{"id":31100,"date":"2014-02-20T10:55:09","date_gmt":"2014-02-20T09:55:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=31100"},"modified":"2014-03-11T13:54:05","modified_gmt":"2014-03-11T12:54:05","slug":"giridhara-r-babu-health-for-indians-who-cares-about-it-anyway","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/02\/20\/giridhara-r-babu-health-for-indians-who-cares-about-it-anyway\/","title":{"rendered":"Giridhara R Babu: Health for Indians\u2014who cares about it anyway?"},"content":{"rendered":"

\"grb\"<\/a>Political parties often pitch intensively against a few\u00a0<\/span>individuals for maximum media bites. There is, however, no real discussion of the issues which affect the\u00a0lives of scores of Indians. “Development” has recently become the buzzword of\u00a0political parties. If development means economic and social transformation, then\u00a0health should be seen as an essential component. Our country\u2019s future will be\u00a0determined by the investment we make in health and education for our “human\u00a0resources.”<\/p>\n

The most we hear from politicians about health is on the subject of reducing\u00a0infant and maternal deaths. Obviously these are issues that matter, but it is a\u00a0shame that most political parties have realized this only now. Over the last seven\u00a0decades they have been largely silent on the issue of India\u2019s poor infant and\u00a0maternal mortality indicators (IMR and MMR). With more voter friendly issues\u00a0to be discussed\u2014such as roads, trains, and buildings\u2014will more fundamental\u00a0societal issues such as health appear at the forefront of political discourse?\u00a0Probably not.<\/p>\n

Although our governments routinely announce grand health schemes, India does\u00a0not (with a few exceptions) use credible evidence to guide health expenditure.<\/p>\n

Evidence based public health policy\u2014which should determine planning and\u00a0spending\u2014is virtually non-existent. For example, labelled as the saviour of people\u00a0below the poverty line (BPL), the Rajiv Aarogyasri scheme (RAS) currently covers\u00a0the healthcare costs of nearly 86% of the total population in the state of\u00a0Andhra Pradesh. It is one of the biggest health schemes in the country. The\u00a0state government is the sole funder for this insurance scheme and pays the\u00a0entire premium on behalf of the BPL families. Replicas of RAS have been set\u00a0up in several other states, effectively draining money from the health sector\u00a0towards profit making private sector hospitals. Addressing the curative services\u00a0is fine, but will the policymakers make a conscious attempt to work towards\u00a0strengthening the public health system? Probably not.<\/p>\n

The generation of evidence for policy needs to be led by state funded and\u00a0autonomous research funding organizations\u2014such as the National Institutes\u00a0of Health (NIH) in the United States. A policy of bestowing grants upon competitive\u00a0independent research organizations or public health researchers should be\u00a0implemented\u2014including building their capacities. Many countries in the world\u00a0have institutions that collect information on the burden of diseases. These\u00a0institutions have statutory and economic powers to enable them to plan and\u00a0implement integrated surveillance for diseases, and to guide policy to determine\u00a0priorities. For India this would be a crucial step\u2014not only from a health\u00a0perspective, but to prepare the country against the threat of biological weapons.<\/p>\n

The National Institute of Communicable Diseases (NICD) has been renamed\u00a0as the National Centre for Disease Control (NCDC). Readers are advised to\u00a0compare the Centers for Disease Control and Prevention (CDC) in the US or\u00a0China with our NCDC. Barring India\u2019s polio programme, which has a world class\u00a0surveillance network (NPSP), we have displayed ambitious intent but futile\u00a0implementation of disease surveillance and response. We do not currently have\u00a0standard operating guidelines regarding reporting diseases, and health hazards,\u00a0which should be implemented throughout the country. Will the next health\u00a0minister lead not only with the right intent but coordinate with state governments\u00a0to implement evidence based public health in India? Probably not.<\/p>\n

Without being swayed by advocacy campaigns of those with vested interests,\u00a0the state must focus on public health planning and implementation. To this end,\u00a0government health departments need to be autonomous with minimal political\u00a0interference. Currently, the majority of health expenditure is from people\u2019s own\u00a0pockets (called out of pocket expenditure\u2014OOP). A total of 28 per cent of people\u00a0in rural areas and 20 per cent in urban areas, however, have no money for their\u00a0healthcare. Middle class families are not invulnerable to major illness or the\u00a0likely subsequent impoverishment. Insufficient funds and a lack of accountability\u00a0in the public health sector has led to the flourishing of the private sector\u2014triggering catastrophic health expenditure. More than 40 per cent of families with\u00a0one member hospitalized would borrow money by mortgaging their property,\u00a0which they would never be able to get back. As per the planning commission\u2019s\u00a0High Level Expert Group (HLEG) report, a total of 35% of families would\u00a0fall below the poverty line if a member gets hospitalized. Will any political party\u00a0pledge to implement universal health coverage ahead of elections? Probably\u00a0no party would do this given that it is not a burning issue for them, even if it will\u00a0\u201cburn\u201d nearly half of all Indian families in the near future.<\/p>\n

It is astonishing that no one talks about the importance of public health training\u00a0and research; two important areas that require immediate attention. Unlike the\u00a0Indian Institute of Technology (IIT) or the Indian Institute of Management (IIM),\u00a0which cater mostly to the private sector, the autonomous public health institutes\u00a0need to focus on the obligations of the local public health system. \u00a0These should\u00a0include keeping the public informed about important general health matters, as\u00a0well as conducting research in an area specific manner within each state, and\u00a0reporting findings to the government so that changes can be implemented. It is\u00a0critical that a well trained and professionally skilled workforce manages the public health system. A new \u201cIndian Health Service\u201d with power and\u00a0financial autonomy equivalent to that of the Indian Administrative Service\u00a0needs to be created. A detailed draft of such a service should be prepared and\u00a0discussed in detail by public health experts. Professionals should be trained\u00a0in addressing public health issues, and in educating the public on general\u00a0health. Have the manifestos of any aspiring leader reflected any of the important\u00a0measures contained here? Probably not.<\/p>\n

On the other hand, private healthcare establishments are rarely accountable\u00a0for any of the services they provide. Advertising leads us to believe the\u00a0private sector is providing a high quality service at an affordable price. Private\u00a0health establishments also make use of the media to criticize every step the\u00a0government takes to provide affordable healthcare to everyone. It is important to\u00a0recognise that the private health system in India is similar to any other profit making\u00a0industry. In this case, poor quality comes at high cost, borne either by the patient\u00a0or the government. The private sector in healthcare is unregulated, including the\u00a0reported splitting of fees. Health related services should have\u00a0uniform prices throughout the country. Governments at central and state level\u00a0need to publish prices for health services, and these must be followed by the\u00a0private health industry. There is nothing wrong with charging for five star facilities\u00a0if the patient prefers and can afford it. It would be wrong to charge high prices for\u00a0everyone. We need regulations to ensure that the average person is able to afford healthcare. In turn the average person must give priority to health as an\u00a0election issue.<\/p>\n

One in three people in India live below the poverty line. The remaining two people\u00a0usually assume that they will stay above the poverty line forever. Here comes the\u00a0surprise. In a paper published in Economic and Political Weekly, Peter Berman\u00a0and colleagues analysed NSSO data and showed that 63.22m individuals\u00a0or 11.88m households were pushed below the poverty line because of\u00a0healthcare expenditure in 2004. This will increase steeply in the years ahead,\u00a0and the Srinath Reddy led HLEG report on universal\u00a0health coverage has warned, “If you are not poor already, illness can make you\u00a0poor.” The only exception to this sudden impoverishment is for millionaires or\u00a0politicians whose healthcare expenses are taken care of by others. Will these\u00a0facts cause the middle class to demand more healthcare expenditure? More\u00a0importantly, will the middle class consider this as an issue before they decide which party to vote for? Probably not.<\/p>\n

The current public health challenges are intense and complex, and cannot be\u00a0addressed by the government\u2019s department of health alone. We cannot allow\u00a0children to suffer from measles, adults to get cardiovascular diseases, or elders\u00a0to succumb to cancer. All these conditions are common in our country and\u00a0there is much work to be done; yet we claim to be one of the fastest growing\u00a0and developed nations. It is time that we focussed on fixing our health system,\u00a0and take steps that will improve public health. Most illness is preventable and\u00a0early screening can minimize costs. WHO defines health as \u201ca state of complete\u00a0physical, mental, and social wellbeing and not merely the absence of disease or\u00a0infirmity.\u201d Yet most health debates occur around sickness and diseases.<\/p>\n

The mainstream media airs debates on most trivial issues but\u00a0do not have time to raise interest in health issues. With the common\u00a0man not knowing the serious consequences, faced with the eternal neglect of\u00a0politicians, and sidelined by private health interests and aiding policy makers, one\u00a0often wonders who cares for the health of people anyway?<\/p>\n

What can the next Government do? Which party can\u00a0ensure this?<\/p>\n

1. Implement universal health coverage, as proposed by HLEG of Planning Commission\u00a0of India.<\/p>\n

2. Establish Centers for Disease Classification away from Delhi. (Similar to CDC,\u00a0Atlanta). For security reasons it is essential to have a site separate from national\u00a0headquarters. Integrate all disease surveillance programmes and strengthen IDSP. Link\u00a0this to the CDC.<\/p>\n

3. Strengthen comprehensive primary healthcare throughout the country. Ensure that\u00a0the control on providing healthcare services is decentralized and only the state\/central\u00a0headquarters controls the quality matters. The NHS in the UK is a good model to follow.<\/p>\n

4. Include mental health as one of the integral components of primary healthcare.<\/p>\n

5. Improve mental health services throughout the country.<\/p>\n

6. Implement a school health programme ensuring every child is healthy.<\/p>\n

7. Increase the flexi pool of health budget to every state.<\/p>\n

8. Similar to IIM and IITs, start one Indian Institute of Public Health (IIPH) of global\u00a0repute in every state of the country. Have four regional public health universities\u00a0situated in Delhi, Bangalore, Bhubaneswar, and Gandhinagar. Link the public health\u00a0cadres in every state to the IIPHs.<\/p>\n

9. Establish a research fund to encourage public health research by any public health\u00a0researcher in the country. This should be along the lines of the NIH in the US.<\/p>\n

10. Workplace based health programmes to get funding from the centre and state.<\/p>\n

11. Cancer care to improve. Every district hospital should have dedicated NCD centre\u00a0with specialist services available for cancer patients.<\/p>\n

12. Start a new programme to take care of the elderly.<\/p>\n

13. Develop an integrated national health policy. This should cover preventive, curative, and rehabilitative services.<\/p>\n

14. Develop a national urban health mission to cover all urban areas.<\/p>\n

15. Social determinants of health should get priority in planning and budget allocation.<\/p>\n

Acknowledgements: I sincerely thank Prashanth Nuggehalli Srinivas for his insightful review and comments in improving this blog post.<\/p>\n

Giridhar R Babu<\/strong> is associate professor at the Public Health Foundation of India.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Political parties often pitch intensively against a few\u00a0individuals for maximum media bites. There is, however, no real discussion of the issues which affect the\u00a0lives of scores of Indians. “Development” has […]<\/p>\n

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