HEALTH FOR ALL
"Health for all" was the Goal adopted by WHO in the 1970s. Health is one of the most crucial indicators of social development of a country and health related schemes have always been part of social security system for most of the countries.
The prevention of disease, diagnosis, treatment of illness, injury in human beings form the subject matter of health care.
Health care delivery includes providing primary care, secondary care and tertiary care.
Primary Health Care (PHC) - They are the basic first level of contact between individuals and families with the health system. The general practitioners, the family physician, the physiotherapist are the usual primary health care providers. Immunisation, basic curative care services, maternal and child health services, prevention of diseases are the type of services provided by PHC's. Family planning, health education, provision of food and nutrition and adequate supply of safe drinking water may also be included in their services.
In India, a network of sub centres and PHC's work in rural areas to provide primary health care. Family welfare centres provide such services in the urban areas. The staff in a PHC includes a medical officer, a staff nurse, the pharmacist and other paramedical support staff. ASHAs and ANMs (Auxilliary Nurse Mid-wives) are also part of PHC.
Secondary Health Centre: Health care services, at such centres are provided by medical specialists. They may not have first contact with patients. Depending on the policies of the National Health System, patients may access these services through physician referral or self referral.
Secondary health care providers include cardiologists, urologists, dermatologists and other such specialists. The health care services include acute care, short period stay in a hospital emergency department for brief but serious illness.
There may be secondary care providers who do not work in hospitals - psychiatrists, physiotherapists, respiratory therapists, speech therapists and so on.
In India, the District Hospitals and Community Health Centres at the block level are examples of Secondary Health Centres within the public health system.
Tertiary Health Centre: This is a specialised consultative health care for inpatients. The patients are admitted into these centres on a referral from primary or secondary health professionals. Tertiary health care is provided in a facility that have personnel and facilities for advanced medical investigation and treatment. Services provided include cancer management, neurosurgery, cardiac surgery and a host of complex medical and surgical interventions. Advanced diagnostic support services and specialised intensive care which cannot be provided by primary and secondary health centres are available at the tertiary health centres.
In India tertiary care services under the public health system, is provided by medical colleges and advanced medical research institutes.
"Health for All - The need for Universal Healthcare in India
The World Health Organisation estimated that in 2008, 5.2 Million Indians died of non-communicable diseases which accounted For 53 per cent of all deaths in the country. In 2015, health inequality resulted in a loss of 24 per cent of India's health index value as per the Inequality adjust Human Development Index computed by the UNDP.
India's health system mirrors the iniquitous nature of development that has taken place in the country. High income and wealth inequality has resulted in a skewed pattern of health care oriented toward secondary tertiary level curative services, leading to neglected of the more basic preventive and primary care services needed for the poor to survive.
Health security is linked inextricably with the notion of universal health care and received prime importance following the Alma Ata Declaration in 1978 to achieve health for all by 2000. This 1978 conference focused on the importance of Primary Health Care as a basic step towards achievement of 'Health For All'.
National Rural Health Mission (NRHM) was initiated in 2005 to revitalize the primary health care system in the country. Despite these policy initiatives, universal health coverage remains an unfinished agenda with basic indicators of health in India continuing to be below those of low income countries such as Bangladesh and crucial health millennium Development Goals (MDGs) being missed.
Further, low Political commitment to ensuring basic primary and preventive health care has meant that unlike education, Health for all has never been an important electoral issue.
The general political apathy towards the health sector is also reflected in low budgetary allocations, with the public spending accounting for not more than 1.5 % of GDP over the last decades despite impressive economic growth. This has meant that 75% of the health care costs are financed by out of the pocket expenses and catastrophic health expanses regularly push a large number below the poverty line.
In India, annually an estimated 63 million people fall into poverty due to health related Out of Pocket Expenditures (OOPE). People who are already below poverty line, go deeper into poverty. In other words, health related expenditure and lack of universal health coverage is undoing all social security efforts including efforts targeted for poverty reduction in the country.
Health insurance in India
Countries such as Brazil, Bolivia, Indonesia and Thailand, all characterised earlier by the situation of high inequality and uneven access to health care system, have revamped policies since the 1980s towards universal health care. The 30 baht scheme in Thailand, decentralization reforms and social health insurance in Indonesia, and the unified health system in Brazil provide examples of how countries have addressed basic health requirement of These examples indicate that strengthening of the primary health care system is a prerequisite for achieving universal health coverage.
Health Insurance in India began with Employment state Insurance Scheme (ESIS) and the Central Government Health Scheme (CGHS) that cater to government employees and their dependants. these schemes focus on high end secondary and tertiary care and together .provide protection to less than 10% of India's population working in public sector undertakings.
A Conditional cash transfer scheme transfer scheme Janani Suraksha Yojna (JSY) was introduced in 2005 to encourage institutional deliveries among poor women in rural areas.
Rashtriya Swasthiya Bima Yojna (RSBY), 2008
• Aims to provide financial protection against catastrophic health expenditure for vulnerable groups and ensure better access to quality health care for people below the poverty line and vulnerable groups in the informal sector such as rickshaw puller and rag pickers.
• The scheme provides a coverage of Rs. 30000 in case of hospital based inpatient care, on an annual registration fee of Rs. 30 by the beneficiary for the family. (The coverage limit has recently been enhanced to one lack rupees.)
• RSBY coverage as on end march 2016 was 41.3 million families out of an eligible 72.8 million families out of an eligible 72.8 million families.
• Total hospitalization cases however were only 11.8 million pointing to low utilization of the scheme .
• Further, evidence from the field indicates that one of the main desired outcomes of the RSBY, to reduce the financial burden of health expenditure among the poor, may not have been realized and out of pocket (OOP) expenditures have not diminished owning to payment for drugs and diagnostics and other inpatient services not covered by RSBY, additional transport expenses and the like.
• The RSBY performance is better in states such as Kerala, that have built a good health care infrastructure.
Can the new National Health Policy, 2017 address the challenges of Healthcare in India?
? In the new policy, the government aims in shifting focus from “sick-care” to “wellness”, by promoting prevention and well-being. This will shift focus on the preventive side of Healthcare, which will address preventable sickness and diseases in India.
? It intends on gradually increasing public health expenditure to 2.5% of the GDP. The enhanced funding will be used to strengthen health systems by ensuring everyone has access to quality services and technology despite financial barriers. The policy proposes increasing access, improving quality and reducing costs. It proposes free drugs, free diagnostics and free emergency and essential healthcare services in public hospitals. This is a step towards universalisation of Healthcare in India.
? To focus on primary health care: The policy advocates allocating two-thirds (or more) of resources to primary care. It proposes two beds per 1,000 of the population to enable access within the golden hour (the first 60 minutes after a traumatic injury).
? To reduce morbidity and preventable mortality of non-communicable diseases (NCDs) by advocating pre-screening.
In order to achieve its objectives, the Policy aims at roping in Private Sector through Public Private Partnerships. Though a welcome move, it must be carried out cautiously so that private sector is held accountable for all the duties assigned to it. A watch must be kept to ensure that it does not enrich itself at the cost of liberal public subsidies.
International experience shows that the objective of "Health for All" can be achieved only when basic health infrastructure is in place and this is a function that the government alone can perform.
(Related Article - Health for All, Page - 20, by K Seeta Prabhu)
Nutrition is an important factor that determines status of health of an individual and the community. India has highest prevalence of undernourished children in world with almost 35-40% children underweight and stunted.
Under-nutrition affects health, immunity, cognitive abilities etc. and prevents children from realising their full potential.
Experts argue that India is suffering from the so called 'triple burden of malnutrition' which includes -
• Food insecurity
• Under nutrition
• Overweight and Obesity
Even though India has attained high production levels of food grains, there are certain problems that contribute to the problem of malnutrition in India -
? Food security consists not just of production but also of distribution and adequate consumption. The Public Distribution System of India is marked by deficiencies like leakages, corruption etc. leading to poor delivery.
? Inadequate consumption even after availability depends on lack of knowledge and information on proper dietary intakes also contributes to the problem of malnutrition
? Focus on food-grains only instead of a diversified food basket that includes pulses, fruits, eggs etc.
? Problems like diarrhea etc prevents absorption of nutrients in body thereby contributing to malnutrition
What needs to be done?
? Diet Diversity -The government should immediately promote the consumption of a diverse diet. The Indian Food Pyramid conceptualized by the National Institute of Nutrition (NIN) was beyond the comprehension of the masses. We need to work out some simple yet catchy promotion mechanism to educate the masses. For example, the United States Department of Agriculture, promotes a colourful plate concept easy to understand from toddlers to adults. The colours signify the composition of food items in the plate every day. The colours pertain to the different food groups like cereals, pulses, fruits, vegetables, meat, etc
? Decentralisation - A top-down approach has never been successful given the diversity of food production, consumption and preparation in the country. Utter importance should be paid to the culture and local food habits, and those that improve nutritional status.
? Education of women - Women empowerment is important in this context. Older women are generally the decision makers in the household, and they should be more educated to promote the consumption of a diverse diet
? Updating the Food Component of the Poverty Line- Both the Tendulkar and Rangarajan Committee recognized the importance of nutrients other than calories, and incorporated the same in the computation of the poverty line. What is proposed is a new measure of diet diversity called the Healthy Eating Index for India. It would help identify the food poor households in terms of their consumption of a diverse basket. This index could be useful for identification of those consuming a less diverse diet for not only the vegetarian but also the non-vegetarian households.
? Digital Solutions - Digital solutions like Aadhaar, Jan Dhan Yojana etc can be used for more targeted and efficient delivery. Cash transfers instead of food-grains can promote a more nutritious and diverse diet consumption. Also, these could be used to track the health status of the poor. (Such a strategy has been implemented in the interiors of Mongolia where households are continuously monitored to lift them out of poverty (not only income, but also food and health poverty) permanently.)
? Affluence and Obesity - Other than malnutrition, India is also suffering from high rates of obesity and micronutrient deficiency diseases. The middle and rich are prone to the latter. Reasons being
o fast pace of urbanization
o easy availability of fatty and oily products
o excessive marketing of the same
So, informing the wealthy is also required. In a sense they need to understand that they are taxing themselves by welcoming a plethora of non-communicable diseases like diabetes, heart attack, etc. Government intervention should be in the form of taxing fatty food products and supermarkets that encourage consumption of unhealthy food items.
(Related Article - Prioritising Agriculture to Nutrition Pathways, Page - 39 by Mousumi Das)