Health indicators have been gradually improving in India, but health for all is yet
to be achieved. The life expectancy is 68.7 years, infant mortality rate is 33/1000
live births, maternal mortality ratio is 130/100,000 live births, and total fertility
rate is 2.3 children/woman; however, large inequities by geography, gender, class,
caste, religion, and region are seen.[1] Health of the Nation's States Report[2] indicates
that despite rising income, poverty and hidden hunger still exist; environmental pollution
has increased, more so, in urban areas; sanitation services and clean fuel use have
not yet improved to the desired level, especially in the villages. In urban areas,
slums have mushroomed, built area has increased, and open spaces have shrunk. Moreover,
dietary patterns have changed in favor of more sugar, salt, fat, and alcohol, whereas
consumption of vegetables and fruits has declined. Mechanization, especially motorized
transport, has encouraged sedentary life styles and a rise in road traffic injuries
is noticed. The gap between aspirations and real-life situations has pushed many into
addictions and mental health problems. To address these issues, multisectoral public
health actions are needed, in addition to the reorientation of health sector.
In the last decade, the implementation of the National Health Mission (NHM) did bring
back some focus on social determinants of health and encouraged development of a health
system based on primary health care.[3] Investments in health system led to improvement
in health services. It had an impact on health indicators, but the full potential
of NHM is yet to be realized.[4] The recently announced Ayushman Bharat Mission (ABM)
has started insurance coverage for selected package of medical and surgical procedures
for hospitalized patients belonging to socioeconomically vulnerable families on the
lines of Rashtriya Swasthya Bima Yojna though the insurance amount is larger.[5] The
development of subcenters into health and wellness centers continues to be under the
NHM. These two missions, i.e., NHM and ABM, deal with primary and secondary care,
respectively. In the absence of a linkage between these two missions, it may not be
possible to maintain a balance. Therefore, the funds earmarked for ABM should flow
through the primary health-care system on per capita basis. The primary health-care
providers should be empowered to decide which patient to refer, to which hospital
(public or private), and at what cost to pay, so that ultimately health services are
cashless for the patient. Coordinated actions are required not only within the health
and family welfare ministry, but across multiple sectors. Hence, to operationalize
multisectoral public health action in a decentralized manner, every village or urban
ward should have Arogya Kendra (health center) financed by the state through a village
or ward fund, but managed by local volunteers under the guidance of the community
it serves, and it should have a decentralized Integrated Health Information System
for Universal Health Care supported by Information Communication Technology (ICT),
if possible.
Devolution of funds to district health societies and decentralization of planning,
implementation, and monitoring would build a sustainable system rooted in local sociocultural
contexts, which will be able to harness the locally available resources. However,
broad policy framework, guidelines, and oversight can remain at the central and state
level. Primary health-care teams should be incentivized to invest in prevention and
health promotion, so that health literacy improves and spending on illness care can
be reduced. Therefore, NHM and ABM should advocate for a comprehensive public health-oriented
“whole-of-government” intersectoral health promotion initiative keeping in view “inclusive
growth” and “health development” as a social goal of the society. Health impact assessment
of all public policies should be mandated by legislation. “Prevention of diseases”
is a more cost-effective strategy than the popular approach of “Treatment.”
Therefore, several countries have reengineered their health systems in a variety of
ways to protect and improve peoples' health. For example, in England, the Health and
Social Care Act 2012 reorganized the health services to create National Health Service
England and Public Health England,[6] and in Thailand, the National Health Security
Act 2002 granted everyone the right to a standard and efficient health service and
established National Health Security Office to improve universal health coverage.[7]
The World Health Organization has also recently planned a call to countries to set
up leadership at all levels to protect the people from public health emergencies,
to improve universal health coverage, and to ensure that people enjoy better health
and well-being.[8]
Indian should also reorganize its health system. Parliament should promulgate Indian
Public Health Act with a mandate to protect and promote health of people as a fundamental
right to health and health care. An autonomous “Public Health Commission” should be
established to implement the provisions of the Act. It should have a public health
commissioner with three deputy commissioners to head (a) epidemiology, (b) public
policy, and (c) health promotion and education divisions. At state level, an additional
public health commissioner should chair the State Public Health Commission which should
have three deputy commissioners representing the above-mentioned three divisions,
and at district level, a public health officer should head the District Public Health
Commission who should be assisted by three additional public health officers. Each
municipality should have a deputy public health officer and three public health supervisors.
The Panchayat Raj Institutions, at district and community development block level,
should have a deputy public health officer and an assistant public health officer.
At Panchayat level, a public health supervisor should be appointed. Public Health
Commission should have sufficient infrastructure (secretarial support staff, technical
staff, equipment, office space, and budget) so that, in coordination with all sectors,
a Public Health Action Plan can be prepared, funded, implemented, and monitored periodically.
In summary, to achieve the universal health coverage, major challenge in India is
promotion of health, prevention of diseases, and provision of health care in a balanced
manner, which will require innovative public policies, strategies, and programs in
many sectors. Development and implementation of a multisectoral approach to achieve
sustainable development goals is the need of the hour. Establishment of a Public Health
Commission will go a long way in achieving coordination of various initiatives not
only in the Ministry of Health and Family Welfare but also in many other relevant
ministries/sectors. At least 5% of the gross domestic product should be earmarked
for public health and a responsive governance mechanism as outlined above should be
set up, to achieve universal health coverage by 2030 as envisaged in the United Nations
sustainable development goals which are also endorsed by the Government of India.[9]