Bridge the Need Gap

Although the total expenditure on health in India is around 5 per cent to GDP, which is roughly comparable to other developing countries, still there is a disproportionally high reliance on private, particularly household's out of pocket expenditures. This reflects a critical imbalance in the healthcare system, which stemmed from deficiencies in the public sector's capacity to deliver basic healthcare. The private sector too has wide variations. At one end of are private hospitals with world class facilities and personnel offering services competitive to similar services abroad, but are beyond the capacity of most Indians due to the price. At the other end, there is an unregulated private sector which is more affordable, but offer services of varying quality and under-qualified practitioners.

The government has taken several steps to decrease the gap and maintain balance in the Healthcare sector. There are various programmes running at State & District level which aims at strengthening the healthcare infrastructure in rural areas, providing sub centres, primary health centres, community health centres, etc. However the major focus should be given for sustained & planned efforts for next 10 years towards this sector since it needs critical attention. The areas which need immediate attention are:

(i)    Infant Mortality Rate (IMR) – specially female feticide
(ii)    Improving child sex ratio for age group 0-6 years
(iii)    Under-nutrition among children
(iv)    Total Fertility Rate (TFR)
(v)    Maternal Mortality Ratio (MMR)
(vi)    Anaemia among women and girls
(vii)    Provision of clean drinking water for all

We must re-strategise to achieve faster progress towards the seven areas listed above and also define our healthcare strategy more broadly. So far the focus has been heavily on child-birth and pre-natal care; however, we have to develop a more comprehensive vision of health care, which includes service delivery for a much broader range of conditions, covering both preventive and curative services. Remedy  of Mental Health, AIDS control, Deafness control, Care of the elderly, information, education and communication, cancer control, tobacco control, cardio vascular diseases, oral health, fluorosis, human rabies control, and leptospirosis should be given due significance. Physical fitness is a prime and basic requirement for ensuring good health and there is a growing recognition of the importance of sports for health, physical fitness and nutrition.

A systematic responsibility allocation of functionaries of the health, women & child development, and water & sanitation departments at all levels should be clearly defined. Definite roles and accountabilities should be assigned to Civil Society Organisations, processes like real time data collection, community-based validation, and medical audits to ensure quality, cost-effectiveness and promptness of healthcare should be introduced. While preventive health care is much cheaper than curative care, it has so far not received the attention it deserved. Existing frontline health educators and counsellors should play a lead role in compiling and disseminating preventive health practices in every nook and corner of the country. The State should play a lead role in building a culture of familiarity and knowledge around public health by involving Panchayati Raj Institutions (PRIs), Rogi Kalyan Samitis, Village Health, Sanitation and Nutrition Committees, Urban Local Bodies (ULBs) and the available cadre of frontline health workers, through innovative use of folk and electronic media, mobile telephony, multimedia tools and Community Service Centers. But most importantly, families and communities must be empowered to create an environment for healthy living.

The effectiveness of a healthcare system is also affected by the ability of the community itself to participate in designing and implementing delivery of services. The opportunity to design and manage such delivery provides empowerment to the community as well as better access, accountability and transparency. In essence, the healthcare delivery must be made more consultative and inclusive. This could be achieved through a three dimensional approach of
(i)    Strengthening PRIs/ULBs through improved devolution and capacity building for better designing and management
(ii)    Increasing users' participation through institutionalized audits of health care service delivery for better accountability
(iii)    Bi-annual evaluation of this process by empowered agencies of civil society organisations for greater transparency

Methodologies based on community based monitoring, which have proved successful in some parts of the country, will need to be introduced in other parts. We must break the vicious cycle of multiple deprivations faced by girls and women because of gender discrimination and under-nutrition. This cycle is epitomised by continued deterioration in the sex ratio in the 0-6 year age group, revealed by the Census 2011. By high maternal and child mortality and morbidity, and by the fact that every third woman in India is undernourished (35.6 per cent have low Body Mass Index) and every second woman is anaemic (55.3 per cent). Ending gender based inequities, discrimination and violence faced by girls and women must be accorded the highest priority and these needs to be done in several ways such as achievement of optimal learning outcomes in primary education, interventions for reducing under-nutrition and anaemia, and promoting menstrual hygiene in adolescent girls and providing maternity support. Also certain essential interventions outside the commonly understood ‘area of health' need to be made, such as provision of sanitation facilities, including construction of toilets with water facility in schools, higher education opportunities and subsequent linkages to skill development. The effort to promote women's health cannot be without participation of men; hence, imaginative programs to draw men into taking part in their health seeking behaviour and practices must be devised.

We must consider children an urgent priority. This will involve convergence of Health and Child Care services. At present, Health and Child Care services to 83 Crore Rural Indians residing across 14 lakh habitations, 6.4 lakh villages and 2.3 lakh Gram Panchayats are provided, rather independently, through a network of around 11 lakh Anganwadi Centres (AWCs) of the Women and Child Development Department and 1.47 lakh Sub-Centres of the Health Department. Often, women attending AWCs with their children have to travel long distances to avail primary health care. While there is a case for expanding the network of AWCs to all habitations, even more urgent is the need to create a direct reporting relationship between AWCs and Sub-Centres so that interventions are better synergized, resources are optimized, while women and children attending AWCs continue to get health and nutritional services under one roof.

The health policy must focus on the special requirements of different groups, e.g., integrated geriatric health care and other needs specific to the elderly, ‘adolescent friendly' health support services (and counselling) for victims of sexual or substance abuse, those infected with HIV/AIDS, and those who belong to the transgendered (LGBT)community. Regional disparities must be addressed especially with respect to maternal health and child under nutrition. The high rate of growth of the population, particularly in certain States, should also be addressed. Mental health services, including psycho-social care and counselling, should be prioritized, in settings of transition due to migration, areas of conflict and disturbances, especially in the NER and J&K and in areas of natural disasters/calamities.

Other infectious diseases such as tuberculosis, malaria, also need focused attention and a continued commitment to prevention and control. India also faces an escalating threat of non-communicable diseases like cardiovascular diseases, diabetes, cancers and chronic respiratory diseases which are major killers, especially in middle age. The government has to respond through a package of policy interventions including tobacco control, early detection and effective control of high blood pressure and diabetes and screening for common and treatable cancers.

One of the major reasons for the poor quality of health services is the lack of capital investment in health for prolonged period of time. According to the Rural Health Statistics (RHS), 2010, there is shortage of 19,590 Sub-centres; 4,252 PHCs and 2,115 CHCs in the country. It is essential to complete the basic infrastructure needed for good health services delivery in rural areas. Government diagnostic services must be strengthened at the block and district levels. This would require not only infrastructural upgrades but also adequate human resource support and well developed service delivery protocols. States also lack infrastructure for ancillary services like drug storage and warehousing, medical waste management, surveillance and cold chain management. Such facilities need to be ensured at the District level.

While the major task is to emphasise on delve & develop health infrastructure in rural areas, we should also remember that there is no such public health care infrastructure at the urban level available to the common person. A major challenge is to ensure that all urban slums and settlements are covered with Sub-centres, and ICDS centres and PHCs, through NUHM. This infrastructure cannot be based on mechanical application of population based norms since many people in urban areas have access to private medical care. There is need for further expansion, especially in areas where lower income people reside. We should initiate & prepare a plan for this segment as well by creating local, low-cost treatment centres around relevant disease groups rather than generic ones, thus using resources more efficiently.

Sufficient funds should be allocated aiming at computerizing and interlinking all health facilities (Sub-centres, Primary Health Centres, Community Health Centres, District hospitals, Referral Hospitals and Medical Colleges) and use IT/Mobile technology for creating new interfaces. IT can be used to create and sustain robust surveillance systems to remedy the present absence of accurate information on disease burdens as well as the frailty of early alert system for outbreak of infectious diseases. The Integrated Disease Surveillance System (ISDP) has not fully delivered and surveillance of non-communicable diseases has just started. The district health system must be strengthened and links established with non-governmental health care providers to develop a reliable and accurate reporting network for infectious diseases and risk factors of non-communicable diseases. Without such information, policy and programme, planning will be enfeebled and impact evaluation will be difficult to undertake. Hence, there is a need to build a vibrant Health Information System for monitoring and evaluation.

Ensuring delivery of safe drugs is a major challenge. There should be a tested model for procurement and distribution to achieve economies of scale and use of power for procuring drugs at substantially marked down prices. The following points could be considered for doing the same:
(i)    Emphasis on local production of drugs, especially those that are relevant to the local disease burden. Public Sector Units (PSUs), which have manufacturing capabilities, can play an important role in ensuring reasonably priced supply of essential drugs and they should be strengthened for this process.
(ii)    Making the prescription of unbranded generic medicines mandatory by State government and Central government institutional doctors and mechanism to ensure its compliance by appropriate audit processes
(iii)    Availability of drugs to be ensured through expansion of the existing Jan Aushadhi Stores in all district, Sub-division and Block hospitals.

As noted earlier, the burden of financing healthcare falls excessively on households in the form of out of pocket expenses. This burden can be lightened by expanding the supply of publicly financed healthcare services in primary, secondary and tertiary care. Ideally, this should be done through high quality, district level plans for health services provision, funded primarily by the states. These plans should become the basis for resource allocation and be made a public document to enable social audits of the progress made towards the goals.

The upcoming Budget should provide an opportunity of bringing together the world's largest health and child care systems through flexible frameworks that ensure a continuum of care with normative standards, while responding to local needs at village and habitation levels. Convergent action over the next financial year will translate this vision into programmes that will touch the lives of all citizens, meet their expectations and also fulfilling their rights – particularly the rights of women and children in the communities, where they live and grow.

(Harpal Singh, Chairman – Nanhi Chhaan Foundation)