The public health needs of a population are diverse and perception and prioritisation vary across the social strata. Public health policies are those decisions made by the government based on the resources available to address people’s health needs. Public health needs include those felt by people (felt needs) based on their lived experiences and those projected upon (projected needs) them by experts — the architects of public health policies. The recent Union Budget has been critiqued for its inadequate focus on the social sector, specifically the public health sector. Public health policies of the government in the last decade indicate that there has been a severe paralysis when it comes to public health policies without any real prescription that addresses the felt needs of people.
Felt needs in public health
Public health needs can be broadly categorised into three groups: First, are the diseases of poverty such as tuberculosis, malaria, undernutrition, maternal death, bouts of illnesses due to food and water-borne infections leading to typhoid, hepatitis, and diarrhoeal diseases faced by the poor and the vulnerable. These problems attain greater significance as attempts to prevent these also pose challenges of addressing livelihood and are non-negotiable from a rights perspective.
Second are the problems of the middle class and those better off on issues that are related to environmental pollution — air, water, waste management, lack of drainage facility and failure to ensure healthy foods and eateries that pose threat to everyday lives, most of which are due to poor infrastructure development and poor market regulations. The list goes on if we add road traffic accidents, climate change and the rise of chronic illnesses. These are also applicable to the first group but may not figure within the hierarchy of priorities.
Third, and the most popular needs in public health, are the curative care needs of a population. Provisioning of curative care is the most critical and controversial policy question in public health. The three levels of curative care envisaged are primary, secondary and tertiary. The poor and the vulnerable rely on primary health-care institutions of the public sector for primary-level care, as it is the most affordable and is closer to their places of residence. Secondary-level care was historically neglected and is still inadequate against population norms. Shortage of infrastructure including health professionals in these facilities aggravates the problem. Tertiary-care needs for curative care among the poor are the focus of the Pradhan Mantri Jan Arogaya Yojana (PMJAY) under Ayushman Bharat.
A history of Indian public health policies in the last decade shows that the National Rural Health Mission, which was started in 2005, and followed by the National Health Mission (NHM) of 2013, were a clear departure from the then existing National Health Policy of 2002, which proposed the commercialisation of health care. It was the NHM’s focus on strengthening public sector health care through architectural correction that has revived an otherwise sinking health system after the reform period of the 1990s. Efforts were taken to follow the principles of primary health care while strengthening the institutions of primary health care by implementing the national health programmes through them, thus building goodwill and trust among the people about public sector health care. This was obvious from the health infrastructure available in India, which was reported as 1,53,655 sub centres, 25,308 primary health centres (PHC) and 5,396 community health centres (CHC) as per the rural health statistics, 2015. The impetus created by NHM would have been capitalised had subsequent policies strengthened the secondary- and tertiary-level health care in the public sector. Instead, the focus has shifted entirely on publicly funded health insurance schemes (PFHI) such as the PMJAY under Ayushman Bharat since 2018. PFHI schemes were implemented by the governments of Maharashtra, Andhra Pradesh, Tamil Nadu, Kerala, and others as an add-on to the overall strengthening efforts under the NHM then.
Private health care, the real beneficiary
The real beneficiary of PFHI schemes in the Indian context is private sector health care. First, a health insurance cover ideally implies covering all health-care expenses, globally. It is unique that India’s health insurance scheme covers only hospitalisation expenses under the scheme. This is based on the market logic that if 50 crore people (12 crore households are the beneficiaries of PMJAY) are enrolled in the scheme; only 2.5 crore people will have an actual need for hospitalisation annually as per epidemiological data.
Further, the outsourcing of secondary and tertiary-care services to the private sector at market rates under the scheme is an open acknowledgement by the government of its failure and a lack of intention to strengthen secondary- and tertiary-level public sector health care in the country. The implication is that the remaining 100 crore population who are not covered under any government schemes are forced to have highly commercialised medical care for their illnesses, incurring an expenditure at market rates. Thus, by monopolising the market for health care, private hospitals pretend to offer services to the government at market rates, at the same time ensuring that the remaining two-thirds of the population must depend on them by making sure that public sector health care is weakened.
The last nail in the coffin of the public health system is the recent transformation of sub centres, PHCs and CHCs into health and wellness centres (HWC) in February 2018. The highlight was to declare that 1,50,000 HWCs were established as new institutions in rural areas, when numbers more than that were already in existence (RHS 2015). The proposal was to have a community health officer, expected to render treatment to a rural population by completing a bridge course. This has transformed the original mandate of sub centres from rendering outreach activity to that which provides curative care. Doctoring gained its acceptance through its act of diagnosis, prognosis, and treatment. Instead, the proposal to equip a community health officer to practise medicine minimally results in the new professional becoming a dignified chemist. The failure to offer curative care in its entirety by any institution will shatter the trust of people in those institutions.
The latest of this was in a 2023 directive to rename all the HWCs (sub centres, PHC and CHC) to ‘Ayushman Arogya mandir’. One could not find any clear justifications for this name change. Several questions arise on how this name is of significance to a non-Hindi speaking population. How does the term mandir resonate as the title of a secular health institution?
Threat to public health system
Public health challenges are diverse in a country such as India and there is a need to address these across social groups without fail. For the vulnerable and the poor, prevention programmes and health promotion activities become a luxury when their day-to-day livelihoods are not addressed. It is basic primary- and secondary-level curative care that are their felt needs in public health. Historically, institutions of primary health care were entrusted with this responsibility and were delivering preventive and promotion activities close to their home, by making it culturally and contextually relevant.
The major curative care challenge posed across the country is the loss of trust towards health-care providers (private sector due to commercial interests) and public sector due to overcrowding of health care with inadequate infrastructure due to low provisioning.
The government has slashed the limbs of the public health system by not strengthening secondary- and tertiary-level care in the public sector and instead favouring the growth of the private sector. Finally, the institutions of primary health care — the lifeline of India’s public health system — were weakened by projecting them as curative care centres, for popularity and branding, without acknowledging their purpose in health programmes and their interconnections with grassroot-level institutions of health care.
Mathew George is Head of the Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala. The views expressed are personal
Published - September 09, 2024 12:16 am IST
