|DR. A. L. SAHA MEMORIAL ORATION
|Year : 2014 | Volume
| Issue : 3 | Page : 156-160
Public health challenges for universal health coverage
Radha Madhab Tripathy
Professor and Head, Department of Community Medicine, MKCG Medical College, Berhampur, Odisha, India
|Date of Web Publication||13-Aug-2014|
Dr. Radha Madhab Tripathy
Prof. and Head, Department of Community Medicine, MKCG Medical College, Berhampur - 760 004, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The effective functioning of any health system requires an efficient public health service. Every human being has the right to enjoy "the highest attainable standard of health," which can be fulfilled by giving every man an affordable and equitable health system he deserves and demands. In these years, complex health changes have complicated the situation in India. Most important gaps in the health care include an understanding of the burden of the disease and what leads to and causes ill health, the availability and use of appropriate technology in the management of disease, ill health and health systems that have an impact on service delivery. Universal Health Coverage (UHC) has the potential to increase economic growth, improve educational opportunities, reduce impoverishment and inequalities, and foster social cohesion. Steps taken for achieving UHC will address the public health challenges and vice versa.
Keywords: Public health challenges, Universal health coverage, Demographic transition
|How to cite this article:|
Tripathy RM. Public health challenges for universal health coverage. Indian J Public Health 2014;58:156-60
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals." It is concerned with threats to health based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). The effective functioning of any health system requires an efficient public health service. Such a service is essentially multi-disciplinary in nature, and the workforce has prime responsibility for delivering nonpersonal, population-based health care within or at times outside the traditional health sector.
The population of India as per provisional census of 2011 was 1.2 billion as compared to 1.02 billion in 2001, that is, the population increased by >181 million during the last decade. Even though, India accounts for only 2.4% of the world surface area the population it supports is as high as 17.5% of the world population. 2011 NHP shows number of allopathic doctors registered is 921,877 and the doctor-population ratio (2010) is 69/100,000. There has been improvement in the health of the population since independence as is evident from the increase in life expectancy. However, still there is a serious gap in health infrastructure on one hand and a double burden of communicable and noncommunicable diseases on the other hand.
In these years, complex health changes have complicated the situation. India's share in global deaths, maternal and peri-natal disorders, communicable and noncommunicable disease, infant mortality and morbidity and nutritional deficiencies, to name a few is staggering. In addition to it inequalities in socioeconomic status, geography and gender are other issues not to be ignored.
India accounts for 21% of the world's global burden of disease and is home to the greatest burden of maternal, newborn and child deaths in the world. Infant mortality rate declined from 83/1000 live births in 1990 to 47/1000 live births in 2010 and maternal mortality ratio (MMR) reduced from 570/100,000 live births in 1990 to 212 in 2007-2009.
Health care that was supposed to be affordable is not so and the out of pocket health care expenditure is a reason for the poverty in India. The poor have to bear the brunt of death and disability. Poverty is the underlying cause of malnutrition, infection, and diseases. As per Planning Commission, GOI 21.98% (2013) of the population belong to below the poverty line (BPL) category. Every year some 150 million people face severe financial hardship, and 100 million are pushed BPL because they fall ill, use health services, and pay out of pocket. Many have to sell assets or go into debt to meet the payments.
As the years progress, infectious diseases like Dengue and Malaria and other vector-borne diseases are spreading like epidemics due to urbanization and migration. The upsurge in the incidence of vector-borne diseases, reported from different parts of the country, during the monsoon, has now become an annual seasonal phenomenon. In India about 25-40 million people have hepatitis B and one lakh die each year from serious liver diseases. National liver foundation has described the disease as a "silent killer." Still people are being affected by hepatitis B and hepatitis C due to faulty sterilization practice of health care givers as reported off and on. Multidrug resistance tuberculosis is on the rise. Though there is a decrease in morbidity and mortality due to vaccine-preventable diseases, poor immunization coverage is a matter of concern. To add to it, we are on the plateau phase in the HIV/AIDS epidemic. Roughly 5 million HIV-infected people are there and probably 1000's need antiretroviral therapy. Some of the states with good health indicator have high-HIV prevalence. Though diseases like neonatal tetanus, Polio or leprosy will become diseases of the past, new ones like severe acute respiratory syndrome, Avian Flu, Cholera, to name a few have returned. Emergence and re-emergence of infectious diseases is again due to urbanization, industrialization, unregulated population growth and lack of public health facilities.
Lack of sanitation is responsible for diseases like typhoid, leptospirosis, malaria and other communicable diseases, creating havoc in the public health system. Almost everyday people are dying of diseases that are treatable. Lack of waste disposal system contaminates the water source which becomes worse in rainy days. About 50% of people living in India do not have access to toilets and hence are forced to defecate in the open. In actual numbers, 50% translates to 600 million.
Coming to noncommunicable diseases an estimated 10 lakhs new cancer cases occur in India annually, and there are 2.8 million cases of cancer in the country at any given point of time, imposing huge costs on state and society in providing tertiary care for advanced chronic cases. Cardiovascular diseases along with diabetes have already attracted the attention of policymakers. India has become the diabetes capital of the world. Hypertension is showing an upward trend. The prevalence of hypertension is one of the risk factors for a few noncommunicable diseases. Noncommunicable diseases are already responsible for two-thirds of the total morbidity burden and about 53% of total deaths (up from 40.4% in 1990 and expected to increase to 59% by 2015). It has been projected that by 2020 ischemic heart disease, cerebro vascular disease and chronic obstructive airway disease will be the leading causes of death. In addition to it, morbidity and mortality due to accidents (both domestic and industrial) are also showing an upward trend. Occupational health is not a priority. Considering the increase in mental illnesses the Supreme Court has issued notice to the central and state governments on a plea by the National Human Rights Commission seeking a country-wide epidemiological survey to identify the magnitude of mental health problems. Non communicable diseases have replaced infectious diseases as the major cause of death. Tobacco-related deaths have become a silent epidemic.
Climate change due to changes in the ecosystem through anthropogenic activity is the most profound of human health threats of this century. The effects of extreme weather events like storms, floods, droughts and heat waves are abrupt and acutely felt. And this has led to an increase in deaths due to malnutrition, diarrhea, heat waves and vector-borne diseases like malaria and dengue.
Gender inequalities are of great public health concern. The gender equality index in India is 0.748, well below China (0.405) or Sri Lanka (0.599). Gender disparities, particularly persistent in anti-female biases, are most glaringly reflected in the declining female-to-male ratios among children below six (with a sex ratio among children declining from 927 girls per 1000 boys in 2001 to 914 in 2011). The World Economic Forum ranked India as 132 nd out of 134 nations in terms of gender equity in health. Furthermore, there remains a disturbingly high MMR of 212 maternal deaths per 100,000 live births, despite the country's rapid economic growth rate. Women are afflicted with a considerable hidden burden of disease, which is often not accounted for in morbidity figures. Violence against women both at home and in the workplace is on the rise in spite of an increase in the number of women in the workforce.
The shocking state of primary healthcare services in both private and public clinics in urban and rural areas of the country is an open secret. Lack of infrastructure and resources (manpower and other logistics) to provide health services are posing a great challenge. Unequal distribution of resources among rural and urban areas and unwillingness of qualified personnel to work in the rural areas make the situation worse. The shortage of human resources extends to all health professions. Former president of the Federation of Indian Chambers of Commerce and Industry Onkar S. Kanwar noted at the Global Healthcare Conference January 2007 that while the projected physician shortfall would top 45,000 in 2012, the shortfall for nurses would be even greater - roughly 350,000 nurses are required for primary and secondary care by 2015. Mushrooming of the private medical colleges in urban areas to produce more doctors to serve the country is adding another problem.
India's public spending on health is just around 1.2% of gross domestic product (GDP) and is among the lowest in the world. It is not considered as an investment but rather as a dead loss! But whatever is sanctioned is not utilized. In the words of Amartya K Sen "Growth in national income by itself is not enough, if the benefits do not manifest themselves in the form of more food, better access to health and education." High cost of medicines has now forced millions of Indians to go without medications because they cannot afford. Faulty planning and inefficient management over the years has made the Indian health care system dysfunctional without benefiting the ordinary citizens. Decrease in spending on medicine, drugs, equipment and preventive care are important causes of slow progress in health outcomes. Private sector, mostly spread over urban India is profit based organization, which never adheres to ethics or professionalism. In addition, over the counter prescriptions and irrational use of antibiotics leading to drug resistance is also of concern to the public health specialists.
People value good health, so health improvements contribute directly to human development as recognized in the Human Development Index. Improved health also contributes to economic growth, something that the WHO Commission on Macroeconomics and Health documented >10 years ago. India is languishing in the Human Development Index (recently released by the UNDP). Even Bangladesh has overtaken India in some vital parameters.
There is a shortage of public health personnel to provide the right methodological expertise to ensure best utilization of resources. Public health surveillance is also not adequate, which is responsible for the disease outbreaks. National programs targeting different aspects of Public health are formulated in the form of programs and policies, but poor implementation of the same is not helping us to achieve the targets. There is an improper match between demand and supply of services.
Most important gaps in the health care include an understanding of the burden of the disease and what leads to and causes ill health, the availability and use of appropriate technology in the management of disease, ill health and health systems that have an impact on service delivery.
In 2012, at the Rio +20 conference it was recognized that UHC has the potential to increase economic growth, improve educational opportunities, reduce impoverishment and inequalities, and foster social cohesion.
However, public health challenges like demographic transition, epidemiological transition, low equity and low GDP will be challenges for UHC. Steps taken for achieving UHC will address the public health challenges and vice versa. Universal health care or UHC means that all people can use health services while being protected against financial hardship associated with paying for them. Universal coverage is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma-Ata declaration in 1978.
As per the discussion on "Towards UHC: Concepts, lessons and public policy challenges of the World Bank of February 2013," no health system in the world can provide everything for everyone: Each country faces trade-offs with regard to what services will be provided, to whom, and with what level of affordability. The prioritization across the three-dimensions of coverage - population, service, and cost - is perhaps the most difficult political challenge on the path toward UHC, and it is ongoing as new health services and technologies are developed. UHC goals like reducing the gap between the need for and use of services, improving quality, and improving financial protection orient the broad directions for progress, but reform in any country begins with its existing system and context. The high-level expert group (HLEG) undertook a situational analysis of each of the key elements of the existing health system and has developed recommendations for reconfiguring and strengthening the health system to align it with the objectives of UHC, bridging the presently identified gaps and meeting the projected health-needs of the people of India over the next decade.
Many recent initiatives ranging from the National Rural Health Mission, the Rashtriya Swasthya Bima Yojana and a number of state-sponsored health insurance schemes are already providing multitude services. The social objectives of all of these schemes would need to be merged, and their scope considerably expanded to create a valued and viable model of UHC in India.
The HLEG also recognizes that, for such a vision of the UHC to be realized, a tax based system of health financing is essential. This is also the global experience, wherein countries which have introduced UHC have mostly depended on general revenues rather than on unsteady streams of contributory health insurance which offer incomplete coverage and restricted services. For UHC to succeed in India, political and financial commitments are required from the central as well as state governments.
The primary level of care, that is, services that are "close to client," are the priority for strengthening, recognizing that it is also important to ensure a balance between services focusing on individuals (e.g., treatment, palliation) and those focusing on populations (e.g., population-based prevention and promotion). Universal coverage with needed health services in turn incorporates many different components, including universal access to essential medicines and health products, sufficiently motivated and well-distributed health workers of the right mix, and information systems that provide timely information for decision-making. Political commitment to UHC can provide a springboard for health system investments and reforms that are essential for ensuring service availability."
Here, it is worth mentioning about the High Level Action Group report on UHC, which can be achieved only when sufficient and simultaneous attention is paid to at least the following health-related areas: Nutrition and food security, water and sanitation, social inclusion to address concerns of gender, caste, religious and tribal minorities, decent housing, a clean environment, employment and work security, occupational safety and disaster management. Second, the very framework and principles of UHC for India will be severely undermined if gender insensitivity and gender discrimination remain unaddressed.
Health challenges have to be faced and corrective measures undertaken by health research, program evaluation and monitoring, operational research, health analysis and accountability for generation of evidence-informed decision-making in policy formulations and implementations. It has been seen that public health measures applied to populations is cheaper and more effective than the individual approach.
Universal Health Coverage goals like reducing the gap between the need for and use of services, improving quality, and improving financial protection orient the broad directions for progress, but reform in any country begins with its existing system and context. Hence before planning further, assessment of the existing services need to be done. Increasing the budgetary allocation and thorough evaluation of the proposed intervention in respect of their cost effectiveness, will strengthen the system. Development of the infrastructure with qualified human recourses and setting standard treatment protocol will ensure quality care. Last but not the least is empowering people about their health issues.
Keeping in view all these the High Level Action Group had recommendations for introducing a system of UHC in India basing on 10 principles:
- Nonexclusion and nondiscrimination;
- Comprehensive care that is rational and of good quality;
- Financial protection;
- Protection of patients' rights that guarantee appropriateness of care, patient choice, portability and continuity of care;
- Consolidated and strengthened public health provisioning;
- Accountability and transparency;
- Community participation; and
- Putting health in people's hands.
| Conclusion|| |
The preamble to the WHO Constitution affirms that it is one of the fundamental rights of every human being to enjoy "the highest attainable standard of health" which can be fulfilled by giving every man an affordable and equitable health system he deserves and demands. The responsibility lies with the individual, the community and last, but not the least with the state. India can aspire to achieve greater equity by bridging health disparities and inequities with UHC.