Healthcare: Grow health for development
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Following a resounding electoral verdict in favour of speedy and sustained development, coupled with assurance of gainful employment for our growing number of young people, there is great interest in seeing how the budget will balance the need for fiscal discipline with stimulus spending for growth and job creation.
Usually, industrial, infrastructure and services sectors are regarded as propellants of both economic growth and employment. It is pertinent to point out that social sector investments can achieve those objectives too. Indeed, there is a strong case for greater public financing of health, recognizing that health has both intrinsic value for well-being and instrumental value for economic development. Will the budget respond to the expectation that health will feature prominently in the new blueprint for development?
Health must become a high priority in a nationally agreed development agenda, with both the Centre and states subscribing to a shared vision and pledging a common commitment to concerted action. This is required not only because the Constitution places the mantle of health services delivery mainly on the states, but also because universal health coverage, unveiled as an aspirational goal in the 12th Plan, cannot be implemented if there is a lack of consensus across this large federal polity.
Health and nutrition are now well recognized as important levers for economic development. The World Health Organization’s Commission on Macroeconomics and Health helped to position this firmly in the global development discourse. The recently published report of the Lancet Commission on Investing in Health estimated the benefits of increased investments for accelerating progress on the global health goals set in 2000—the economic returns would be ninefold for low income countries and 20-fold for low-middle income countries such as India. On the other hand, failure to prevent child malnutrition and adult heart disease can cause a huge loss of brain power and productivity, impairing growth and escalating healthcare costs.
If the government decides to increase investment in health, as indeed it must, it has to prioritize the initiatives which are likely to yield maximal aggregate health benefits across the whole population, while reducing health equity gaps between different groups. It has to ensure that actions within the health sector are supported by actions in other sectors that will promote, and not erode, population health. It is inconceivable that we can protect and promote societal health without providing safe drinking water, country-wide sanitation, adequate and appropriate nutrition at all ages, and clean air to breathe.
Multi-sectoral collaboration for health will only become an operational reality if inter-agency task forces are established with set targets and timelines. There must be shared ownership across many ministries, at central and state levels, with joint accountability. This calls for clear vision, strong political will and the ability to create a national consensus. The Prime Minister’s Office must set and monitor this agenda, if it is to succeed. The recent policy pronouncements by the Prime Minister and the health minister convey their commitment to promoting good health at the population level, while improving services for individual healthcare.
Within the health sector itself, the health system must be strengthened to make it capable of meeting a multitude of health challenges with assured access, efficiency, equity, quality and affordability of a wide range of services. Vertical health programmes that fragmented the health system in the past, as well as the disconnected health insurance programmes that are unable to reduce the high out-of-pocket expenditure on essential healthcare, must be operationally integrated under a well-designed programme of universal health coverage (UHC). Rashtriya Swasthya Bima Yojana and the various state-funded health insurance schemes must be reviewed and integrated to create a single-payer system for UHC, which can accommodate state priorities within a broad national framework.
Comprehensive primary healthcare, to be provided in both rural and urban areas, must become the highest priority. The platform for UHC must provide an essential package of basic preventive, promotive, diagnostic, therapeutic, palliative and rehabilitative services, dealing with a wide range of health needs and providing continuity of care throughout the life course. The family must become the unit of service provision, with care extending from the newborn to the elderly.
To overcome healthcare provider shortage and maldistribution, programmes for primary healthcare delivery must extensively train and employ technology-enabled frontline health workers, who should be a mix of community health workers, nurses and mid-level community health officers. They should be supported by doctors trained in allopathic or Indian systems of medicine. Hand-held point of care diagnostic devices like Swasthya Slate and mobile phones can transform primary healthcare.
Advanced medical care, too, will need to be strengthened. The government must mobilize all the resources of a mixed health system to deliver this in a well regulated framework of UHC, which assures quality while controlling costs. While strengthening district hospitals and medical colleges, the private sector would need to be engaged to support UHC through clearly defined and transparent contractual arrangements.
Access to essential drugs, vaccines and technologies must be ensured. Free provision of essential, quality-assured generic drugs through public healthcare facilities will help needy patients and reduce the impoverishing effects of healthcare. Health information and disease surveillance systems must be strengthened through innovative use of information technologies. An autonomous expert body must be established for health technology assessment. It is heartening that the health minister has already made these his priorities.
What of employment? The number of new community health workers, allied health professionals, nurses, public health professionals and doctors needed to reinvigorate the health system will be nearly 10 million over the next five years. Investments in training and deployment of this technology-enabled, multi-layered and multi-skilled workforce will not only transform the health system, but will also create a surge of youth employment, especially for women. What can be a better indicator of inclusive social and economic development?
K. Srinath is president, Public Health Foundation of India.