By Kapou Malakar
Background
Covid 19 while leaves everyone at peril, inevitably fetches the role of public health care of India to the forefront. The risk that the humanity faced is quite pervasive and pertinent to all population. Importance of public health arrangement lies in equitable access to benefits for all. Covid circumstances entails the urgent demand for advancement of core capacities of health sector combined with surveillance preparedness to make our country ready for the risk.
Liberalization has provided some scope for expansion of private curative sector that nullifies the primacy of welfare role of government. Even a cursory look emerged out of disinvestment and privatization show how government thinks more of market and money instead of service to be delivered.
Since colonial period, communication around health promotion has been looking outside the crisis, calamity and environmental emergency barring the only exception in the form of national policy of health in 1983 which underlined the objective of having a quick response to contingency outbreak. The crisis that we are in has been perennial that can only be mitigated through revival of public health sphere.
Ills of health care system
The health care delivery system in India is based on need built supply of service delivery where health issues of masses are the needs and supplying curative medicine is conceived as solution. Unforeseen wrongs dwells in, when the delivery system narrows down to supply side of solution to the problem of health delivery ignoring the diversity of health seeking behaviour of population. This will not be wrong to presume that most Indians do not know their health needs and priorities. Health rights are merely considered as privileges rather than rights. This mentality has been pervaded since colonial period and yet to be changed among people irrespective of rural urban milieu. Given the fact, in response to the outbreak of novel pandemic, it requires critical preparedness for public health agencies of our country by availing mandatory safety gears, making it equipped with informed, trained and pro-active health care workers.
Five decades old public healthcare network in India is plagued with many problems. The acute shortage of doctor, paramedical staff, inadequate infrastructure and insufficient numbers of beds, appalling condition of district hospitals are common to our eyes. Moreover, the increased density of population in the country and seemingly low quality of life, reportedly higher mortality rates among women and children bear severe implication on health care system in India. Not featuring adequate numbers of available diagnostics centre still in city areas before we canvass on the rural urban disparity in health care delivery is another challenge before mass .
In a report published in economic times saying “55 million Indians were pushed into poverty in a single year because of having to fund their own health care and 38 million of hem fell below poverty line due to spending on medicine alone”. Essential drugs are not free for poor whereas availing free primary health care is the prime thrust area of health policies. Another age old grim picture shows that poor in our country are increasingly resorted to debt. At times, they rise to sell their assets to meet the cost of health care.
Public health care facilities are distributed population wise across the state. The third five year plan sought to increase the number of public health centre (PHC) and dispensary facilities for rural poor. PHCs are considered as the bedrocks of rural health care in India. The high level expert group in 2011 recommended for a boosted primary care. Considerable importance is given in prevention and early management of health problems which can reduce the need for complicated specialist care provided at tertiary level.
Since 2005, NRHM (National Rural Health Mission), remarkably, evolves to reorient medical and health education by strengthening community health care centre making it the first referral point to support rural health issues. NRHM brought 9,00,000 ASHA workers closer to public service, yet they are not salaried govt. staff. ASHA workers are designated community health volunteers. ASHA workers are women and their service to the community is volunteered by nature which further questions the gender implication of instituting only women volunteers for care service narrowing public health service to few aspects . Due to sectoral emphasis on health catering to selected aspects, NRHM fails to prove its effectiveness during outbreak of epidemics. Similarly, around 1,000 ambulances are deployed for emergency responses and patient transport services. There are instances that local control of resources without any vertical monitoring mechanism and bottom-up coordination could often lead to misuse of scare local resources. Statistics alone can’t provide a substantive inquiry into the actual health care delivery in India. The creation of large rural health workforce may seem to display a major achievement of the country that is running short of resources and struggling with great disparities in health status. Yet, the gap in supply of health care facility, dearth of fund allocation, the run-down condition of public health infrastructure eventually demotivate both the deliverers and patients. These factors are sufficient enough to delegitimise the confidence on public health care services among people. Most of the public hospitals are characterized by no or less numbers of beds, thin presence of doctors, nurses and modern amenities which can only perpetuate premodern belief systems among people and affect their health seeking behaviour.
Existing health care policy and numb action
National health policy claims to be the systematic blueprint for future health care system in India. Providing free comprehensive primary health service is one of the major goal of national health policy. It also seeks to ensure the universality of health services and making it accessible for all. It takes in its fold, some predominant communicable and non-communicable disease by further counting on the aspects of reproductive, maternal, child and adolescent health.
In post independent period till now, public health system in India has not achieved remarkable transformation beyond some periodic landmark recommendations. Health policy in India has inherited a colonial character which ceases to go away in current health plans. Since colonial period, our health policies have been focusing more on remedial medicine and curative care instead of preventive care.
Indian health sector is no exception in experiencing the paradigm shift in macro policy environment since 1991 onwards. The changeover from socialism to neo-liberalism encouraged the growth of private health care industry and medical technologies. State withdrawal from social sector to walk in line with global economy has thrown a blow to a developing country like India. Liberalism imposed SAP ( structural adjustment programme)conditionalities on health sector which results in declining investment in public health sector in India. The total health care allocation in the union budget, 2020-21 is Rs. 69000 crore. It is apparent from the budget outlay how India continues to lag in terms of expenditure in public health sector which scores below 1.5 percent of GDP.
All the more, the coveted capital expenditure for building of physical infrastructure, purchasing essential drugs constitute a minuscule amount of overall health spending outlay when lion’s share is taken up by staff salary.
India like many other developing countries is yet to achieve demographic and epidemiological transition in view of health performance. Developed countries with falling numbers of aged population, lessening rate of mortality and fertility have already reached the demographic transition. India experiences mounting numbers of non-communicable disease like diabetic, cancer and heart patients in recent decades with a noticeable age pattern that support the higher numbers of death attributed to old ages.
Oblivious attitude of policy makers towards the need and priorities of public health facilities , followed by disinvestment in public health sector can be argued for low score in demographic transition. Even the influence of social epidemiological factors are not less liable in this respect. To achieve the demographic transition has been one of the major agenda of earlier health policies of India. During the intervening time, investment on epidemiological transition emerged out to be major program of health policies of India. A little progress is noticed in lesser extent in declining numbers of communicable disease, that is shifted to the rise of chronic non-communicable diseases and lifestyle disease coupled with ecological change. Still, there are list full unfinished health agendas ,e.g., complicated and high risk maternity, child mortality, other key communicable diseases like diarrhoea in children, malaria, tuberculosis, HIV/AIDS pandemic and so on which never cease to bother India, thus, have been exerting double burden on health system of India.
Who are at the helm of affairs ?
It was 1848 when Rodolf Carl Virchow, in the report on the Typhus Epidemic in Upper Silesia had underscored the importance of social epidemiology of health. Virchow identified numerous socio economic causes that could wield strains on the public health system of a country. Those socio economic causes are defined as socio-epidemiological determinants that comprise feudal aristocracy, lack of democracy, unfair tax policies of government, ignorant and poor mass who were accustomed for centuries to extreme mental and corporal deprivation, hunger and starvation, lack of culture and so on. In view of Covid 19, poor living condition of people, poor habitation, lack of available safe drinking water and hygiene could inevitably compound the risk of people, eventually aggravate the community outbreak of coronavirus. Particularly the dwelling areas of migrants, basti in tea estate, slum areas, ghettos are more exposed to the risk of infection of contagious disease.
In case of earlier epidemics, it is not that mass were not able to understand the nature of disease and even the underlying causes. Trust and legitimacy on health care system is bound by the social milieu of the people. The social setting of the natives are determined by the level of exposure to health information, timely interaction with expert or doctors and existence of modern amenities. The social setting of rural vicinity is characterised by alternative models of healing, indigenous medical practices with few immunity booster and dearth of trust on the western bio-medical approach to health care.
PHC can work like a stimulator of change in a community. However, just because the sector is so underfunded with no or less number of competent paramedics, a potential health care unit at local level fails to perform the least preventive functions such as providing seasonal alert to community or circulate any community health information fetching doctors from public and private sectors and so on. Considering the situation, it is also the demand of hour to make panchayat body fully informed and competent to have a stake in health care . States like Tamil Nadu and Kerela stand testimony of devolution of much of the heath care activities to local units. These examples articulate how PHC and local units are filled with competent members, connecting women to reorganize the practice of drug purchase and distribution among natives.
Decentralization, in India, is simply a verbalization of health services to keeping in tune with global policy makers in post liberal era. Decentralization cannot be realized in true sense unless it is backed by proper distribution of resources. Decentralization in India is reduced to a slogan that promote disinvestment in public sector, enable private hospitals make inroad into the rural area. In India, mere articulation of decentralization in terms of devolution of responsibilities without having a sound monitoring mechanism would simply end up concentrating power in the hands of few at local level.
In terms of preventive health care provision, local governance in India can perform its due to make people aware of cleanliness. What is important in current scenario is to build a grassroot pressure on government in order to necessitate the adoption of safety measures and procedural norms complemented by the supply of safety gears for doctors, paramedics and staff.
Reach of health insurance schemes
Another objective of national health policy 2015 is to reduce out of pocket expenditure for availing health care service for all households. Major sections of population in India are not covered by any scheme of health expenditure support, government sponsored health scheme and private insurers. High out of pocket health care expenditure pushes many into below poverty line each year.
Government has introduced several social security scheme for health, yet those scheme could not make a widest reach to cover BPL and unorganised sector. Moreover, those schemes are not run on regular basis. Once a person makes entree to get benefits, same person cannot continue to get access to that scheme. Most of the schemes are merely populist announcement of government, hence, do not give any firm figure of insurance coverage of the community in India. Social security legislation and social health insurance cover miniscule percentage of population who belong to organised sector. These beneficiaries are mostly employees who are covered through Central Government Health Scheme (CGHS) and Employees’ State Insurance Scheme (ESIS). National Health Protection Mission was announced during 2018-19. It aims to cover Rs. 5 lakh per family belonging to poor and vulnerable section by providing insurance coverage through targeted hospitalization. The welfare measures of these kinds should not reduce to mere figures.
As per the statistics of national health accounts of 2015-16, only 30 percent of total health expenditure is covered by public sector whereas around 70 percent of health expenditure is borne by consumer households. 95 percent of out of pocket expenditure dominates the total household expenditure that include payment at the point of service such as drugs, patient transportation, diagnostic labs, private hospitals, which are not covered by any financial protection scheme.
Analogy from the past
Similar to current situation in view of Covid 19, the decade of 1950s and 1960s hold an analogy, when the primary focus of Indian health sector was to contain periodic epidemics. Mass campaign played a significant role in eradicating disease like malaria, small pox, tuberculosis, leprosy, cholera under direct patronage of several international funding agencies like UNICEF, WHO during 50s and 60s. Several programmes with top-down approach were taken extensively yet without any epidemiological consideration. These programme provide seasonal employment generation on commission basis, which entails the short term benefits of emergency policy. MP Singh and Himangshu Roy in the book, “ Indian political system” states, “National malaria eradication programme alone required the training of 150000 workers spread over 400 units for prevention and curative aspects of medical control.” Yet, the situation has not shown any significant change in terms of administration of those programmes as implementation of most of the programmes are technologically determined based on western aid and agencies.
What is new in Covid 19? Covid 19 has directly attacked the curative oriented western model of health care. The socio economic scenario has provided a scope for re-looking into national health policy and stressing practically on salient features, i.e. prevention, promotion and rehabilitation as mandatory approach.
Implications
Certain implications for the improvement of the current health scenario of India is discussed below.
· According to World Health Organization, “Health is a state of complete physical mental and social wellbeing and not merely the absence of disease or infirmity.” The indicators of health status are socio-economic in nature. These comprise per capita income, nutrition, housing sanitation, safe drinking water, social infrastructure , health medical services provided by government. Hence, in line with preventive measures and awareness campaign, government should simultaneously focus on improving the access to safe drinking water and creation of sanitation facilities.
· In opposed to gradual bending towards market and profit mind of government in compliance with the norms of global economy and in tune with privatization, Covid19 has provided a scope to merge out in solidarity with a pledge to ensuring health service at an affordable price for all specially for poor. In view of perpetual resource constraints situation, none but government promotes partial entry of private sectors in delivering preventive services.
· Covid 19 has called for everyday health promotion and disease prevention activities. Communication is the basis for everyday health information exchange. There is a need to adopt universal precautions against the infectious disease like novel corona virus.
· This is high time to relook at how health care services of the state could be standardised and optimised so that poor and deprived are not left out in times of crisis. Government scheme should be directed to facilitate capacity of the poor to pay and take responsibility of their own health. Trajectory of health care performance depends on overall change in political economy.
· There is a need for intervention in order to stimulate common general effort in India. Civil society organizations have been aiding us to get through this difficult time by contributing to food for poor and unorganised sector.
· Our preferred model of development highlights the importance of public private partnership. It may refer the role of state to contracting out certain services to private sectors including private hospitals , NGOs and distribute fund or subsidies to private groups to deliver the essential most services.
· PHCs should be equipped enough to treat simpler cases from the vicinity, practicing which would reduce the waste involved in needlessly referring to tertiary hospital.
· The basic recommendation backs the argument for expansion of allocation of public health expenditure so that government could put in place the basic public health facilities, testing centres, improved infrastructure, trained staff and safety gears.
· Health is still a state subject and state has the prerogative to perform. It is challenging on the part of state to perform better and faster in responding to a pandemic. As per the recommendation of 14th finance commission, states are to be given greater autonomy and flexibility to spend according to health priorities. I too advocate for more autonomy for public hospitals and district public authorities to make them enable to plan and implement certain essential services under vertical supervision.
· District societies should build the capacity to monitor the quality of health care. The standard for improving public health care lies in promoting good administration and building structural and managerial aptitude of public hospitals and hospitals at district and subdistrict levels.
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