The Human Development Report 2022 highlights the impact of public health deficits on India’s growth. Neglecting public health is an invitation to disaster. Given the wide array of the determinants of health, every minister is also a health minister—water, sanitation, housing, environment, petroleum, nutrition, women’s empowerment, agriculture, horticulture, urban, power, transport, education, skills, livelihoods, roads, railways, industry, science & technology, all have consequences for a person’s health. India has done well to focus on pro-poor welfare and ease of living over the last eight years.
The National Health Policy of 2017 laid out a roadmap for the health sector. Many initiatives for creating public health capacity, setting up holistic Wellness Centres, cashless secondary and tertiary hospitalised care for the deprived, a National Digital Health Mission (NDHM), telemedicine, proposed strengthening of laboratories, primary urban health units, are all steps in the right direction. While a lot has been done, there are a few key gaps that need to be addressed.
First, it is imperative to connect households to point of first care with doctor, drugs and diagnostics (like the GPs under the UK’s NHS) with strong community connect. Decentralised management systems have to be strengthened using technology to make public systems accountable for service guarantees. Community accountability and social audit with decentralised funds, functions and functionaries with panchayats and urban local bodies is the way forward. Public health knows no narrow departmentalism, and therefore the role of the community and local governments is of paramount importance.
The household, the elected local government functionary, the women’s SHGs, the ASHA, ANM, Aanganwadi workers all must be facilitated for accessing the first point of contact with health-records of beneficiaries available under the NDHM. Public information, community connect, handholding, use of technology, will help in making the first point of primary care play the gate-keeping role for secondary and tertiary referrals.
Second, assessments of out-of-pocket expenditures show two-thirds of the expenditure on health are on account of drugs and diagnostics. National Sample Survey(NSS) data from the 75th (2017-18) and 71st Round (2014) clearly establish that medicines take lion’s share of personal health care spending in India. It is followed by non-medical costs such as travel, food and lodging. A study by Subramanian et al (2022) shows that the mean doctor consultation charges were 12-fold higher in private hospitals than in public hospitals and seven-fold higher in private clinics for out-patient services. They were 24-fold higher in private hospitals compared with public hospitals for in-patient services. Sundararaman et al (2021) point that there is a significant increase in use of public facilities both for outpatient and in-patient care in recent years. In the light of this evidence, it is argued that it is more prudent to invest more in strengthening public healthcare delivery.
Out of pocket expenses for medicines is lowest in Tamil Nadu as they have a robust system of generic drug supply through the Tamil Nadu Medical Services Corporation (TNMSC) with digitised databases linked to every district warehouse from where primary units and hospitals can indent and collect medicines through their passbook. There are no stock outages, and quality generic drugs (and medical equipment) is available to every facility. Efforts to set up TNMSC-like corporations was made in 22 states, but digitisation up to the last point has lagged behind in most, making stock outages a problem in many places. States must focus on overcoming this challenge.
Third, the human-resource aspect, both in terms of numbers and skills upgrade, needs immediate attention as shortfalls can affect outcomes. The frontline teams and the paramedics have already demonstrated their worth during Covid as well as through meeting other public health needs. Tamil Nadu’s public health cadre offers important lessons. Multi-medium, distance-mode courses are needed. A skill continuum for ASHAs, ANMs, GNMs, and staff nurses ought to be promoted. Tamil Nadu’s systems of excellence in nurses is also an outstanding practice worth emulation. Nursing Skill Labs, where trained nurses from advanced facilities, help train nurses at grassroot-levl facilities could be of immense use.
Standardisation of allied para -medical skills is also critical, as is the role of hospital managers, for delivering high-quality services. With an ageing population, palliative and geriatric care services are needed. Preventive public health measures require a range of skill sets, more so in urban areas. Promotion of six month courses for emergency obstetric care (EmOC), life saving anaesthesia skills (LSAS), paediatric and general surgery skills for General Duty Medical Officers (GDMOs) should be encouraged without compromising quality.
To promote district-level medical colleges, faculty-shortages can be tackled through 6-9-month programmes for post-graduate government doctors as that is the biggest pool of specialists working as GDMOs. Fourth, the promotion of holistic care through promotion of AYUSH does make a difference. AYUSH is already being subjected to research scrutiny, and mainstreaming efforts need to be encouraged. Co-location, scientific studies and use, disease-specific performance of Ayush, etc, need promotion. It is an opportunity for India to make health holistic and affordable, without sacrificing scientific temper.