Public Health

India is presently in a state of transition — economically, demographically, and epidemiologically — in terms of health. While the last decade has seen remarkable economic development particularly in terms of gross domestic product (GDP) growth rate, unfortunately, this progress is accompanied by growing disparities between the rich and the poor. There is strong evidence to suggest that this income inequality or disparity between the different socioeconomic classes is associated with worse health outcomes. Widening the gap between the rich and the poor has damaging health and social consequences. While financial inclusion and social security measures are being implemented by the Government to bridge economic inequalities, health sector too must ensure that health disparities between and among social and economic classes are also addressed adequately.

The unprecedented demographic changes underway are likely to contribute to a substantially increased labor force. However, it will benefit the country only if the population is healthy. The country at present suffers from the triple burden of disease — the unfinished agenda of infectious diseases; the challenge of non-communicable diseases (NCDs), linked with lifestyle changes; and the emergence of new pathogens causing epidemics and pandemics. In addition, the health infrastructure is already over-stretched and needs to be strengthened to enable it to confront these challenges in the twenty-first century.

Challenges:

In the health sector, India has made enormous strides over the past decades. The life expectancy has crossed 67 years, infant and under-five mortality rates are declining as is the rate of disease incidence. Many diseases, such as polio, guinea worm disease, yaws, and tetanus, have been eradicated.

In spite of this progress, the communicable diseases are expected to continue to remain a major public health problem in the coming decades posing a threat to both national and international health security. Besides endemic diseases such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), malaria, and neglected tropical diseases, the communicable disease outbreaks will continue to challenge public health, requiring a high level of readiness in terms of early detection and rapid response. In this regard, vector-borne diseases, such as dengue and acute encephalitis syndrome, are of particular concern. Antimicrobial resistance is one of the biggest health challenges facing humanity that must be tackled with all seriousness.

In addition, non-communicable diseases or NCDs are now the leading cause of death in the country, contributing to 60% of deaths. Four diseases namely heart disease, cancer, diabetes, and chronic pulmonary diseases contribute nearly 80% of all deaths due to NCDs and they share four common risk factors namely tobacco use, harmful use of alcohol, unhealthy diet, and lack of physical activities.

Also of significant concern is the maternal mortality ratio and infant mortality rate (IMR) remain unacceptably high. The IMR, which was 81 in 1990, according to the World Health Organization (WHO), declined to 41.4 per 1,000 live births in 2013. However, it still is much higher than the global average for the same period of 33.6 per 1,000 live births (World Health Statistics 2015). According to the sample registration system (SRS) report of Oct 2015, the IMR is now 40 per 1,000 live births.

The epidemiological transition is, in fact, being fueled by the social and economic determinants of health and by some old and some new risk factors such as globalization, unplanned and unregulated urbanization, changing lifestyles, environmental causes (e.g., climate change and air pollution), and increasing influence of media and advertising. Moreover, great disparities between the rich and poor (and between those living in urban and rural areas) in access to health services continue to exist in the society. For example, the poorest of the poor and the most marginalized sections of the society are not only at a greater risk for communicable and NCDs, but are also least able to cope with the diseases resulting from these risk factors. If someone in the family gets sick, the family often gets trapped in poverty, partly due to the high cost of health care. The health-care system is also overstretched.

Opportunities for Health Reform:

Given the centrality of health in economic development, a paradigm shift in our approach is needed. The following are some suggestions for consideration:

First, investing more in health and recognizing disease prevention and health promotion as the topmost priority. Consequently, government health expenditure on health should increase from 1.3% of GDP at present to at least 2.5% before the end of 13th Five-Year Plan (2013-19). Presently, India has one of the lowest allocations to health among all countries of the world as a percentage of GDP. As a result of such a low investment in health and due to high out-of-pocket expenditure (85.6% which according to the World Bank is among the highest in the world), nearly 60 million people are pushed further into poverty and into the poverty trap from that, they are unable to escape.

Second, the health system should be strengthened to improve the process of service delivery. In order to make health services responsive to the need of the community, it is necessary to improve the functioning of the existing government health infrastructure.

Third, focusing on evidence, excellence, and equity. An evidence-based policy-making requires data on disease burden and the associated determinants. The focus should be on strengthening a widespread research and innovation culture throughout the country and generating homegrown data, obtained through surveillance, research, and monitoring and evaluation (M&E), so that these data can be used for policy and strategy development, priority setting, and evaluating the impact.

Fourth, leveraging technology to transform public health. Modern technology has great potential in bringing efficiency in service delivery and enhancing the reach of health services. It can, for example, connect remote areas with national centers of excellence or patients in villages with doctors in hospitals in urban areas through audio or video conferencing.

Finally, empowering health leadership and governance. It is now clear that most of the risk factors for ill health lie outside of the health sector. Therefore, action to combat these risk factors requires an inter-sectoral and interdisciplinary approach.

Uniquely, the role of the government is to formulate policies, plan services, and coordinate activities. It also has mobilizing and facilitating roles. It should reach out to the sectors other than the health sector to develop a consensus on national policies and to build the partnership between different sectors.