://www.who.int/about/role/en/. [Last accessed on 2019 Jun 19].  Back to cited text no. 5
    
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Bloom DE, and Canning D. Population Health and Economic Growth. World Bank Group-Health and Growth; 2009. Available from: https://elibrary.worldbank.org/doi/abs/10.1596/978-0-8213-7659-1#page=79. [Last accessed on 2019 Jun 25].  Back to cited text no. 6
    
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World Health Organization. Macroeconomics and Health: investing in Health for Economic Development: Executive Summary/Report of the Commission on Macroeconomics and Health. Available from: https://apps.who.int/iris/handle/10665/42463. [Last accessed on 2019 Jun 20].  Back to cited text no. 7
    
8.
India Fast-Tracked Initiatives for Universal Health Coverage: Nadda. Economic Times; 03 September, 2018. Available from: https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/india-fast-tracked-initiatives-for-universal-health-coverage-nadda/articleshow/65659027.cms?from=mdr. [Last accessed 2019 Jun 24].  Back to cited text no. 8
    
9.
Narain JP. Is Ayushman Bharat a Game Changer? The Indian Express; 15 August, 2018. Available from: https://indianexpress.com/article/opinion/is-ayushman-bharat-a-game-changer-national-health-insurance-scheme-5054394/. [Last accessed on 2019 Jun 26].  Back to cited text no. 9
    
10.
United Nations Sustainable Development Goals, Adopted; 2015. Available from: https://sustainabledevelopment.un.org/?menu=1300. [Last accessed on 2019 Jun 21].  Back to cited text no. 10
    
11.
Narain JP. India epidemic intelligence service: Advocating for a unique mentor-based epidemiology training program. Indian J Public Health 2018;62:143-5.  Back to cited text no. 11
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