While 'Health Assurance' has been proclaimed as a policy priority for the government, the pathways for delivering on that promise have not been profiled so far. Health of the people can be assured only when there is an efficiently functioning health system that reliably provides accessible, appropriate and affordable healthcare to all, supported by pro-health policies in other sectors to foster social and environmental conditions that promote rather than endanger health.Clearly, we are far from that ideal. Large sections of our rural population and urban poor cannot access quality healthcare even for basic services. The draft National Health Policy document put out by the health ministry states that over 63 million Indians face the threat of poverty each year due to unaffordable healthcare expenditure. Nearly 70 per cent of healthcare expenditure is 'out of pocket spending' (OOPS), placing India among the countries with the highest level of personal vulnerability for health expenditure. Public financing of health is around 1 per cent of the GDP, among the lowest in the world. Huge shortages exist in the numbers of doctors, nurses, allied health professionals and skilled community health workers.
The mixed health system, with uncoordinated and poorly regulated functioning of public and private providers, is groaning under the strain of coping with multiple disease burdens. We lag behind many of our neighbours on key health indicators such as infant and maternal mortality rates, child immunisation and life expectancy. A third of the world's TB patients reside in India, with a rising danger of drug resistance. At the same time, a host of non-communicable diseases-cardiovascular and respiratory disorders, cancers, diabetes and mental illness-pose a rapidly growing threat. Sterilisation deaths in Chhattisgarh, cataract camp blindings in Punjab, and the Vyapam scam of fraudulent medical college admissions in Madhya Pradesh are all symptomatic of a poorly performing and badly governed health system.Even as poverty remains a barrier to good health, policies and programmes in other sectors have largely remained unresponsive to public health concerns. Water, sanitation, nutrition, air pollution and road safety remain major concerns. Varying levels of political commitment to health and differences in quality of governance have also led to marked inter-state disparities in health, even as the responsibility for design and delivery of health services shifts further to the states from the Centre.
There are, of course, solutions that can help redress this sorry state. While many areas need specific attention, here are five potentially transformational paths that can energise the health system and enhance its effectiveness.
Employ technology-enabled workers to deliver basic health services at or near home
At present, trained auxiliary nurse midwives deliver maternal, child and reproductive health services in six districts of Jammu & Kashmir under the National Health Mission. They use an android tablet configured to deliver a range of diagnostic tests, backed up by decision support systems. The Swasthya Slate can also be used for cardiovascular risk-profiling and diagnosis of diabetes and several infections. This, as well as mobile phone and telemedicine linkages, can bridge access and quality gaps. As the role and numbers of frontline workers expand, a huge employment window will open up for skilled young persons, especially women.
Timeline Feasible by 2017.
Provide essential drugs and diagnostic tests free of cost at public facilities
Central and state governments must together provide drugs listed in the National List of Essential Medicines (starting with 100 high-priority drugs) and basic and emergency diagnostic tests free of cost. Since more than 70 per cent of out-of-pocket spending is due to the cost of medicines and outpatient care, this will reduce healthcare-related impoverishment and improve health outcomes. Pooled public procurement will reduce the cost greatly and make it affordable at a modest level of health financing.
Timeline Feasible by 2016.
Strengthen district hospitals and add training functions
District hospitals need a boost of added infrastructure and staff to deliver quality higher-level healthcare, linking up with primary care services for efficient referral and follow-up. New medical and nursing colleges should be attached to these upgraded hospitals, especially in states that have few colleges, and also provide training to various categories of allied health professionals. Orienting medical students to the district- and sub-district-level healthcare settings will make them a better fit for rural health service than those trained in city-based tertiary care hospitals.
Timeline Feasible by 2019.
Integrate all health financing schemes into a single payer system
The many central and state government-funded health insurance programmes as well as employer-funded insurance schemes should be coalesced into a single-payer system that purchases services from public and contracted private providers for cashless delivery of a defined package of services. This will initiate progressive universalisation of healthcare, which India has endorsed at the World Health Assembly and will soon commit to at the UN summit in September. This will help cut costs of care while improving quality through prescribed standard practice guidelines for appropriate care.
Timeline This is a complex political space, which will be a test for cooperative federalism. If political will and wisdom prevail, it will be feasible by 2018.
Raise taxes on tobacco, alcohol, sugary drinks and junk food
Modelling by Sanjay Basu of Stanford shows that raising taxes on all forms of tobacco and an effective ban on smoking in public places will prevent 25 per cent of heart attacks that are projected to occur in India between 2012 and 2021. Similarly, a 20 per cent tax on sugary drinks is projected to prevent 400,000 cases of diabetes over 2014-23. Mexico's 10 per cent tax on sugary drinks and 8 per cent tax on junk food have worked. The Philippines is using revenue from raised tobacco taxes to finance universal health coverage. We should also reap the benefits of such taxation-of driving down consumption of unhealthy products and using the expanded revenue pool for more health financing.
Timeline Union budget of 2016.
K. Srinath Reddy is president, Public Health Foundation of India
For more news from India Today, follow us on Twitter @indiatoday and on Facebook at facebook.com/IndiaToday
For news and videos in Hindi, go to AajTak.in. ताज़ातरीन ख़बरों और वीडियो के लिए आजतक.इन पर आएं.