India's constitution guarantees free healthcare for all its citizens. All government hospitals are required to provide free of cost healthcare facilities to the patients. Each district headquarters in most states have one or more Government hospitals where everything from diagnosis to medicine is given for free. Most experts agree that building on these Government and public healthcare units across the nation is crucial to India's future while private insurance is probably not conducive to India's conditions. The private healthcare sector is responsible for the majority of healthcare in India. Most healthcare expenses are paid out of pocket by patients and their families, rather than through insurance. In fact, recent world health statistics have indicated that India has the highest out of pocket private healthcare costs for families, among many other comparable developing nations including Pakistan, Sri Lanka, and Mexico. Penetration of health insurance in India is low by international standards. Private health insurance schemes, which constitute the bulk of insurance schemes availed by the population, do not cover costs of consultation or medication. Only hospitalisation and associated expenses are covered.
Public healthcare is free for those below the poverty line. The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status. However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Most of the public healthcare caters to the rural areas; and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation.
Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved. Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.
Following the 2014 election which brought Prime Minister Narendra Modi to office, Modi's government unveiled plans for a nationwide universal health care system known as the National Health Assurance Mission, which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments. In 2015, implementation of a universal health care system was delayed due to budgetary concerns.
With the help of numerous government subsidies in the 1980s, private health providers entered the market. In the 1990s, the expansion of the market gave further impetus to the development of the private health sector in India. After 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector.
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas. In terms of healthcare quality in the private sector, a 2012 study by Sanjay Basu et al., published in PLOS Medicine, indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare.
However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure (CHE), which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living. One study found that over 35% of poor Indian households incur CHE and this reflects the detrimental state in which Indian health care system is at the moment. With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services. Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the World Bank, about 25% of India's population had some form of health insurance in 2010. A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured. Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices. On 27 May 2012, the popular actor Aamir Khans program Satyamev Jayate did an episode on "Does Healthcare Need Healing?" which highlighted the high costs and other malpractices adopted by private clinics and hospitals. In response to this, Narayana Health plans to conduct heart operations at a cost of $800 per patient.
The National Rural Health Mission (NRHM), was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on 18 states which have poor public health indicators and/or weak infrastructure. It has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff. Other regional programs such as the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India have also been implemented by state governments to assist rural populations in healthcare accessibility, but the success of these programs (without other supplemental interventions at the health system level) has been limited.
In addition, only 2% of doctors are in rural areas - where 68% of the population live. Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities. Full immunization coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India. Inequalities in healthcare can result from factors such as socioeconomic status and caste, with caste serving as a social determinant of healthcare in India.
Access to healthcare in rural South India
A 2007 study by Vilas Kovai et al., published in the Indian Journal of Ophthalmology analyzed barriers that prevent people from seeking eye care in rural Andhra Pradesh, India. The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).
Recent research studies have also examined the willingness of people in rural South India to pay for health care services, and how this affects the potential access to healthcare. A study by K.Ramu, published in the International Journal of Health (2017) specifically compared the willingness of people to pay for various health care services in rural versus urban districts of Tamil Nadu. The findings indicated that willingness to pay for healthcare services of all types were greater in the urban areas of Tamil Nadu compared to the rural areas, attributing this statistic to the greater awareness of healthcare importance in urban areas. In addition, as educational level increased in the rural districts of Tamil Nadu, the willingness to pay for healthcare services also increased, indicating the link between education and access to healthcare.
The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care. Specifically, in one 2014 study conducted by Sherwin DeSouza et al. in a rural village near Karnataka, India, it was found that participants in community who owned a mobile phone (87%) displayed a high interest rate (99%) in receiving healthcare information through this mode, with a greater preference for voice calls versus SMS (text) messages for the healthcare communication medium. Some specific examples of healthcare information that could be provided includes reminders about vaccinations and medications and general health awareness information.
Access to healthcare in rural North India
The distribution of healthcare providers varies for rural versus urban areas in North India. A 2007 study by Ayesha De Costa and Vinod Diwan, published in Health Policy, conducted in Madhya Pradesh, India examined the distribution of different types of healthcare providers across urban and rural Madhya Pradesh in terms of the differences in access to healthcare through number of providers present. The results indicated that in rural Madhya Pradesh, there was one physician per 7870 people, while there was one physician per 834 people in the urban areas of the region. In terms of other healthcare providers, the study found that of the qualified paramedical staff present in Madhya Pradesh, 71% performed work in the rural areas of the region. In addition, 90% of traditional birth attendants and unqualified healthcare providers in Madhya Pradesh worked in the rural communities.
Studies have also investigated determinants of healthcare-seeking behavior (including socioeconomic status, education level, and gender), and how these contribute to overall access to healthcare accordingly. A 2016 study by Wameq Raza et al., published in BMC Health Services Research, specifically surveyed healthcare-seeking behaviors among people in rural Bihar and Uttar Pradesh, India. The findings of the study displayed some variation according to acute illnesses versus chronic illnesses. In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased. Educational level did not correlate to probability of healthcare-seeking behavior for acute illnesses, however, there was a positive correlation between educational level and chronic illnesses. This 2016 study also considered the social aspect of gender as a determinant for health-seeking behavior, finding that male children and adult men were more likely to receive treatment for acute ailments compared to their female counterparts in the areas of rural Bihar and Uttar Pradesh represented in the study. These inequalities in healthcare based on gender access contribute towards the differing mortality rates for boys versus girls, with the mortality rates greater for girls compared to boys, even before the age of five.
Other previous studies have also delved into the influence of gender in terms of access to healthcare in rural areas, finding gender inequalities in access to healthcare. A 2002 study conducted by Aparna Pandey et al., published in the Journal of Health, Population and Nutrition, analyzed care-seeking behaviors by families for girls versus boys, given similar sociodemographic characteristics in West Bengal, India. In general, the results exhibited clear gender differences such that boys received treatment from a healthcare facility if needed in 33% of the cases, while girls received treatment in 22% of the instances requiring care. Furthermore, surveys indicated that the greatest gender inequality in access to healthcare in India occurred in the provinces of Haryana, and Punjab.
The National Urban Health Mission as a sub-mission of National Health Mission was approved by the Cabinet on 1 May 2013. It aims to meet health care needs of the urban population with the focus on urban poor, by making essential primary health care services available to them and reducing their out of pocket expenses for treatment.
Rapid urbanisation and disparities in urban India
India's urban population has increased from 285 million in 2001 to 377 million (31%) in 2011. It is expected to increase to 535 million (38%) by 2026 (4). The United Nations estimates that 875 million people will live in Indian cities and towns by 2050. If urban India were a separate country, it would be the world's fourth largest country after China, India and the United States of America. According to data from Census 2011, close to 50% of urban dwellers in India live in towns and cities with a population of less than 0.5 million. The four largest urban agglomerations Greater Mumbai, Kolkata, Delhi and Chennai are home to 15% of India's urban population.
Child health and survival disparities in urban India
Analysis of National Family Health Survey Data for 2005-06 (the most recent available dataset for analysis) shows that within India's urban population – the under-five mortality rate for the poorest quartile eight states, the highest under-five mortality rate in the poorest quartile occurred in UttarPradesh (110 per 1,000 live births), India's most populous state, which had 44.4 million urban dwellers in the 2011 census followed by Rajasthan (102), Madhya Pradesh (98), Jharkhand (90) and Bihar (85), Delhi (74), and Maharashtra (50). The sample for West Bengal was too small for analysis of under-five mortality rate. In Uttar Pradesh was four times that of the rest of the urban populations in Maharashtra and Madhya Pradesh. In Madhya Pradesh, the under-five mortality rate among its poorest quartile was more than three times that of the rest of its urban population.
Maternal healthcare disparities in urban India
Among India's urban population there is a much lower proportion of mothers receiving maternity care among the poorest quartile; only 54 per cent of pregnant women had at least three ante-natal care visits compared to 83 per cent for the rest of the urban population. Less than a quarter of mothers within the poorest quartile received adequate maternity care in Bihar (12 percent), and Uttar Pradesh (20 percent),and less than half in Madhya Pradesh (38 percent), Delhi (41 percent), Rajasthan (42 percent), and Jharkhand (48 percent). Availing three or more ante-natal check-ups during pregnancy among the poorest quartile was better in West Bengal (71 percent), Maharashtra (73 percent).
High levels of undernutrition among the urban poor
For India's urban population in 2005–06, 54 percent of children were stunted, and 47 percent underweight in the poorest urban quartile, compared to 33 percent and 26 percent, respectively, for the rest of the urban population. Stunted growth in children under five years of age was particularly high among the poorest quartile of the urban populations in Uttar Pradesh (64 percent), Maharashtra (63 percent), Bihar (58 percent), Delhi(58 percent), Madhya Pradesh (55 percent), Rajasthan (53 percent), and slightly better in Jharkhand (49 percent). Even in the better-performing states close to half of the children under-five were stunted among the poorest quartile, being 48 percent in West Bengal respectively.
High levels of stunted growth and underweight issues among the urban poor in India points to repeated infections,depleting the child's nutritional reserves, owing to sub-optimal physical environment. It is also indicative of high levels of food insecurity among this segment of the population. A study carried out in the slums of Delhi showed that 51% of slum families were food insecure.
Quality of healthcare
Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges. Rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector. But there are incidents where doctors were attacked and even killed in rural India  In 2015 the British Medical Journal published a report by Dr Gadre, from Kolkata, exposed the extent of malpractice in the Indian healthcare system. He interviewed 78 doctors and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions were commonplace.
According to a study conducted by Martin Patrick, CPPR chief economist released in 2017 has projected people depend more on private sector for healthcare and the amount spent by a household to avail of private services is almost 24 times more than what is spent for public healthcare services.
In many rural communities throughout India, healthcare is provided by what is known as informal providers, who may or may not have proper medical accreditation to diagnose and treat patients, generally offering consults for common ailments. Specifically, in Guntur, Andhra Pradesh, India, these informal healthcare providers generally practice in the form of services in the homes of patients and prescribing allopathic drugs. A 2014 study by Meenakshi Gautham et al., published in the journal Health Policy and Planning, found that in Guntur, about 71% of patients received injections from informal healthcare providers as a part of illness management strategies. The study also examined the educational background of the informal healthcare providers and found that of those surveyed, 43% had completed 11 or more years of schooling, while 10% had graduated from college.
In general, the perceived quality of healthcare also has implications on patient adherence to treatment. A 2015 study conducted by Nandakumar Mekoth and Vidya Dalvi, published in Hospital Topics examined different aspects that contribute to a patient's perception of quality of healthcare in Karnataka, India, and how these factors influenced adherence to treatment. The study incorporated aspects related to quality of healthcare including interactive quality of physicians, base-level expectation about primary health care facilities in the area, and non-medical physical facilities (including drinking water and restroom facilities). In terms of adherence to treatment, two sub-factors were investigated, persistence of treatment and treatment-supporting adherence (changes in health behaviors that supplement the overall treatment plan). The findings indicated that the different quality of healthcare factors surveyed all had a direct influence on both sub-factors of adherence to treatment. Furthermore, the base-level expectation component in quality of healthcare perception, presented the most significant influence on overall adherence to treatment, with the interactive quality of physicians having the least influence on adherence to treatment, of three aspects investigated in this study.
In a particular district of Uttarakhand, India known as Tehri, the educational background of informal healthcare providers indicated that 94% had completed 11 or more years of schooling, while 43% had graduated from college. In terms of the mode of care delivered, 99% of the health services provided in Tehri were through the clinic, whereas in Guntur, Andhra Pradesh, 25% of the health care services are delivered through the clinic, while 40% of the care provided is mobile (meaning that healthcare providers move from location to location to see patients), and 35% is a combination of clinic and mobile service.
In general throughout India, the private healthcare sector does not have a standard of care that is present across all facilities, leading to many variations in the quality of care provided. In particular, a 2011 study by Padma Bhate-Deosthali et al., published in Reproductive Health Matters, examined the quality of healthcare particularly in the area of maternal services through different regions in Maharashtra, India. The findings indicated that out of 146 maternity hospitals surveyed, 137 of these did not have a qualified midwife, which is crucial for maternity homes as proper care cannot be delivered without midwives in some cases. In addition, the 2007 study by Ayesha De Costa and Vinod Diwan analyzed the distribution of healthcare providers and systems in Madhya Pradesh, India. The results indicated that among solo practitioners in the private sector for that region, 62% practiced allopathic (Western) medicine, while 38% practiced Indian systems of medicine and traditional systems (including, but not limited to ayurveda, sidhi, unani, and homeopathy).
In certain areas, there are also gaps in the knowledge of healthcare providers about certain ailments that further contribute towards quality of healthcare delivered when treatments are not fully supported with thorough knowledge about the ailment. A 2015 study by Manoj Mohanan et al., published in JAMA Pediatrics, investigatethe knowledge base of a sample of practitioners (80% without formal medical degrees) in Bihar, India, specifically in the context of childhood diarrhea and pneumonia treatment. The findings indicated that in general, a significant number of practitioners missed asking key diagnostic questions regarding symptoms associated with diarrhea and pneumonia, leading to misjudgments and lack of complete information when prescribing treatments. Among the sample of practitioners studied in rural Bihar, 4% prescribed the correct treatment for the hypothetical diarrhea cases in the study, and 9% gave the correct treatment plan for the hypothetical pneumonia cases presented. Recent studies have examined the role of educational or training programs for healthcare providers in rural areas of North India as a method to promote higher quality of healthcare, though conclusive results have not yet been attained.
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Role of government in public health: Current scenario in India and future scope
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Address for correspondence: Dr. Subitha Lakshminarayanan, 57, Bharathy Street, Kadhirgamam, Pondicherry-605 009, India. E-mail: firstname.lastname@example.org
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The new agenda for Public Health in India includes the epidemiological transition, demographical transition, environmental changes and social determinants of health. Based on the principles outlined at Alma-Ata in 1978, there is an urgent call for revitalizing primary health care in order to meet these challenges. The role of the government in influencing population health is not limited within the health sector but also by various sectors outside the health systems. This article is a literature review of the existing government machinery for public health needs in India, its success, limitations and future scope. Health system strengthening, human resource development and capacity building and regulation in public health are important areas within the health sector. Contribution to health of a population also derives from social determinants of health like living conditions, nutrition, safe drinking water, sanitation, education, early child development and social security measures. Population stabilization, gender mainstreaming and empowerment, reducing the impact of climate change and disasters on health, improving community participation and governance issues are other important areas for action. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.
Keywords: Health sector, intersectoral issues, public health, role of government
The practice of public health has been dynamic in India, and has witnessed many hurdles in its attempt to affect the lives of the people of this country. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus (HIV) have been addressed through a concerted action of the government. Social development coupled with scientific advances and health care has led to a decrease in the mortality rates and birth rates.
This article is a literature review of the existing government machinery for public health needs in India, its success, limitations and future scope.
CHALLENGES CONFRONTING PUBLIC HEALTH
The new agenda for Public Health in India includes the epidemiological transition (rising burden of chronic non-communicable diseases), demographic transition (increasing elderly population) and environmental changes. The unfinished agenda of maternal and child mortality, HIV/AIDS pandemic and other communicable diseases still exerts immense strain on the overstretched health systems.
Silent epidemics: In India, the tobacco-attributable deaths range from 800,000 to 900,000/year, leading to huge social and economic losses. Mental, neurological and substance use disorders also cause a large burden of disease and disability. The rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000 deaths in 2005) makes it next in the list of silent epidemics. Behind these stark figures lies human suffering.
Health systems are grappling with the effects of existing communicable and non-communicable diseases and also with the increasing burden of emerging and re-emerging diseases (drug-resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic). Inadequate financial resources for the health sector and inefficient utilization result in inequalities in health. As issues such as Trade-Related aspects of Intellectual Property Rights continue to be debated in international forums, the health systems will face new pressures.
The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender and race or ethnicity. Lack of adequate progress on these underlying social determinants of health has been acknowledged as a glaring failure of public health.
In the era of globalization, numerous political, economic and social events worldwide influence the food and fuel prices of all countries; we are yet to recover from the far-reaching consequences of the global recession of 2008.
ADDRESSING PUBLIC HEALTH ISSUES – THE STRATEGY AND STAKEHOLDERS
To meet the formidable challenges described earlier, there is an urgent call for revitalizing primary health care based on the principles outlined at Alma-Ata in 1978: Universal access and coverage, equity, community participation in defining and implementing health agendas and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 30 years. Attempts to achieve “Health For All” have been carried forward in the form of “Millenium Development Goals.”
Public health is concerned with disease prevention and control at the population level, through organized efforts and informed choices of society, organizations, public and private communities and individuals. However, the role of government is crucial for addressing these challenges and achieving health equity. The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India's public health system.
Contribution to health of a population derives from systems outside the formal health care system, and this potential of intersectoral contributions to the health of communities is increasingly recognized worldwide. Thus, the role of government in influencing population health is not limited within the health sector but also by various sectors outside the health systems.
ROLE OF GOVERNMENT WITHIN THE HEALTH SECTOR
Health system strengthening
Important issues that the health systems must confront are lack of financial and material resources, health workforce issues and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The National Rural Health Mission (NRHM) launched by the Government of India is a leap forward in establishing effective integration and convergence of health services and affecting architectural correction in the health care delivery system in India.
Health information system
The Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector. Health profiles published by the government should be used to help communities prioritize their health problems and to inform local decision making. Public health laboratories have a good capacity to support the government's diagnostic and research activities on health risks and threats, but are not being utilized efficiently. Mechanisms to monitor epidemiological challenges like mental health, occupational health and other environment risks are yet to be put in place.
Health research system
There is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.
Regulation and enforcement in public health
A good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes, e.g., water quality monitoring, slaughterhouse hygiene and food safety. Wide gaps exist in the enforcement, monitoring and evaluation, resulting in a weak public health system. This is partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and lack of community involvement. Revival of public health regulation through concerted efforts by the government is possible through updation and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and their enforcement procedures.
Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened. Much can be done to improve the effectiveness of health promotion by extending it to rural areas as well; observing days like “Diabetes day” and “Heart day” even in villages will help create awareness at the grassroot level.
Human resource development and capacity building
There are several shortfalls that need to be addressed in the development of human resources for public health services. There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. The Public Health Foundation of India is a positive step to redress the limited institutional capacity in India by strengthening training, research and policy development in public health. Preservice training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. Changes in the undergraduate curriculum are vital for capacity building in emerging issues like geriatric care, adolescent health and mental health. Inservice training for medical officers is essential for imparting management skills and leadership qualities. Equally important is the need to increase the number of paramedical workers and training institutes in India.
Public health policy
Identification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector, e.g. in the United States, the “Healthy People 2010” offers a simple but powerful idea by providing health objectives in a format that enables diverse groups to combine their efforts and work as a team. Similarly, in India, we need a road map to “better health for all” that can be used by states, communities, professional organizations and all sectors. It will also facilitate changes in resource allocation for public health interventions and a platform for concerted intersectoral action, thereby enabling policy coherence.
Scope for further action in the health sector
School health, mental health, referral system and urban health remain as weak links in India's health system, despite featuring in the national health policy. School health programs have become almost defunct because of administrative, managerial and logistic problems. Mental health has remained elusive even after implementing the National Mental Health Program.
On a positive note, innovative schemes through public-private partnerships are being tried in various parts of the country in promoting referrals. Similarly, the much awaited National Urban Health Mission might offer solutions with regards to urban health.
ROLE OF GOVERNMENT IN ENABLING INTERSECTORAL COORDINATION TOWARD PUBLIC HEALTH ISSUES
The Ministry of Health needs to form stronger partnerships with other agents involved in public health, because many factors influencing the health outcomes are outside their direct jurisdiction. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.
Social determinants of health
Kerala is often quoted as an example in international forums for achieving a good status of public health by addressing the fundamental determinants of health: Investments in basic education, public health and primary care.
Safe drinking water and sanitation are critical determinants of health, which would directly contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of drinking water supply and sanitation through existing programs, in both rural and urban areas, is achievable and affordable.
Provision of urban basic services like water supply, sewerage and solid waste management needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works to develop financially sustainable cities in line with the Millenium Development Goals, which needs to be expanded to cover the entire country. Other issues to be addressed are housing and urban poverty alleviation.
Revival of rural infrastructure and livelihood
Action is required in the following areas: Promotion of agricultural mechanization, improving efficiency of investments, rationalizing subsidies and diversifying and providing better access to land, credit and skills.
Elementary education has received a major push through the Sarva Siksha Abhayan. In order to consolidate the gains achieved, a mission for secondary education is essential. “Right of children to Free and Compulsory education Bill 2009” seeks to provide education to children aged between 6 and 14 years, and is a right step forward in improving the literacy of the Indian population.
Nutrition and early child development
Recent innovations like universalization of Integrated Child Development Services (ICDS) and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive growth under the eleventh 5-year plan. The government needs to strengthen ICDS in poor-performing states based on experiences from other successful models, e.g., Tamil Nadu (upgrading kitchens with LPG connection, stove and pressure cooker and electrification; use of iron-fortified salt to address the burden of anemia). Micronutrient deficiency control measures like dietary diversification, horticultural intervention, food fortification, nutritional supplementation and other public health measures need intersectoral coordination with various departments, e.g., Women and Child Development, Health, Agriculture, Rural and Urban development.
Social security measures
The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee Scheme (MREGS) has the potential to change the complexion of rural India. It differs from other poverty-alleviation projects in the concept of citizenship and entitlement. However, employment opportunities and wages have taken the center stage, while development of infrastructure and community assets is neglected. This scheme has the necessary manpower to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry, horticulture, anti-erosion projects and rain water harvesting. The unlimited potential of social capital has to be effectively tapped by the government.
Food security measures
Innovations are required to strengthen the public distribution system to curb the inclusion and exclusion errors and increase the range of commodities for people living in very poor conditions. It is essential that the government puts forth action plans to increase domestic food grain production, raise consumer incomes to buy food and make agriculture remunerative.
Other social assistance programs
The Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security measures for the unorganized sector (91% of India's workforce). The National Old Age Pension scheme has provided social and income security to the growing elderly population in India.
There is all round realization that population stabilization is a must for ensuring quality of life for all citizens. Formulation of a National Policy and setting up of a National Commission on Population and Janasankhya Sthiratha Kosh reflect the deep commitment of the government. However, parallel developments in women empowerment, increasing institutional deliveries and strengthening health services and infrastructure hold the key to population control in the future.
Gender mainstreaming and empowerment
Women-specific interventions in all policies, programs and systems need to be launched. The government should take steps to sensitize service providers in various departments to issues of women. The Department of Women and Child Development must take necessary steps to implement the provisions of “Protection of Women from Domestic Violence Act, 2005.” Training for protection officers, establishment of counseling centers for women affected by violence and creating awareness in the community are vital steps. Poverty eradication programs and microcredit schemes need to be strengthened for economic and social empowerment of women.
Reducing the impact of climate change and disasters on health
Thermal extremes and weather disasters, spread of vector-borne, food-borne and water-borne infections, food security and malnutrition and air quality with associated human health risks are the public health risks associated with climate change. Depletion of non-renewable sources of energy and water, deterioration of soil and water quality and the potential extinction of innumerable habitats and species are other effects. India's “National Action Plan on Climate Change” identifies eight core “national missions” through various ministries, focused on understanding climate change, energy efficiency, renewable energy and natural resource conservation. Although there are several issues concerning India's position under UNFCCC, it has agreed not to allow its per capita Greenhouse gas emissions to exceed the average per capita emissions of the developed countries, even as it pursues its social and economic development objectives.
The Ministry of Health, in coordination with other ministries, provides technical assistance in implementing disaster management and emergency preparedness measures. Deficient areas include carrying out rapid needs assessment, disseminating health information, food safety and environmental health after disasters and ensuring transparency and efficiency in the administration of aid after disasters. Implementation of Disaster Management Act, 2005 is essential for establishing institutional mechanisms for disaster management, ensuring an intersectoral approach to mitigation and undertaking holistic, coordinated and prompt response to disaster situations.
Community participation builds public support for policies and programs, generates compliance with regulations and helps alter personal health behaviors. One of the major strategic interventions under NRHM is the system of ensuring accountability and transparency through people's participation – the Rogi Kalyan Samitis. The Ministry of Health needs to define a clear policy on social participation and operational methods in facilitating community health projects. Potential areas of community participation could be in lifestyle modification in chronic diseases through physical activity and diet modification, and primary prevention of alcohol dependence through active community-based methods like awareness creation and behavioral interventions.
Private sectors, civil societies and global partnerships
Effective addressing of public health challenges necessitates new forms of cooperation with private sectors (public-private partnership), civil societies, national health leaders, health workers, communities, other relevant sectors and international health agencies (WHO, UNICEF, Bill and Melinda Gates foundation, World Bank).
In order to ensure that the benefits of social security measures reach the intended sections of society, enumeration of Below Poverty Line families and other eligible sections is vital. Check mechanisms to stop pilferage of government funds and vigilance measures to stop corruption are governance issues that need to be attended. The government should take strict action in cases of diversion of funds and goods from social security schemes through law enforcement, community awareness and speedy redressal mechanisms. Social audits in MREGS through the Directorate of Social Audit in Andhra Pradesh and Rajasthan are early steps in bringing governance issues to the fore. This process needs strengthening through separate budgets, provisions for hosting audit results and powers for taking corrective action. Similar social auditing schemes can be emulated in other states and government programs like ICDS, which will improve accountability and community participation, leading to effective service delivery.
“The health of people is the foundation upon which all their happiness and all their powers as a state depend”
– Benjamin Disraeli, British Prime Minister.
In this changing world, with unique challenges that threaten the health and well-being of the population, it is imperative that the government and community collectively rise to the occasion and face these challenges simultaneously, inclusively and sustainably. Social determinants of health and economic issues must be dealt with a consensus on ethical principles – universalism, justice, dignity, security and human rights. This approach will be of valuable service to humanity in realizing the dream of Right to Health. The ultimate yardstick for success would be if every Indian, from a remote hamlet in Bihar to the city of Mumbai, experiences the change.
It is true that a lot has been achieved in the past: The milestones in the history of public health that have had a telling effect on millions of lives – launch of Expanded Program of Immunisation in 1974, Primary Health Care enunciated at Alma Ata in 1978, eradication of Smallpox in 1979, launch of polio eradication in 1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few. It was a glorious past, but the future of a healthy India lies in mainstreaming the public health agenda in the framework of sustainable development. The ultimate goal of great nation would be one where the rural and urban divide has reduced to a thin line, with adequate access to clean energy and safe water, where the best of health care is available to all, where the governance is responsive, transparent and corruption free, where poverty and illiteracy have been eradicated and crimes against women and children are removed – a healthy nation that is one of the best places to live in.
Source of Support: Nil
Conflict of Interest: Nil
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Articles from Journal of Family & Community Medicine are provided here courtesy of Wolters Kluwer -- Medknow Publications