Policy Wise

Searching For A New Balance

Public health is concerned with the health of the community as a whole. Its key goal is to reduce a population’s exposure to disease. It has been said that: “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time’’.

The public health system in India faces multiple challenges. In 2005, the average life expectancy was 62 years for males and 64 years for females—one of the lowest in the South Asian region. In the same year, only 44 per cent of children aged 12 to 23 months were fully immunized. Infant mortality rate, generally considered as the gold standard in judging the public health system of a country remains at an unacceptable 55 deaths per 1000 live births. If one looks at infectious diseases, the picture is not much better. India, despite some encouraging results in the last few years carries one fourth of the total TB burden in the world. What is especially worrying is the rise of Multiple-Drug Resistance (MDR) tuberculosis cases despite widespread adoption of DOTS. Despite strenuous efforts, polio has still not been eradicated. In fact, in some states most noticeably Uttar Pradesh, polio has shown a marked resurgence. Without discounting the progress made in the last few decades, it can be safely said that in almost every important public health indicator, India lags far behind not only the developed world but also countries with equivalent income levels.

If India has to reap the full benefits of the so-called demographic dividend, it needs to urgently improve public health. The crucial question is how. Here the debate tends to gets more ideological. Many public health professionals argue for a greater expansion of government’s role in the public health system. The agenda was set as far back as in 1943, the Bhure committee argued that ‘’The idea that the state should assume full responsibility for all measures, curative and preventive, which are necessary for safeguarding the health of the nation, is developing as a logical sequence’’. The committee not only rejected the role of private sector in health care but also strongly opposed private practice for government doctors and the levy of user charges. While many of its ideas remain unimplemented, they continue to influence the philosophical debate vis-à-vis state’s role in the public health system.

On the other hand, many economists have argued that the public health system has become a self-serving bureaucratic behemoth designed to serve its own interests rather than advance public health. They advocate a greater private sector role in health care and a gradual retreat of the state as had happened in other sectors post-globalization.

As it usually happens in such debate, both sides are right and wrong. There is little doubt that the state public health system has failed abysmally in delivering public health. On the other hand, in a country as poor as India, it would be hardly be prudent to dismiss its role entirely. Hence, any public health plan must recognize that state would continue to play a significant role along with a much greater involvement of the private sector in the health care delivery system.

The essential pre-requisite for rejuvenating India’s public health system would be tackling the acute shortage of public health professionals. . In 2006, the government launched the Public Health Foundation of India, a private-public initiative to establish five public health institutes. These institutes will produce 1000 public health professionals every year. It is questionable if such a grandiose scheme would succeed. Even if the government is able to lure the largely US based faculty (largely due to lack of suitable faculty in India), the graduates of these institutes would be difficult to accommodate within the existing public health system. A far better way would be to strengthen the existing community medicine department in state medical schools and expand them into full-pledged public health schools. Most community medicine departments are poorly funded and have a very low research output. A public health school on the other hand would bring specialists from disciplines like biostatics, health policy, epidemiology etc. together, and by exploiting existing linkages with clinical disciplines encourage a more holistic approach to public health. This would not only be more cost-effective but because many diseases are endemic in nature—Japanese Encephalitis to give just one example—would allow for more effective local interventions.

Another human resource challenge is the shortage of primary care physicians. India currently has very few family medicine departments—existing ones are largely restricted to large academic centers like the All India Institute of Medical Sciences. Since specialist courses are extremely limited in comparison to the number of M.B.B.S graduates, by expanding opportunities for family medicines in medical colleges, the state would not only help improve the primary care system to a great extent but also help the M.B.B.S graduates whose talents are largely wasted in the current system.

India currently has one of the most privatized medical systems in the world where the government meets only 17% of the total health care costs compared to 46% in United States and almost 92% in United Kingdom. Unsurprisingly, the government annual per capita expenditure on health care is an abysmal $4. There is an urgent need to increase government spending in health care so health care expenditure as a % of GDP is increased to at least 5% from the current low of 3%. Unfortunately, most of the government health spending is devoted to running large super-specialist centers like A.I.I.M.S and P.G.I Chandigarh—a task best left to the private sector. In fact, as far as possible, the government should outsource the health care delivery system to the private sector. As has been well documented, the government health system especially primary health care centers—the very bedrock of public health system is marked by chronic absenteeism, corruption and lack of even basic laboratory and radiological facilities.

One of the main reasons why the private sector has been unwilling to invest in primary care—especially in rural areas is because it is seen as unrenumerative. It is here the government is required to step in. It can either expand the existing health insurance schemes for the poor or introduce a system of health vouchers analogous to school vouchers. These vouchers would be freely encashable at health providers of the patient’s choice thus introducing a modicum of competition and accountability.

No doubt, in some remote areas, the private sector would be unwilling to invest and here the government may continue to provide health services.

Any system where the government acts merely as a payer and not the provider faces two problems. First, who should be eligible for government subsidy. The currently thinking in India as largely shaped by the Bhure committee which was strongly against introducing means tests. This is ill advised. A means test to decide eligibility would not only ensure that only the poor benefit but also keep government expenditure to the minimum. The second problem is that of moral hazard: people are more likely to utilize health care when they don’t have to pay for it. Hence, a system of co-payments should be introduced whereby the beneficiary would be required to pay a part of the total bill. This would also yield a useful policy tool; it has been well documented that spending in preventive care minimizes cost—both human and capital. Thus the government can have zero co-payment for preventive care like pre-natal and ante-natal visits, mammography and dental checks etc. On the other hand, co-payments would be higher for clinical care. To further encourage preventive care, the government can establish health services accounts where small amounts of money is deposited in the beneficiary’s account as a reward for meeting preventive care goals and practicing healthier life styles. The beneficiary can utilize this money to buy additional uncovered care.

Another problem which requires attention is the rural health care system. The availability of physicians as well as hospital beds in rural areas is much below recommended levels. Worse, in many areas, the patients are restricted to either poorly run government hospitals or quacks with the number of qualified private practitioners being extremely low. This is mainly due to lack of basic infrastructure: roads, electricity, good schools—reasons which are linked to India’s overall growth and development and have no short term solution. The government has attempted to tackle this problem by making rural service compulsory for medical graduates—a measure which is almost guaranteed to fail. The government needs to be less dogmatic and more innovative. It should revive the system of Licentiate Medical Practitioners—registered medical professionals which was abolished in 1952. By using state medical schools and district hospitals, government can offers short term courses in primary health care and recruit local talent to train them in imparting professional care designed to meet the needs of the local population. Another avenue which the government can explore is Nurse Practitioners. The nursing education system in India is generally of high quality. Nursing schools should offer 1-2 years masters level courses in primary care and government should allow such nursing practices independent of licensed doctors.

Finally, the public health system must be localized and attuned to the needs of the specific population–especially in a country as large as India. While, constitutionally, public health is largely in the domain of states–the center exercises a great deal of power
through fiscal control. While India has followed a tradition of centralized planning
and policy making and decentralized implementation—the policy development is largely controlled by the center by virtue of its greater financial strength. A more effective system would be one in which states are more empowered and can exercise effective control over local health policies. It has been noticed that in many public health crises, the state governments are handicapped by lack of financial and administrative control, and have to wait for center’s intervention which is usually delayed.

In conclusion, public health system in India needs urgent attention. It has hitherto been constrained by ideological straitjackets. A public-private partnership where state restrict itself to a) provision of basic health services in under-served areas b) as a payer for the indigent c) funding fundamental research leaving health care delivery to the private sector is the need of the hour.

(An edited version appeared in the latest issue of Pragati)