Introduction
- The Union Budget 2024-25 has faced criticism for its insufficient emphasis on the social sector, particularly public health.
- Earlier this year, the Supreme Court of India raised concerns about the increasing out-of-pocket healthcare expenses in the country, attributing this issue to the lack of a strong public health infrastructure.
Definition of Public Health
According to WHO, public health involves all organized efforts to prevent diseases, promote health, and extend life among the general population. Its focus is on creating conditions for health across entire populations, rather than addressing individual diseases or patients.
Categorization of Public Health
- Disease Prevention for the Poor and Vulnerable: This includes the prevention of diseases like tuberculosis, malaria, undernutrition, maternal mortality, and water-borne infections such as typhoid, hepatitis, and diarrheal diseases, which disproportionately affect impoverished communities.
- Environmental Health for the Middle Class: Middle-class populations face public health challenges from air and water pollution, inadequate waste management, poor drainage systems, and rising rates of chronic illnesses related to lifestyle and environmental factors like climate change and road accidents.
- Curative Public Health: This focuses on providing curative care, which is often the most demanded public health service. Curative care deals with the treatment and management of illnesses once they have occurred and is essential for health policy.
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Structure of the Public Health Sector in India
Primary Health Care:
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- Sub-Centers (SCs): These are the first point of contact in the health system for a population of 5,000 in plain areas and 3,000 in tribal/hilly regions.
- Primary Health Centers (PHCs): PHCs serve 20,000-30,000 people and are the first contact with a qualified doctor. They provide preventive, promotive, curative, and rehabilitative services.
- Role: Primary healthcare facilities are essential for poor and vulnerable populations, providing the most affordable and accessible health services.
Secondary Health Care:
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- Community Health Centers (CHCs): These 30-bed facilities provide specialist care in surgery, obstetrics, pediatrics, and medicine for populations of 80,000-120,000 in plains and 40,000-60,000 in tribal areas.
- Role: CHCs function as referral centers for PHCs, offering higher-level healthcare services.
Tertiary Health Care:
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- District Hospitals: With 100-300 beds, these facilities provide specialized care at the district level.
- Medical College Hospitals and Specialty Centers: Advanced tertiary care is provided by institutions like medical colleges, mental health institutes, and cancer centers.
- Role: Tertiary facilities handle complex health issues and act as referral centers for secondary and primary levels.
Key Government Initiatives for Public Health Development
- National Health Mission (NHM): Aims to strengthen the public health system by developing infrastructure such as sub-centers, PHCs, and CHCs.
- Ayushman Bharat – PMJAY: A public-funded health insurance scheme, covering secondary and tertiary hospitalization for over 100 million families.
- Health and Wellness Centers (HWCs): PHCs are being transformed into HWCs to offer comprehensive healthcare, including preventive and promotive services.
- Pradhan Mantri Swasthya Suraksha Yojana (PMSSY): Focuses on increasing tertiary care facilities by establishing new AIIMS and upgrading medical colleges.
- Jan Aushadhi Scheme: Provides affordable generic medicines through Jan Aushadhi Kendras to improve access to quality healthcare.
- National Digital Health Mission (NDHM): Developing a digital health infrastructure, including health IDs for citizens, to improve service delivery.
Existing Challenges in India’s Public Health Sector
Inadequate Access to Healthcare:
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- There is a shortage of infrastructure and healthcare professionals, particularly in rural areas, contributing to unequal access to services. According to the Rural Health Statistics 2021, there is a 76% shortage of specialists in Community Health Centers (CHCs), and around 5% of primary health centers function without doctors. For example, states like Bihar and Uttar Pradesh suffer from severe shortages of health professionals, with doctor-to-patient ratios far below WHO-recommended levels.
Short-Term Focus:
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- The emphasis on short-term results, such as hospital openings and subsidized treatments, neglects the long-term development of healthcare capabilities. An example is the proliferation of new hospitals in states like Telangana and Andhra Pradesh under populist policies. While these initiatives gain political favor, they do not address critical issues like preventive healthcare or the training of healthcare professionals.
Low Government Spending:
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- With only 1.1% of GDP spent on health, India lags behind countries like China and Sri Lanka, impacting overall healthcare quality. For example, during the COVID-19 pandemic, the underfunded health system was overwhelmed, leading to a shortage of hospital beds, oxygen, and essential medicines, highlighting the need for increased spending on healthcare infrastructure.
Neglect of Public Health Basics:
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- Areas like sanitation, disease surveillance, and health education have been overlooked, contributing to disease outbreaks. Additionally, the Swachh Bharat Mission, while improving sanitation access, still faces challenges in behavior change regarding open defecation and waste disposal, which continues to exacerbate public health issues.
Profit-Driven Pharmaceutical Sector:
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- A focus on profits has led to marginalization of essential public health areas, such as the treatment of diseases like tuberculosis. For example, drug-resistant tuberculosis (DR-TB) has been on the rise in India, yet investment in research and development for effective TB treatments remains low compared to drugs for more profitable diseases. A 2019 report by Médecins Sans Frontières (MSF) highlighted that TB drugs remain inaccessible to many due to high prices, demonstrating the conflict between public health needs and pharmaceutical profit motives.
Limited Preventive Care:
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- Preventive healthcare is undervalued, despite its potential to reduce disease incidence and healthcare costs, particularly as India faces a ‘triple burden’ of diseases (communicable, non-communicable, and emerging). For example, non-communicable diseases (NCDs) now account for over 60% of deaths in India, yet public health campaigns and infrastructure remain inadequate for NCD prevention.
Advantages of a Robust Public Health Sector
- Improved Access: Strengthening the public health sector will ensure more equitable access to healthcare services across the population. For example, improving healthcare infrastructure can address disparities highlighted by the Lancet, which ranked India 145th out of 195 countries for healthcare quality and accessibility.
- Better Health Outcomes: Early detection and treatment through a strong public health system can reduce the burden of non-communicable diseases like cardiovascular disease.
- Reduced Financial Burden: A robust public health system reduces out-of-pocket healthcare expenditures, preventing poverty caused by catastrophic healthcare costs.
- Social Equity: A well-functioning public health sector promotes social justice by providing timely and free care to all sections of society, fulfilling constitutional directives related to social equity.
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Way Forward
- Increased Health Expenditure: Implement the NITI Aayog recommendation to raise health spending to 2.5% of GDP, with a focus on preventive care.
- Health Cost Management: Establish a National Commission to make recommendations on healthcare spending and monitor performance.
- Depoliticize Health Decisions:] Public health policy should be based on scientific evidence and long-term planning, rather than political gains.
- Focus on Nutrition: Investing in nutrition programs can improve long-term health outcomes and economic productivity.
- Comprehensive Public Health Approach: A multi-disciplinary approach, integrating environmental health, community health, and preventive measures, is crucial for effective public health management.
- Universal Health Coverage: State governments should experiment with pilot programs to achieve universal health coverage, ensuring that all citizens have access to necessary healthcare services.