A jobs scheme to improve public health
The tragedy of children with encephalitis dying in a Gorakhpur hospital has caused much outrage about hospital mismanagement. Far more outrageous is the fact that encephalitis threatens many thousands of lives every year in Gorakhpur alone, and this in the 21st century.
People living in places with a high prevalence of communicable diseases understandably consider it normal to succumb to disease. This was also the case a century ago in the developed world. The state has to improve sanitation and public health services to reduce the prevalence of these diseases, despite lack of public demand for such services. Most countries around the world have made this a priority, viewing it as essential to building development infrastructure, improving human capital and labour productivity, and reducing poverty.
Health services in India have prioritized medical services, neglecting public health services that seek to reduce the population’s exposure to disease. This neglect is evidenced in many ways, such as the explosive growth of an array of mosquito-borne diseases. Faecally transmitted diseases, which include infections from a whole cafeteria of parasites, viruses and bacteria, cause widespread debility and can be fatal. Treatment for such diseases is sought on a huge scale across the country, while faecal waste continues to be poorly managed. Studies show that major Indian rivers now contain antibiotic-resistant matter, supplying water that can threaten immunity to available drugs.
Reducing exposure to communicable diseases is of the highest priority in public health services, as their spread causes severe negative spillovers. This applies also in countries where these diseases have long been eliminated, to avoid their resurgence. For example, there is constant monitoring of mosquito-breeding in the US, although malaria was eliminated by the 1940s. There is constant surveillance of imported cases of communicable diseases, so as to quickly limit their spread. As Laurie Garrett, senior fellow for global health at the Council on Foreign Relations in New York, put it, “Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running.”
These services save incalculable medical costs. Quantifying such counterfactuals is difficult, but consider the cost to the developed world if communicable diseases were still endemic there. An indirect indicator of the gains from communicable disease control is the small gap in life expectancy between the richest and the poorest in the US, despite their vast differences in living conditions and access to healthcare. A 2016 study by Raj Chetty and colleagues, published in the Journal Of The American Medical Association, finds that US female life expectancy at age 40 is 79 years in the lowest 1% of the income distribution, only 10 years lower than those in the top 1%. This suggests that Indian public funds could improve health outcomes far more if spent on public health instead of subsidizing health insurance.
India’s employment guarantee schemes could use lessons from the US’ Depression-era public works programme. In areas badly affected by malaria, this labour was used for large-scale drainage and other works to control malaria, with technical inputs from public health personnel and sanitary engineers. The Swachh Bharat campaign could also use such technical expertise to maximize its impact in reducing exposure to diseases.
Charitable foundations can emulate the Rockefeller Foundation’s efforts to improve public health and sanitation. In the early 20th century, they found that 40% of school-aged children in the southern US had hookworm, an aggressive faecally transmitted parasite that can cause listlessness and stunting. They sponsored demonstration projects combining deworming treatment, campaigns to raise people’s awareness of the problem, and technical assistance in building latrines in homes and public buildings. The state health authorities learnt from this approach and applied it widely. Hoyt Bleakley’s 2006 analysis in the Quantitative Journal Of Economics finds that programme beneficiaries gained in school attainment and earnings.
The Central government can do much to strengthen public health service delivery in India. Tamil Nadu offers some basic organizational principles whereby other states can strengthen their public health systems within their existing administrative and fiscal resources. My colleagues and I described this system in a 2010 article in the Economic And Political Weekly. The Central government could link its fiscal support to states with phased progress in (1) the establishment within the state health departments of separate public health directorates with their own budgets and staff, managed by medical doctors trained in public health administration; (2) the enactment of public health Acts to provide the basic legislative underpinning for public health action; and (3) the revitalization of public health cadres.
These measures can help use public funds more effectively for protecting people’s health. The government can do much else with more innovative and better-focused use of other programmes such as the employment guarantee programme and the Swachh Bharat campaign.
Monica Das Gupta is a research professor at the University of Maryland, College Park.
This article is the fourth and last in a series on public health in India.
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