Think differently about healthcare

“India certainly has a serious problem with health literacy and it is the responsibility of public health professionals to close this gap.“ Stubble burning in Dadri, Uttar Pradesh in 2018.R.V. Moorthy  

In India, public health and health services have been synonymous. This integration has dwarfed the growth of a comprehensive public health system, which is critical to overcome some of the systemic challenges in healthcare.

A stark increase in population growth, along with rising life expectancy, provides the burden of chronic diseases. Tackling this requires an interdisciplinary approach. An individual-centric approach within healthcare centres does little to promote well-being in the community. Seat belt laws, regulations around food and drug safety, and policies for tobacco and substance use as well as climate change and clean energy are all intrinsic to health, but they are not necessarily the responsibilities of healthcare services. As most nations realise the vitality of a robust public health system, India lacks a comprehensive model that isn’t subservient to healthcare services.

A different curriculum

India’s public health workforce come from an estimated 51 colleges that offer a graduate programme in public health. This number is lower at the undergraduate level. In stark contrast, 238 universities offer a Master of Public Health (MPH) degree in the U.S.

In addition to the quantitative problem, India also has a diversity problem. A diverse student population is necessary to create an interdisciplinary workforce. The 2017 Gorakhpur tragedy in Uttar Pradesh, the 2018 Majerhat bridge collapse in Kolkata, air pollution in Delhi and the Punjab narcotics crisis are all public health tragedies. In all these cases, the quality of healthcare services is critical to prevent morbidity and mortality. However, a well organised public health system with supporting infrastructure strives to prevent catastrophic events like this.

Public health tracks range from research, global health, health communication, urban planning, health policy, environmental science, behavioural sciences, healthcare management, financing, and behavioural economics. In the U.S., it is routine for public health graduates to come from engineering, social work, medicine, finance, law, architecture, and anthropology. This diversity is further enhanced by a curriculum that enables graduates to become key stakeholders in the health system. Hence, strong academic programmes are critical to harness the potential that students from various disciplines will prospectively bring to MPH training.

Investments in health and social services tend to take precedence over public health expenditure. While benefits from population-level investments are usually long term but sustained, they tend to accrue much later than the tenure of most politicians. This is often cited to be a reason for reluctance in investing in public health as opposed to other health and social services. This is not only specific to India; most national health systems struggle with this conundrum. A recent systematic review on Return on Investment (ROI) in public health looked at health promotion, legislation, social determinants, and health protection. They opine that a $1 investment in the taxation of sugary beverages can yield returns of $55 in the long term. Another study showed a $9 ROI for every dollar spent on early childhood health, while tobacco prevention programmes yield a 1,900% ROI for every dollar spent. The impact of saving valuable revenue through prevention is indispensable for growing economies like India.

Problem of health literacy

Legislation is often shaped by public perception. While it is ideal for legislation to be informed by research, it is rarely the case. It is health literacy through health communication that shapes this perception. Health communication, an integral arm of public health, aims to disseminate critical information to improve the health literacy of the population. The World Health Organisation calls for efforts to improve health literacy, which is an independent determinant of better health outcome. Data from the U.S. show that close to half of Americans lack the necessary knowledge to act on health information and one-third of Europeans have problems with health literacy. India certainly has a serious problem with health literacy and it is the responsibility of public health professionals to close this gap.

Equally important is a system of evaluating national programmes. While some fail due to the internal validity of the intervention itself, many fail from improper implementation. Programme planning, implementation and evaluation matrices will distinguish formative and outcome evaluation, so valuable time and money can be saved.

The public health system looks at the social ecology and determinants focusing on optimising wellness. Healthcare services, on the other hand, primarily focus on preventing morbidity and mortality. A comprehensive healthcare system will seamlessly bridge the two.

A council for public health

A central body along the lines of a council for public health may be envisaged to synergistically work with agencies such as the public works department, the narcotics bureau, water management, food safety, sanitation, urban and rural planning, housing and infrastructure to promote population-level health. In many ways, these agencies serve to bring in many facets of existing State and federal agencies and force them to see through the lens of public health. The proposed council for public health should also work closely with academic institutions to develop curriculum and provide license and accreditation to schools to promote interdisciplinary curriculum in public health.

As international health systems are combating rising healthcare costs, there is an impending need to systematically make healthcare inclusive to all. While the proposed, comprehensive insurance programme Ayushman Bharat caters to a subset of the population, systemic reforms in public health will shift the entire population to better health. Regulatory challenges force governments to deploy cost-effective solutions while ethical challenges to create equitable services concerns all of India. With the infusion of technology driving costs on the secondary and tertiary end, it is going to be paramount for India to reinvigorate its public health system to maximise prevention. India’s public health system can no longer function within the shadow of its health services.

Ravikumar Chockalingam is a public health scholar and psychiatrist at the Veterans Affairs Medical Center, Saint Louis, Missouri