CENTRE for POLICY ANALYSIS

CENTRE for POLICY ANALYSIS

“Social progress can be measured by the social position of the female sex” - Karl Marx

ARTICLE


Healing the Health System


Healthy families are the foundation of healthy communities. There is nothing more important than good health, sanitation, clean air and water, and reliable health and medical care for all the family. Universal health coverage, the provision of quality healthcare to all people without imposing financial hardship, is an integral part of the United Nations Sustainable Development Goals.

Poor health and sanitation provision is one of the main impediments to eliminating poverty, and a driver of persisting inequalities. India's economy gets all the attention but its healthcare system is in worse crisis. For millions of people, increasing costs of treatment are eating away their household savings. This is largely on account of the country's dilapidated system of public health provision, which is only a symptom of the dire denial of funds.

India ranks poorly compared with most countries including our neighbours on most health indices. Illnesses pose a severe risk and having to resort to commercial healthcare can wipe out a family's hard earned savings in low income communities. Out of pocket expenses on high-priced medical care are the main route to bankruptcy and falling back into poverty.  

Much blame must be laid upon our screwed-up healthcare system, which scorns the very idea of public health, and treats access to medical care as a private luxury that is rightfully available only to some. Healthcare has now become a critical leverage point, where government action could have the maximum impact. The government's development wisdom is now focused on identifying the strategic leverage points where successful action could trigger many supportive reactions.  

The growth of healthcare facilities has been concentrated in the commercial sector even as public hospitals continue to be under-resourced, understaffed and poorly managed, thus delivering poor quality care. This has led to a rapid mushrooming of unregulated commercial providers. Health systems-including strong primary health services-are imperative to deliver on health for all.  

Healthcare expenses are a major cause of impoverishment for working families. Commercial healthcare has catastrophic costs with spillover consequences, resulting in less money being available to families for food, education, housing and long-term investments and plans. An illness in the family is a bigger risk to farmers than a perished crop. Forced to sell their livestock or land, they become indentured labourers for a generation or more.  

The effects of poor health on productivity in wage-work are well documented, too. Indians work for just 6.5 years at peak productivity, compared to 20 years in China, 16 in Brazil and 13 in Sri Lanka, ranking 158th out of 195 countries in the World Bank's Human Capital Index.  

Besides public provision, community-based health insurance, rather than market-mediated or government-provided insurance, is widely considered an appropriate way of reaching and protecting the poor. Subsidising commercial health insurance at public cost has potential risks and benefits in terms of healthcare access for the poor. It could result in substantial long-term welfare benefits but it is unaffordable for most low-income families. Synergy between businesses and governments can help ensure that everyone has the rights and access to improved health outcomes.  

India must revitalize its public health system to ensure access, outcome, quality and affordability. The focus must be on finding solutions which are affordable, scalable and yet of a high quality. The government needs to supplement curative services with preventive measures by strengthening ancillary civic services like insect management, water purification systems, sewage systems and plants for the treatment of industrial effluents and waste.  

Due to poor hygiene and sanitation, people are suffering from preventable diseases like pneumonia, malnutrition, malaria and tuberculosis. The biggest disease burden sits on the bottom pyramid of 500 million people. They don't have access to reliable diagnosis or proper treatment. If they get diagnosed, they find it hard to get treatment. Government-run hospitals are free for everyone but access is difficult, quality is abysmal and corruption is endemic.  

Another challenge for the health sector is the lack of provisions to deal with non-communicable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Unlike the short-term effects of communicable diseases, the dual health and economic impacts of non-communicable diseases on individuals, families and households are devastating and long-lasting. Changing this would mean providing a clean environment and potable water so that infectious diseases are contained to the minimum and a stress-free and healthy lifestyle to ward off the growing threat of non-communicable diseases.  

There is a massive shortage of healthcare professionals in the country and their supply must therefore be expanded rapidly if we want to fulfil our commitments in this sector.    

Because of these factors, a disease that is not bothersome is often ignored. The main providers of healthcare are doctors, who are unevenly distributed and quite expensive. The need to repeatedly visit a faraway doctor to manage chronic conditions makes quality sustained care unaffordable.  

Stakeholders now agree that increasing penetration in care delivery for chronic non-communicable diseases will require us to move away from Euro-American physician-based models of healthcare delivery, which favour the relatively privileged. We will have to identify resources in the community and co-opt them to improve efficiency, with programmes made transparent to the people to ensure fairness. Health policies should remove user fees, tackle social discriminations, innovate in service delivery, and break down public expenditure by quintiles.  

Several innovative efforts in community-based health services in rural India have given people living in remote communities access to affordable preventive and primary healthcare. Village health workers provide prenatal care, monitored child immunisations, and initiate self-help groups to fund cooperative business enterprises.  

Any visitor to a village where these community healthcare models are the primary drivers of health awareness will marvel at the ability of the health workers to connect with and explain things to women. Their lack of a degree is not a handicap, it is an advantage. They understand how to reach the people who most need reaching: illiterate, vulnerable and poor village women. They know how they think and live, because they are one of them.  

Co-designing, co-creating, and co-owning health services is an increasingly effective and scalable path to achieving inclusive and sustainable health outcomes. Putting people and communities in charge of their own healthcare also leads to better outcomes and increased effectiveness through the use of traditional knowledge and local healing flora and fauna.  

The central government, too, has learnt from these initiatives and its public health programmes are modelled around them. Community health workers, including the Accredited Social Health Activists (ASHA) and the Auxiliary Nurse Midwife, are the foundation of our under-resourced public health system and have played a central role in its success, reducing maternal and child mortality. These professionals are central to India's strategy to improve maternal and child health and are selected by the village they serve. They are the best health mentors, since they are often closest to the people in most need.  

We cannot achieve the goal of reaching everyone, everywhere with vital health services without an effective last mile, and ensuring that all people can access quality and affordable health services. Public policy needs to actively promote those innovations that can accelerate our journey to universal healthcare: increased access, quality and affordability of healthcare; increased responsiveness of the system to healthcare needs; greater health equity; autonomy in healthcare choices; and above all, improvements in the social determinants of healthcare.

World governments recognised the importance of primary health care forty years ago at Alma-Ata. That declaration did gain traction, but there was slow implementation for a variety of reasons-above all the lack of political will. Today, we have political momentum and the technological advancements needed to make universal healthcare a reality.  

Several laudable policies are already in place. The direction of travel, so to speak, is right but we have to accelerate the pace of the journey. For reforms to be successful we need hard-coded timelines and the accountability of those tasked with the administration. It is now for the policy doctors to collaborate with the medical professionals to come up with radical solutions that can build a healthier world for everyone.    

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