Public health: Why is now the best chance?
A universal health coverage, ensuring the availability of affordable healthcare, needs to be rolled out.
Typically, the rich and the powerful are the people with vast resources at their disposal and therefore, have higher propensity to be healthy. The ill-fated adage was, “If you are poor, you are destined to be sick or die (earlier).”
Given that inequalities in soc-ial status lead to different health status in different population groups, how to fix them? An ostensibly hard proposition is to make everyone rich, which is beyond anyone’s scope, let alone public health professionals.
The feasible alternative is to take affirmative actions in breaking the unfavourable social gradient affecting health. However mammoth these issues sound, these disparaging factors in the environment can be modified by simple policy conditions affecting their risk, consequences and helplessness.
To prevent greater risk of the disadvantaged, provision of better services in the immediate environment can be beneficial. There are several programmes under the current administration, which have provided the glimpse of this. One such is the Swachh Bharat Abhiyaan.
It has the scope of transforming the environment of millions of unhygienic areas surrounding socially disadvantaged Indians. The ambitious goal to accelerate the efforts to achieve universal sanitation coverage by 2019 is in itself an astonishing feat. When toilets are built and most people stop open defecation, nearly 50 crore rural Indians will automatically have better environment.
The Centre is also providing assistance to states for having Any Time Water (ATWs) kiosks which provide safe drinking water in villages and small towns. Currently, women have to walk great distances to fetch water. Providing safe drinking water prevents nearly 1,600 deaths each day caused due to water borne diseases.
In addition, building better roads improves access to schools and healthcare. Transportation of food can be changed dramatically if roads are built at the current proclaimed pace of 25 km per day. These initiatives are remarkable in addressing some of the important health determinants. Stress on yoga or some form of physical exercises has brought nation’s focus on lifestyle factors affecting health.
Several researchers have suggested that social and environmental conditions along with individual behaviour comprises nearly 60% of determinants of health. Ensuring economic stability and improving the environment (physical and social) are addressed by the Centre. A stronger resolve and roadmap is needed for addressing other determinants of health. These include, education needs of the community, alleviating hunger and creating positive policies for healthy food options.
In the long run, social integration of the vulnerable communities and creating empowering systems can be ensured. Creating Mudra bank partly provides some affirmative action but more daunting steps are needed.
Finally, the healthcare system needs to rollout universal health coverage, ensuring availability of affordable, appropriate health care with assured minimum quality. In order to create healthy communities, a multi-pronged and systematic effort is needed covering all determinants of health including addressing challenges in healthcare system.
These have provided the best opportunity for public health efforts. However, treading ahead requires a well-defined road map for accomplishing the goals of reducing inequities. First, the government has to set in an integrated approach to coordinate and align different departments, sectors and diverse organisations in the pursuit of health and development as a collective goal. Second, the health ministry should be reoriented towards promoting health, (not merely sickness prevention and control) and reducing health inequities.
This includes prioritisation of addressing health and wellness of people belonging to varying socio-economic or geographical status. Instead of using insurance as the main mechanism, the health system should aim to reduce discriminating burden of out-of-pocket expenses and high proportion of catastrophic household spending on health. This can be achieved by operationalisation of the universal health assurance as recommended by an expert group.
Third, the implementation and impact of ongoing and future policies must be monitored in quantifying reduction in inequities in social determinants and health outcomes. Finally, it is vital to facilitate participation of the people who do not have access to public services, who cannot write, read or use internet. This will ensure that the most disadvantaged people are included in formulation and implementation of public policies.
Highest focus has now been provided to healthcare system. Using simple checklist of resp-onsibilities of each department/ sector can aid the PM and senior administration in reviewing the progress of each determinant of health. Modi has clearly been successful in shifting the priority towards much needed determinants of health. He distinctly deserves the respect but not before successful implementation of ongoing programmes and expanding to address other determinants of health.
(The writer is Additional Professor, Indian Institute of Public Health, Bengaluru)