PUBLIC HEALTH is the science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society (WHO). It is a social and political concept aimed at improving health, quality of life among whole population through health promotion, disease prevention and other forms of health interventions.
PUBLIC HEALTH APPROACH is a holistic approach which encompasses all elements required for healthy living. It controls disease through health promotion, specific protection and by restoration and rehabilitation. In addition, disease surveillance which informs about ongoing as well as emerging public health issues is a core public health function. Other important functions are developing partnerships, formulation of regulations/laws, planning/policies and Human Resources Development.
WHAT THE INDIAN CONSTITUTION SAYS? Directive Principles of State Policy consider that the State shall regard raising of the level of nutrition and standard of living of its people and improvement of public health as among its primary duties under ARTICLE 47. In addition, ARTICLE 42, the State shall make provisions for securing just and humane conditions of work and for maternity relief. The health system in India is expected to perform with objectives based on these principles and evolve its spirit and structure to achieve these objectives.
EVOLUTION OF PUBLIC HEALTH IN INDIA: The most comprehensive health policy and plan document ever prepared in India was on the eve of Independence in 1946. This was the ‘HEALTH SURVEY AND DEVELOPMENT COMMITTEE REPORT’ popularly referred to as the ‘BHORE COMMITTEE’. This Committee prepared a detailed plan of a National Health Service for the country, which would provide a universal coverage to the entire population free of charges through a comprehensive state run salaried health service. Later, many other committees reviewed the existing health infrastructure/situation in the country and made recommendations needed to prevent and control diseases including communicable, non-communicable and emerging diseases.
Recently, the ‘EXPERT COMMITTEE ON PUBLIC HEALTH SYSTEM (1996)’, the‘NATIONAL COMMISSION ON MACROECONOMICS AND HEALTH (2005)’, NATIONAL FIVE YEAR PLANS, ‘NATIONAL HEALTH POLICY (1983, 2002)’, and many international initiatives such ‘UN MILLENNIUM DEVELOPMENT GOALS (2000)’, have also provided strong policy directives for the development of health care delivery system to control/prevent diseases.
PUBLIC HEALTH SYSTEM IN INDIA: Broadly, the healthcare services are divided under STATE LIST and CONCURRENT LIST in India. While some items such as public health and hospitals fall in the State list, others such as population control and family welfare, medical education, and quality control of drugs are included in the Concurrent list. The UNION MINISTRY OF HEALTH AND FAMILY WELFARE (UMHFW)is the central authority responsible for implementation of various programmes and schemes in areas of family welfare, prevention, and control of major diseases.
The public sector ownership is divided between central and state governments, and municipal and panchayat local governments. The facilities include hospitals, secondary level hospitals, first level referral hospitals (community health centres [CHCs] or rural hospitals), dispensaries, primary health centres (PHCs) and sub centres, and health posts.
WEAKNESS OF THE PUBLIC HEALTH SYSTEM IN INDIA
Broadly, the major weaknesses in the Public Health system in India have emanated from –ISSUES RELATED TO QUALITY AND FUNCTIONING OF PUBLIC HEALTH SERVICES.
DEFINITION: ‘QUALITY OF PUBLIC HEALTH SERVICES’ is defined by the extent of their availability and coverage, economic affordability and social accessibility to all sections of society, efficacy, safety and epidemiological rationale, and attitudes of the personnel. This, in turn, is dependent upon the ‘CULTURE OF HEALTH SERVICES’, which consists of the organizational principles, motivations of personnel at all levels and their interactions among themselves as well as with those to whom they provide services.
FACTORS THAT HAVE CONTRIBUTED TOWARDS DILUTION IN THE QUALITY AND REACH OF PUBLIC HEALTH SERVICES ARE GIVEN HEREUNDER:
- Public health has effectively remained a low priority for the Indian state in terms of financing and political attention in successive five-year plans. The overall system of health planning and decision making remained highly centralized and top-down with minimal accountability, giving little scope for genuine community initiatives.
- It may be noted that until 1983 India had no formal health policy. Although, significant expansion of healthcare infrastructure did take place after‘NATIONAL HEALTH POLICY-1983’ yet this remained grossly underutilized because of poor facilities and low attendance by medical staff, inadequate supplies, insufficient hours, lack of community involvement and lack of proper monitoring mechanisms. The Primary Healthcare Approach was never implemented in its full form, and selective vertical programmes were pushed as a substitute for comprehensive health system development.
- This already unsatisfactory situation seriously worsened with the onset of liberalisation era from 1990s onwards. This phase has witnessed staggering health inequities, resurgence of communicable diseases and an even more unregulated drug industry with drug prices shooting up, adding up to the current crisis in public health. Along with the retreat from the goal of universal access, special health needs of women, children and other sections of society with special needs have become further sidelined or are inadequately addressed.
- Closely related to this, and compounding this situation has been a Techno-managerial model of healthcare inspired by the West, with an inability to evolve effective indigenous models and appropriate technologies, or to effectively integrate modern and indigenous systems of medicine.
- Consequently, more emphasis is on more curative services and with inadequate lab capacity in the system and poor participation of private sector in public health activities. As per NFHS III, the pattern of health care expenditure in India shows that more than 70% of expenditure is from out of pocket by households. Estimates suggests that in India the total health expenditure is around 6% of GDP, and is dominated by out of pocket spending i.e. around 5%. The government/public expenditure on health care is around 1% of GDP. Due to this low public expenditure the reach and quality of public health services are below the desired level.
REJUVENATING THE PUBLIC HEALTH SYSTEM IN INDIA
Making right to health care a fundamental right is an important step to initiate changes in the public health delivery mechanism. The other major steps that may be taken for rejuvenation are:
- FIRST, a considerably strengthened, accountable and reoriented public health system needs to be nurtured. Such a rejuvenation of the public health system would require changes at levels of policy, structure, programmes, and processes. Such strengthening should ensure adequate infrastructure, human power, services and supplies at various levels, restoring the basic functionality of the system and rebuilding public confidence.
- SECOND, the base of strengthened public health would need to be a framework of comprehensive Primary Health Care including Community health workers in every habitation; much more functional and accountable Primary health centres (PHCs) and First referral units (FRUs), combined with a range of appropriate preventive and promotive activities.
- THIRD,to institutionalize accountability would require a legal and constitutional framework to assure health services as a Right. Once right to health care is considered, the task of the health movement would be to make sure the range of services is as comprehensive as possible, and to ensure that the services required by various marginalized sections and groups with special needs are definitely included.
- FOURTH,substantially raising public finances for the public health system, through general taxation along with various forms of special taxation and cesses for health security. Ending subsidization of the private medical sector and effectively taxing this sector, especially its upper end; a special health security cess on all financial transactions above a certain level; and preferential taxation of industries with negative health impacts are some other measures that may be considered.
- FIFTH,specific health care requirements of various groups with special needs – such as women, children, and elderly persons – would need to be met through sets of special measures, sensitively delivered by the general health system.
- SIXTH, specific major health problems, both communicable diseases such as TB and HIV-AIDS, and non-communicable health issues such as mental health would need to be addressed through programmes closely integrated with a robust comprehensive health system.
- SEVENTH, progressively bringing the private medical sector under social regulation would be essential for realization of health rights in meaningful manner. A first step in this direction would consist of legally and organizationally ensuring that this sector meets minimum standards -follows standard treatment guidelines, and observes ceilings on prices of essential health services.
- EIGHTH, much more effective public health support to indigenous healing systems is required, including active research on areas such as community based evaluation of indigenous healing methods and synergistic combination with modern medicine.
- NINTH, ensuring access to essential drugs in rights based framework, both in form of ensuring availability of the range of essential drugs free of cost in public health facilities, and stringent price control.
- TENTH, operationalising accountability and redressal mechanisms to ensure regular civil society monitoring and inputs at various levels.
CONCLUSION: Besides above, for realization of ‘PUBLIC HEALTH FOR ALL’, in its fullest and most humane sense, coordination and synchronization with other conditions such as- comprehensive nutritional and food security (linked to livelihood security), universal access to safe drinking water and sanitation, provision of healthy housing and local environments, universal healthy working conditions and a safe general environment, access to health related education and information for all, and an equitable, gender-just social milieu, free from violence are required