India is a big country and is currently passing through demographic, economic, epidemiological and environmental transition. During independence India was left with crippled economy, devastated health care system and over-population. But post independence, there has been development in various fields like economy, healthcare, communication, transport and connectivity etc. In the public health field there were developments post 1947 and some of the major important milestones are only mentioned here.
1. Formation of Bhore Committee in 1946:
In 1946, a committee (Health survey and development committee) was formed known as Bhore Committee. This committee gave some important recommendations which were implemented only after 1947;
- Integration o
- f preventive measures in every sector (Personal Hygiene, hand washing, environmental hygiene, Sanitation and disposal of waste)
- Development of PHC’s (more focus was on remote and rural areas)
- Recommendations were made for changes in medical education curriculum
2. Indian Public Health Association in 1956:
Indian Public Health Association (IPHA) was established in 1956 at Kolkata. This association helps the government to frame policy and promote public health measures in the country to provide best possible health care services to its citizens. IPHA also serves its role in publishing journals and articles in public health and preventive medicine.
3. Medical Education Committee in 1960:
Medical education committee was established in 1960 to upgrade and reform medical education in the country. It was established primarily to reform the curriculum of the medical students. Medical education committee was named as the Medical Council of India and then changed to the National Medical Commission in 2020 through an ordinance bill.
4. National Institute of Health and Family welfare in 1977:
NIHFW was established in 1977 by merging two national institutes. The institute aims at addressing various issues on health and family welfare through various departmental collaboration like Health administration, adult education, epidemiology, health management, hospital administration, Human development, family planning and demography. The main focus is around the major issues in line with Millennium Development Goals (MDGs).
5. Public Health Foundation of India:
PHFI was established in 2006 to strengthen training and education of public health professionals, research and policy development, affordable health care technologies, health promotion and formation of prioritised health settings in the area of public health in the country.
6. National (Rural, Urban) Health Mission:
National Rural and Urban Health Mission was started in 2005 to provide health care services both at rural and urban levels. The goals of the NR & UHM include reduction in Infant Mortality Rate (IMR) and Maternal Mortality, universal access to integrated and comprehensive public health services , child health, water, sanitation and hygiene and prevention and control of communicable and non-communicable diseases. It was later changed to the National Health Mission in 2013
Major Achievements in Public Health post Independence
- In the past five decades, life expectancy has increased from 50- 69 years ( 72 years in females and 69 years in males).
- Infant mortality rate came down from 57 to 30 per 1000 births (as of 2020).
- Fertility rate decreased from 5.5 to 2.2 live births (as of 2020).
- Establishment of PHC’S and CHC’S as part of rural primary health care.
- Prevention of maternal deaths due to improved institutional deliveries and better trained health attendees.
- Antenatal screenings to eliminate neonatal risks.
- Child health and nutrition through Food Fortification under National Food Security Act (NFSA – 2013).
- India is a Polio free country.( Declared Polio free in 2014)
- Target already set for Malaria and TB eradication.
- Malaria control through National Malaria Control Policy 1950.
- Establishment of DOTS program for TB eradication.
- HIV AIDS control through National Aids Control Organization ( NACO).
- Swachh Bharat Abhiyan, Cleanliness Drive Campaign was launched in 2014 to control open defecation and aimed at environmental Hygiene, personal hygiene and to reduce spread of diseases in the community. ( A great example of which is Asia’s Cleanest Village in Mawlynnong, Shillong-Meghalaya)
- To provide clean and easily accessible tap water to every household through the Jal Shakti Program (Har Ghar Jal Program).
- National Immunisation program for all children below 5 years to reduce mortality and morbidity.
- National Action Plan for Antimicrobial resistance (AMR): Antimicrobial resistance is an upcoming public health challenge. To prevent this, a National Action Plan was drafted in 2017 to counter Antimicrobial Resistance. The main objectives of the National Action Plan include public awareness, surveillance and collaborative efforts to counter AMR e.g. prescription is mandatory for most of the over-the-counter (OTC) drugs to prevent self medication which is probably a basic cause of AMR.
- Public Private partnership: Public Private partnership is important to restructure the poor quality health sector. Modern health care systems and services can only be achieved through public private partnership.
- Universal Health Coverage through PM- JAY: Pradhan Mantri Jan Arogya Yojna (PM-JAY) was launched in 2017 through National Health Policy. It is aimed to provide universal health coverage, free and easily accessible health care services and to provide free health insurance coverage to the poor in order to meet the requirements of Sustainable Development Goal’s (SDG’s).
There is a strong evidence that economic inequality and disparity among people is related to worse health outcomes.
India is presently going through a state of transition environmentally, economically, demographically and epidemiologically in terms of health. Since last decade, unprecedented economic development particularly in terms of Gross Domestic product (GDP) is significantly visible, but unfortunately this progress has created disparities between the rich and the poor. There is correlation between economy and health outcomes. There is a strong evidence that economic inequality and disparity among people is related to worse health outcomes. This in turn widens the gap between the rich and the poor and has damaging health and social consequences. Financial and social security measures are being implemented by the Government to bridge economic inequalities but there is need to do more. Presently India is having a triple burden of disease;
- Some unfinished Infectious diseases and their disease burden like TB
- The challenge of non communicable Diseases (NCDs) which are linked with lifestyle changes and behaviour
- Emergence of new infections due to population growth causing epidemics and pandemics.
Diseases, like polio, tetanus have been eradicated due to successful vaccination programs and effective community participation.
In addition to these, the health care system is already substandard and needs to be strengthened to enable it to confront these challenges. In the health sector, India has made remarkable progress over the past decades. The life expectancy reached 67 years in males and 69 years in females, and infant as well as under-five mortality rates have declined subsequently over the years. Diseases, like polio, tetanus have been eradicated due to successful vaccination programs and effective community participation. In spite of this progress made, communicable diseases and their burden is expected to continue and to remain a major public health problem in the coming decades. Besides endemic diseases such as HIV/AIDS, Tuberculosis (TB), Malaria, and neglected tropical diseases, the communicable disease outbreaks will continue to challenge public health. Also vector-borne diseases, such as dengue and acute encephalitis syndrome, are of particular concern and need effective intervention. Antimicrobial resistance is one of the biggest public health challenges currently.
This has arisen due to uncontrolled drug policy and it must be tackled with all efforts in upcoming years. In addition, non-communicable diseases are now the leading cause of death in the country, contributing to 60% of deaths. Noncommunicable diseases (NCDs) like Heart disease, cancer, diabetes, and chronic pulmonary diseases are leading ones. Approximately 80% of all deaths are due to these four diseases. These diseases have multiple causal factors like smoking, alcohol, unhealthy diet, and lack of exercise. Also important concern is the maternal mortality ratio and infant mortality rate (IMR) which still remain unacceptably high as compared to other South Asian Neighbouring countries except Pakistan. The IMR, which was 81 in 1990, according to the World Health Organization (WHO), declined to 30 Per 1,000 live births as of 2019. According to the sample registration system (SRS) report as of 2018 the IMR is 36 per 1,000 live births. Since mortality rates have declined significantly but the rate of incidence is still high, compared to that being achieved by other South Asian neighbours with exception of Pakistan.
A Framework To Strengthen Public Health Sector: Covid-19 Fallout
COVID-19 pandemic caused deleterious effects and is devastating nations and has incapacitated the health systems of nations globally. Nations weren’t fully prepared and the pandemic has been carried out with great losses both physically and economically. On one hand Developed nations were bearing the after effects of COVID-19 while on other hand developing countries are still taking steps to control the pandemic while facing economic hardships.
Universal health coverage is needed more than ever to recover from the effects of the current pandemic more importantly in developing countries like India. Post pandemic lessons need to be learnt which I already have mentioned especially for developing economies like India where the public healthcare system is not up to the mark.
COVID-19 pandemic has emphasized the need for strengthening public health care systems globally. The fate of COVID-19 pandemic in countries with well-established health systems stresses on the need for a strong public health system that goes beyond hospitals and health establishments. Government should take measures to develop sustainable capacity to respond to rapidly spreading epidemics and must recognize overlooked public health services as vital, and adequately finance them as part of the UHC model. The current framework is aimed to highlight the key concerns in the public healthcare system of India and areas that need prioritization learned from the pandemic.
WHO Leadership; An important element to support developing world
The World Health Organization, the world’s health body, has emphasized the importance of national health, works on its planning and monitors critical functions to improve health systems globally. There should be a sophisticated and robust approach to deal with any kind of pandemic without political interests and WHO should work on this uniquely and be autonomous. Developed nations need to fund this organisation without any interests and more focus should be emphasized to developing countries ( South East Asia, Middle East and Africa). WHO needs to adapt a policy to fund the developing countries with economic packages to counter economic hardships due to pandemic.
A national action plan for pandemic preparedness should be formulated for developing countries while taking all the key factors (economy, geography, climate change, population, health system) in account. India has already enforced many acts like Epidemic Diseases Act, Disaster Management Act, Essential Commodities Act, Healthcare Establishment Act, etc. as part of the action plan. Unfortunately many of such acts have their own drawbacks and these need to be modified for the current scenario.
Health care system and its Financing
The healthcare model in India was designed and aimed to provide basic health services as primary care to the population (prioritizing women’s and children’s health). But it came out more as an “Out of Pocket model” where the rich acquire high quality health care services and the poor suffer due to economic hardships and unreasonable high cost of private hospitals. To support the health care system and services, the Government of India launched Ayushman Bharat Scheme under National Health Policy 2017. It is aimed at two core issues, free accessible Health services under Health and Wellness Centres and free access to health insurance coverage under National Health Protection Scheme (NHPS). Health and Wellness Centres are working as foundation of the health system to provide basic primary care, free essential drugs and diagnostic services to all the citizens, whereas National Health Protection Scheme is working on to provide financial services to poor and vulnerable families which arises due to high costs at secondary and tertiary care hospitalization. The National Health protection Scheme should ensure financial protection also for marginal people when they seek treatment during pandemics.
The Indian government’s expenditure on health is merely around 2%, one of the lowest in the world. More than 60% of households in urban areas, and 50% of households in rural areas consult private hospitals when they need medical attention. During the pandemic, health expenditures rose because of the high cost offered by the private healthcare system which is unfortunately not regulated by the government. Health care budget should be given priority along with the education sector (prioritising maternal education). Policies should be made to invest in the health care sector, priority should be made to rural areas, up-gradation of hospitals to modern levels, all technological advancements should be made available and easily accessible and finally there should be Public private partnership which is an important step to formulate sophisticated modern health care system.
The country’s public healthcare system should have technological advancements with an easy accessibility and applicability to people.
Strengthening Public Health System
There is an immediate need for strengthening the public health system in India with priority focused on building public health professionals. Healthcare workers need to be strengthened by continuous capacity building and training in public health fields. There should be Public health laws to ensure active participation of the private health sector and other health related sectors. The country’s public healthcare system should have technological advancements with an easy accessibility and applicability to people. There is a need for cooperation between local and state public health agencies with the centre, in order to apply guidelines at its first phase and on priority basis. There should be robust and sophisticated mechanisms for data sharing especially during outbreaks. This will prove beneficial during challenging times.
Moreover there is a need to come up with policy development for public health education in India. Master of Public Health(MPH), which is a two year Master’s program mainly aimed at education of health care workers in the public health field. There’s more that needs to be done in terms of financing the public health education sector. Unfortunately uptil now there is no governing body or council to represent this field. There should be immediate action devised by the government.
Health care workforce
Manpower is important for every system to work properly. Public health care system can’t cope with the current challenges without a health care workforce. India has had a shortage of healthcare workers from the beginning and it still persists, as was visible during the pandemic. In order to cope up with the current challenges and a future policy, the government of India should come up with a policy to educate, train other health care workers (AYUSH, Nursing). The training should be focused mainly on modern medicine skills. Alternatively these professionals can be posted at rural areas to cope up with the shortage of health care workers and can also prove handy in challenging times like during pandemics.
Pandemics like COVID-19, Influenza, HIV have timely reminded us that public health systems are core social institutions for any country. The government has already made policies to overcome the issues in the public health system through schemes like the National Medical Commission Act, 2019, Pradhan Mantri Jan Arogya Yojana etc. However, there is more to be done to sophisticate the public health care system like in developed countries. First step is to go with an adequate investment in health care for creating a health system that can withstand any kind of public health challenges, can deliver universal health coverage at all levels by all means and can meet the targets of the Sustainable Development Goals.
Composed by: “Dr Sameer Ul Haq is an MBBS graduate and is pursuing Master’s in Public Health at Indian Institute of Public Health Shillong. He has many achievements to his badge in various fields like Public Health, Global Health, Epidemiology besides having Clinical skills too.”