The practice of public health has been dynamic in India and has witnessed many hurdles in its attempt to affect the lives of the Indian people. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus (HIV) have been addressed through the concerted actions of the government. Social development coupled with scientific advances and health care has led to a decrease in the mortality rates and birth rates. This article is a literature review of the existing government machinery for public health needs in India, its success, limitations, and future scope.
Challenges Confronting Public Health
The new agenda for Public Health in India includes the epidemiological transition (rising burden of chronic non-communicable diseases), demographic transition (increasing elderly population) and environmental changes. The unfinished agenda of maternal and child mortality, HIV/AIDS pandemic and other communicable diseases still exerts immense strain on the overstretched health systems.
Silent epidemics: In India, the tobacco-attributable deaths range from 800,000 to 900,000/year, leading to huge social and economic losses. Mental, neurological and substance use disorders also cause a large burden of disease and disability. The rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000 deaths in 2005) makes it next in the list of silent epidemics. Behind these stark figures lies human suffering. Health systems are grappling with the effects of existing communicable and non-communicable diseases and also with the increasing burden of emerging and re-emerging diseases (drug-resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic). Inadequate financial resources for the health sector and inefficient utilization result in inequalities in health. As issues like Trade-Related aspects of Intellectual Property Rights continue to be debated in international forums, the health systems will face new pressures.
The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender, and race or ethnicity. Lack of adequate progress on these underlying social determinants of health has been acknowledged as a glaring failure of public health. In the era of globalization, numerous political, economic and social events worldwide influence the food and fuel prices of all countries; we are yet to recover from the far-reaching consequences of the global recession of 2008.
Addressing Public Health Issues- The Strategy and Stakeholders
To meet the formidable challenges described earlier, there is an urgent call for revitalizing primary health care based on the principles outlined at Alma-Ata in 1978: “Universal access and coverage, equity, community participation in defining and implementing health agendas and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 30 years. Attempts to achieve “Health For All” have been carried forward in the form of “Millenium Development Goals.”
Public health is concerned with disease prevention and control at the population level, through organized efforts and informed choices of society, organizations, public and private communities, and individuals. However, the role of government is crucial for addressing these challenges and achieving health equity. The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India’s public health system. Contribution to the health of a population derives from systems outside the formal health care system, and this potential of intersectoral contributions to the health of communities is increasingly recognized worldwide. Thus, the role of government in influencing population health is not limited within the health sector but also by various sectors outside the health systems.
Role of Government Within the Health Sector
1. Health system strengthening
Important issues that the health systems must confront are the lack of financial and material resources, health workforce issues and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The National Rural Health Mission (NRHM) launched by the Government of India is a leap forward in establishing effective integration and convergence of health services and affecting architectural correction in the health care delivery system in India.
2. Health information system
The Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector. Health profiles published by the government should be used to help communities prioritize their health problems and to inform local decision making. Public health laboratories have a good capacity to support the government’s diagnostic and research activities on health risks and threats but are not being utilized efficiently. Mechanisms to monitor epidemiological challenges like mental health, occupational health, and other environmental risks are yet to be put in place.
3. Health research system
There is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.
4. Enforcement in public health
A good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes, e.g., water quality monitoring, slaughterhouse hygiene, and food safety. Wide gaps exist in the enforcement, monitoring, and evaluation, resulting in a weak public health system. This is partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and lack of community involvement. The revival of public health regulation through concerted efforts by the government is possible through updating and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and their enforcement procedures.
5. Health promotion
Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened. Much can be done to improve the effectiveness of health promotion by extending it to rural areas as well; observing days like “Diabetes day” and “Heart day” even in villages will help create awareness at the grassroot level.
6. Human resource development and capacity building
There are several shortfalls that need to be addressed in the development of human resources for public health services. There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. The Public Health Foundation of India is a positive step to redress the limited institutional capacity in India by strengthening training, research and policy development in public health. Preservice training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. Changes in the undergraduate curriculum are vital for capacity building in emerging issues like geriatric care, adolescent health, and mental health. In-service training for medical officers is essential for imparting management skills and leadership qualities. Equally important is the need to increase the number of paramedical workers and training institutes in India.
7. Public health policy
Identification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector, e.g. in the United States, the “Healthy People 2010” offers a simple but powerful idea by providing health objectives in a format that enables diverse groups to combine their efforts and work as a team. Similarly, in India, we need a road map to “better health for all” that can be used by states, communities, professional organizations and all sectors. It will also facilitate changes in resource allocation for public health interventions and a platform for concerted intersectoral action, thereby enabling policy coherence.
8. Scope for further action in the health sector
School health, mental health, referral system, and urban health remain as weak links in India’s health system, despite featuring in the national health policy. School health programs have become almost defunct because of administrative, managerial and logistic problems. Mental health has remained elusive even after implementing the National Mental Health Program.
On a positive note, innovative schemes through public-private partnerships are being tried in various parts of the country in promoting referrals. Similarly, the much awaited National Urban Health Mission might offer solutions with regards to urban health.
Role of Government in Enabling Intersectoral Coordination Towards Public Health Issues
The Ministry of Health needs to form stronger partnerships with other agents involved in public health because many factors influencing the health outcomes are outside their direct jurisdiction. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.
1. Social determinants of health
Kerala is often quoted as an example in international forums for achieving good status of public health by addressing the fundamental determinants of health: Investments in basic education, public health, and primary care.
2. Living conditions
Safe drinking water and sanitation are critical determinants of health, which would directly contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of drinking water supply and sanitation through existing programs, in both rural and urban areas, is achievable and affordable.
3. Urban planning
Provision of urban basic services like water supply, sewerage, and solid waste management needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works to develop financially sustainable cities in line with the Millenium Development Goals, which needs to be expanded to cover the entire country. Other issues to be addressed are housing and urban poverty alleviation.
4. The revival of rural infrastructure and livelihood
Action is required in the following areas: Promotion of agricultural mechanization, improving the efficiency of investments, rationalizing subsidies and diversifying and providing better access to land, credit, and skills.
Elementary education has received a major push through the Sarva Siksha Abhayan. In order to consolidate the gains achieved, a mission for secondary education is essential. “Right of Children to Free and Compulsory education Bill 2009” seeks to provide education to children aged between 6 and 14 years, and is a right step forward in improving the literacy of the Indian population.
6. Nutrition and early child development
Recent innovations like universalization of Integrated Child Development Services (ICDS) and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive growth under the eleventh 5-year plan. The government needs to strengthen ICDS in poor-performing states based on experiences from other successful models, e.g., Tamil Nadu (upgrading kitchens with LPG connection, stove and pressure cooker, and electrification; use of iron-fortified salt to address the burden of anemia). Micronutrient deficiency control measures like dietary diversification, horticultural intervention, food fortification, nutritional supplementation, and other public health measures need intersectoral coordination with various departments, e.g., Women and Child Development, Health, Agriculture, Rural and Urban Development.
7. Social security measures
The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee Scheme (MREGS) has the potential to change the complexion of rural India. It differs from other poverty-alleviation projects in the concept of citizenship and entitlement. However, employment opportunities and wages have taken the center stage, while the development of infrastructure and community assets is neglected. This scheme has the necessary manpower to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry, horticulture, anti-erosion projects, and rainwater harvesting. The unlimited potential of social capital has to be effectively tapped by the government.
8. Food security measures
Innovations are required to strengthen the public distribution system to curb the inclusion and exclusion errors and increase the range of commodities for people living in very poor conditions. It is essential that the government puts forth action plans to increase domestic food grain production, raise consumer incomes to buy food and make agriculture remunerative.
9. Other social assistance programs
The Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security measures for the unorganized sector (91% of India’s workforce). The National Old Age Pension scheme has provided social and income security to the growing elderly population in India.
10. Population stabilization
There is all round realization that population stabilization is a must for ensuring the quality of life for all citizens. Formulation of a National Policy and setting up of a National Commission on Population and Janasankhya Sthiratha Kosh reflect the deep commitment of the government. However, parallel developments in women empowerment, increasing institutional deliveries and strengthening health services and infrastructure hold the key to population control in the future.
11. Gender mainstreaming and empowerment
Women-specific interventions in all policies, programs, and systems need to be launched. The government should take steps to sensitize service providers in various departments to issues of women. The Department of Women and Child Development must take necessary steps to implement the provisions of “Protection of Women from Domestic Violence Act, 2005.” Training for protection officers, the establishment of counseling centers for women affected by violence and creating awareness in the community are vital steps. Poverty eradication programs and microcredit schemes need to be strengthened for economic and social empowerment of women.
12. Reducing the impact of climate change and disasters on health
Thermal extremes and weather disasters, the spread of vector-borne, food-borne and water-borne infections, food security and malnutrition and air quality with associated human health risks are the public health risks associated with climate change. Depletion of non-renewable sources of energy and water, deterioration of soil and water quality and the potential extinction of innumerable habitats and species are other effects. India’s “National Action Plan on Climate Change” identifies eight core “national missions” through various ministries, focused on understanding climate change, energy efficiency, renewable energy, and natural resource conservation. Although there are several issues concerning India’s position under UNFCCC, it has agreed not to allow its per capita Greenhouse gas emissions to exceed the average per capita emissions of the developed countries, even as it pursues its social and economic development objectives.
The Ministry of Health, in coordination with other ministries, provides technical assistance in implementing disaster management and emergency preparedness measures. Deficient areas include carrying out a rapid needs assessment, disseminating health information, food safety, and environmental health after disasters and ensuring transparency and efficiency in the administration of aid after disasters. Implementation of Disaster Management Act, 2005 is essential for establishing institutional mechanisms for disaster management, ensuring an intersectoral approach to mitigation and undertaking holistic, coordinated and prompt response to disaster situations.
13. Community participation
Community participation builds public support for policies and programs, generates compliance with regulations and helps alter personal health behaviors. One of the major strategic interventions under NRHM is the system of ensuring accountability and transparency through people’s participation – the Rogi Kalyan Samitis. The Ministry of Health needs to define a clear policy on social participation and operational methods in facilitating community health projects. Potential areas of community participation could be in lifestyle modification in chronic diseases through physical activity and diet modification, and primary prevention of alcohol dependence through active community-based methods like awareness creation and behavioral interventions.
14. Private sectors, civil societies, and global partnerships
Effective addressing of public health challenges necessitates new forms of cooperation with private sectors (public-private partnership), civil societies, national health leaders, health workers, communities, other relevant sectors and international health agencies (WHO, UNICEF, Bill and Melinda Gates Foundation, World Bank).
15. Governance issues
In order to ensure that the benefits of social security measures reach the intended sections of society, enumeration of Below Poverty Line families and other eligible sections is vital. Check mechanisms to stop pilferage of government funds and vigilance measures to stop corruption are governance issues that need to be attended. The government should take strict action in cases of diversion of funds and goods from social security schemes through law enforcement, community awareness, and speedy redressal mechanisms. Social audits in MREGS through the Directorate of Social Audit in Andhra Pradesh and Rajasthan are early steps in bringing governance issues to the fore. This process needs strengthening through separate budgets, provisions for hosting audit results and powers for taking corrective action. Similar social auditing schemes can be emulated in other states and government programs like ICDS, which will improve accountability and community participation, leading to effective service delivery.
“The health of people is the foundation upon which all their happiness and all their powers as a state depend” – Benjamin Disraeli, British Prime Minister.
In this changing world, with unique challenges that threaten the health and well-being of the population, it is imperative that the government and community collectively rise to the occasion and face these challenges simultaneously, inclusively and sustainably. Social determinants of health and economic issues must be dealt with a consensus on ethical principles – universalism, justice, dignity, security, and human rights. This approach will be of valuable service to humanity in realizing the dream of Right to Health. The ultimate yardstick for success would be if every Indian, from a remote hamlet in Bihar to the city of Mumbai, experiences the change.
It is true that a lot has been achieved in the past: The milestones in the history of public health that have had a telling effect on millions of lives – launch of Expanded Program of Immunisation in 1974, Primary Health Care enunciated at Alma Ata in 1978, eradication of Smallpox in 1979, launch of polio eradication in 1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few. It was a glorious past, but the future of a healthy India lies in mainstreaming the public health agenda in the framework of sustainable development. The ultimate goal of great nation would be one where the rural and urban divide has reduced to a thin line, with adequate access to clean energy and safe water, where the best of health care is available to all, where the governance is responsive, transparent and corruption free, where poverty and illiteracy have been eradicated and crimes against women and children are removed – a healthy nation that is one of the best places to live in.
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11. National Action Plan on Climate Change. Prime Minister’s Council on Climate Change, Government of India, New Delhi. 2008