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HEALTH
With urbanisation and globalisation propelling rapid transitions in living patterns, we will have to simultaneously deal with the disorders of maladapted modernity alongside the diseases of under-development. Mid-life heart attacks, diabetes, cancers, obesity, mental illness and injuries are already major threats, co-existing with malaria, tuberculosis and AIDS. Across the country, health inequity is starkly evident. A baby girl born in Madhya Pradesh is six times more likely to die before her first birthday than if born in Kerala. A pregnant woman in Jharkhand or Chhattisgarh is three times more likely to die in childbirth than in Tamil Nadu. In Kerala 75 per cent of all children are fully immunised, compared to 33 per cent in Bihar. It is pertinent to note that Kerala has higher levels of education and spent Rs 287 per capita on health, in 2004-05, compared to Bihar’s Rs 93, and that Tamil Nadu has a well-defined public health cadre.
To overcome these challenges and improve the health of our people over the next decade, we must initiate concerted action to: Develop and implement a framework for Universal Health Coverage (UHC): Political commitment is required to ensure equitable access for all citizens to appropriate, affordable and accountable health services (promotional, preventive, curative and rehabilitative). The government must become the guarantor of such services, even if it is not the sole provider. Public financing for health should increase, to a minimum of 3 per cent of the GDP by 2020. Health expenditure will have to be mainly tax financed, with additional contributions from employers and private insurance. A universal health insurance scheme must integrate all health-financing programmes into a single payer system and ensure cashless delivery of health services. Strengthen primary health care: Both rural and urban primary health care need to be reconfigured to promote greater outreach and better quality of services. The National Rural Health Mission must be supplemented by a National Urban Health Mission, to ensure that all basic health services are available within easy reach. At least 70 per cent of all public financing must be directed towards primary health care, since efficient primary health services will substantially reduce the demand for costly secondary and tertiary care. Expand and reconfigure the health workforce: A planned expansion of the health workforce must be undertaken by developing more training institutions, preferably in states and districts where they are few or absent. Even as more health professionals are trained, competencies must be redefined and responsibilities reassigned to enable effective ‘task shifting’ (from specialist physicians to non-specialist physicians, from physicians to nurses and from nurses to community health workers). Incentives for recruitment and retention in primary care and public services must be increased. Create a Public Health Cadre: Traditional medical or nursing education prepares students for facility- based care of individual patients. Dealing with the population dimensions of health, whether it is immunisation or tobacco control or managing a nutrition programme or mobilising communities for health action, are not part of the skill set of such professionals. Epidemiology, health economics, social and behavioural sciences and management are critical areas of knowledge deficiency that undermine health planning and programme implementation. There is a need to train a large number of public health professionals, from among physicians as well as non-physicians, and create public health cadres in central and state health services. Create a strong regulatory framework for quality and cost control: If the private sector has to be responsibly integrated into a system of universal health coverage and the public sector, too, must become a benchmark of quality and cost, a robust regulatory framework is needed. Technical guidelines and pricelists, for common disorders, must be produced periodically by experts, prescribed by governments and independently audited. Ensure availability of medicines at affordable prices: Policies must be developed for protection of the domestic generic drug industry, price fixation and compulsory licensing, when required. The public procurement of drugs at low cost, with free supply in primary health care, has been shown to be very effective in Tamil Nadu and needs replication in other states. Align policies and programmes in other sectors to health needs: Policies in sectors which impact on health (such as water, sanitation, agriculture, food processing, environment, urban design and transport) must be made more sensitive and responsive to health concerns. The writer till recently also headed the Department of Cardiology at AIIMS
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AS India advances into
2011, optimism about accelerated economic growth must be tempered by
the realisation that our health indicators are lagging far behind. A
country in which 45 per cent of the children under five are
undernourished and account for a third of the global deaths due to
measles cannot claim to be a rapidly developing nation. Our infant
mortality rate of 53 per 1000 live births is higher than Nepal’s 43
and far exceeds Sri Lanka’s 17. With per capita public expenditure
on health at 25 per cent of the level in Sri Lanka and 10 per cent of
that in China, we cannot bear comparison with our neighbours on the
resources devoted to health.
When we hope to benefit
from the demographic dividend that India will have over the next four
decades, of having the world’s largest working age population in the
15-59 year range, we cannot ignore the imperative of protecting and
promoting the health of these human resources. The public financing of
health is at 1 per cent of the GDP and, as a result, the out-of-pocket
expenditure of 78 per cent is among the highest in the world. With the
neglect of public services, an unregulated private sector emerged as a
default option and has escalated healthcare costs without
significantly increasing outreach to rural areas. Severe shortage in
the health workforce has resulted in inadequate availability and
mal-distribution of doctors, nurses and paramedical personnel. Poor
governance and widespread corruption further enfeeble the system and
dilute the quality of services.