The public health scenario in India has been undergoing a rather fast economical, demographical and epidemiological transition over the last few years. It is a fact that along with the remarkable economic progress of the country, particularly in terms of gross domestic product (GDP) growth rate, the disparities between the rich and the poor have unfortunately been growing. Studies indicate that this income inequality or disparity between the different socioeconomic classes is associated with highly undesirable worse health outcomes with damaging health and social consequences. Several measures aimed at financial inclusion and social security are being implemented by the Government to tackle the issue of economic inequalities. However, much needs to be done to ensure that health disparities among various social and economic classes are also addressed adequately.
India has been witnessing a substantial increase in its labour force along with its unprecedented demographic changes. However, it will benefit the country only if the population is healthy. The country at present is confronted with a few broad public health issues like the unfinished agenda of infectious diseases, the challenge of non-communicable diseases (NCDs) linked with lifestyle changes and emergence of new pathogens causing epidemics and pandemics. Further, there is imperative necessity of strengthening the health infrastructure to enable it confront these challenges in the emerging scenario.
The public health challenges
India has made enviable strides in the public health sector over the past few decades. The life expectancy has crossed 67 years, infant mortality rates are declining as is the rate of disease incidence. The country has succeeded in eradicating many diseases, such as polio, guinea worm disease, yaws, and tetanus. However, the communicable diseases are expected to continue to remain a major public health problem in the coming decades posing a threat to both national and international health security. Besides endemic diseases such as human immune-deficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), malaria, and neglected tropical diseases, the communicable disease outbreaks will continue to challenge public health, requiring high level of readiness in terms of early detection and rapid response. Vector-borne diseases, such as dengue and acute encephalitis syndrome, are of particular concern in this regard. Antimicrobial resistance, which is the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarials) from working against it, is one of the biggest health challenges facing humanity which warrants tackling with all seriousness.
Further, non-communicable diseases or NCDs are now one of the leading causes of death in the country, contributing to 60% of deaths. Four diseases namely heart disease, cancer, diabetes, and chronic pulmonary diseases contribute nearly 80% of all deaths due to NCDs and they share four common risk factors namely tobacco use, harmful use of alcohol, unhealthy diet, and lack of physical activities.
Another factor of significant concern is the high incidence of maternal mortality ratio and infant mortality rate (IMR), though the trend is towards the decline. The IMR, which was 68 deaths per 1000 live births in 2000 declined to 34 per 1,000 in 2016 according to the NITI Aayog. However, it still is much higher than the global average of 29 per 1000 in 2017. Though IMR in India has been declining, the rate of decline remains relatively slow, compared to that being achieved by other South Asian neighbors except Pakistan.
The epidemiological transition in India is being fueled by the social and economic determinants of health and by and some risk factors such as globalization, unplanned and unregulated urbanization, changing life styles, environmental causes like climate change and air pollution, and increasing influence of media and advertising. Moreover, there are great disparities between the rich and poor and between those living in urban and rural areas in access to health services. For instance, the poorest and the most marginalized sections of the society are not only at a greater risk for communicable and NCDs, but are also least able to cope with the diseases resulting from these risk factors. If someone in the family gets sick, the family often gets trapped in poverty, partly due to the high cost of health care. The health-care system is also overstretched.
Case for paradigm shift in approach
Considering the imperative significance of health in economic development, a paradigm shift is warranted in our approach. It is felt that the scenario warrants investing more in health and recognizing disease prevention and health promotion as the topmost priority areas. Presently, India has one of the lowest allocations to health among all countries of the world as percentage of GDP. As a result of such a low investment in health and due to high out-of-pocket expenditure (85.6% which according to the World Bank is among the highest in the world), nearly 60 million people are pushed further into poverty and into the poverty trap from that they are unable to escape.
Of the total health budget allocation for health, a higher portion of the fund should be earmarked for disease prevention, health promotion, and improving the quality of health services at the primary care level. Health is now recognized in many developed countries as the people's right.
There is the need for strengthening the health system to improve the process of service delivery. It is necessary to improve the functioning of the existing government health infrastructure. The existing public health system and facilities needs to be assessed and improvements need to be brought based on the findings of the assessment, including augmented human and material resources, and monitoring their performance and fixing accountability in a systematic manner, by setting targets and trying to achieve them through a comprehensive and integrated approach, with full involvement of the community. Improved access to government health services, which are used primarily by the poor and the disadvantaged sections of the society, will go a long way in achieving better health outcomes.
An efficient public-health workforce is vital for efficient and effective delivery of services. India has one of the lowest density of health workforce; with density of physicians (7 per 10 000 population) and nurses (17.1 per 10 000 population) as against the global average of 13.9 and 28.6 respectively (World Health Statistics, 2015). The nurses-to-physicians ratio in India is about 0.6:1, as against the nurses-to-physicians ratio of 3:1 in some of the developed countries. The issue is very serious, particularly in the rural areas, as most doctors and hospital beds are concentrated in urban areas catering to only 20% of the India's population. Public health planners should make all efforts to fill vacant posts through efficient recruitments, and build skill of the existing staff through training activities and by creating enabling environment including adequate facilities for health workers to stay in rural areas. To enhance skill training activities, health can leverage with and benefit from the national skill development mission launched in India in August 2015.
An evidence-based policy-making requires data on disease burden and the associated determinants. Focus should be on strengthening a widespread research and innovation culture throughout the country and generating homegrown data, obtained through surveillance, research, and monitoring and evaluation, so that these data can be used for policy and strategy development, priority setting, and evaluating the impact.
The purpose of public health should be the welfare of the weakest and most vulnerable sections of the society and hence addressing the issue of equity is crucial. In this regard, the priority should be given to understanding the barriers to equitable access, integrating equity goals in policy and programs, and targeting resources and efforts to reach the poor and vulnerable sections of the society with the needed services.
Then there is the necessity of leveraging technology to transform public health. Modern technology has great potential in bringing efficiency in service delivery and enhancing the reach of the health services. It can connect remote areas with national centers of excellence or patients in villages with doctors in hospitals in urban areas through audio or video conferencing. The government has already established a network of telemedicine services, mother and child tracking system of weekly voice messages to pregnant women and new mothers, web-based TB registration scheme called Nikshay, and implementing a mobile app for the training of Accredited Social Health Activist (ASHA) workers.
Mobile technology holds great promise in public health especially due to its ubiquitous nature. With more than one billion mobile users in the country, the mobile phones offer tremendous opportunities in efficient health service delivery which include ensuring treatment adherence by sending messages to patients with diabetes or HIV/AIDS reminding them to take their treatment, quick reporting of cases during outbreaks or epidemics, alerting next level of health services regarding emergency situation such as difficult or complicated labor in a remote rural area, informing populations and creating awareness about emerging health issues or health programs etc. The internet connectivity is presently being used to enhance e-governance and making patient consultations with experts such a tele-ophthalmology in some States. Low-smoke stoves can help reduce indoor pollution and respiratory infections, and the use of point-of-care diagnostic methods, such as a lab in a suitcase for diagnosis in areas where such facilities do not exist, can be of great help. These examples show that technology already available can enhance the quality and efficiency of the services, and this should be expanded and scaled up rapidly, in order to make health services available and accessible for the people living in geographically remote areas.
It can be seen from the above that most of the risk factors for ill health lie outside the health sector. Therefore, action to combat these risk factors requires an inter-sectoral and interdisciplinary approach. Besides policy, the programs also should have inbuilt mechanism to ensure transparency and fix accountability. In this context, highly laudable is the nation-wide campaign of the India government for the period 2014 to 2019 by the name Swachh Bharat Abhiyan that aims, inter alia, to clean up the streets, roads and infrastructure of India's cities, towns, and rural areas, to eliminate open defecation through the construction of household-owned and community-owned toilets and to establish an accountable mechanism of monitoring toilet use. Run by the Government of India, the mission aims to achieve an "open-defecation free" (ODF) India by 2 October 2019, the 150th anniversary of the birth of Mahatma Gandhi, by constructing 90 million toilets in rural India at a projected cost of Rs.1.96 lakh crore. The mission will also contribute to India reaching Sustainable Development Goal 6 (SDG 6), established by the UN in 2015.
Private sector can also support the health promotion and disease prevention activities under public–private partnership and through the corporate social responsibility initiatives. Engaging them in a creative and positive manner as partners for health action coordinated by the government can go a long way in addressing the public health challenges in the next decade and beyond.