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
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.