The urgent need for a National Commission on Public Health & Healthcare.
Article Type: Viewpoint essay
Subject: Public health (Research)
Health care industry (Management)
Health care industry (Services)
Author: John, T. Jacob
Pub Date: 03/01/2010
Publication: Name: Indian Journal of Medical Research Publisher: Indian Council of Medical Research Audience: Academic Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2010 Indian Council of Medical Research ISSN: 0971-5916
Issue: Date: March, 2010 Source Volume: 131 Source Issue: 3
Topic: Event Code: 310 Science & research; 200 Management dynamics; 360 Services information Computer Subject: Health care industry; Company business management
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: India Geographic Code: 9INDI India
Accession Number: 224711424
Full Text: India's health system is not shining. The country is progressing on many other fronts, particularly with its growing economy and infrastructure development. Unfortunately, education and health, the two basic ingredients of human-capital development, have not kept pace with progress in other sectors. Consequently India's Human Development Index rank is only 134 among 182 countries evaluated by United Nations Development Program in 2009 (1).

There is recent progress in the education sector. The Government of India (Gol) has taken steps to ensure free and compulsory primary education for all children, for which it has recently enacted the Right to Education Bill, making education of children 6-14 yr a fundamental right (2). If implemented properly, this will pave the way for equity in primary education (2). Currently moves are afoot to make even secondary education free for all children. These steps are initiated according to the 2009 election manifesto of the Indian National Congress (INC), the major party in the United Progressive Alliance (UPA), illustrating that progress in social sectors begins with the articulation of vision by the political party that comes to power (3).

Disappointingly, there is no innovative or imaginative vision in the manifesto of the INC to improve the health sector significantly (3). It envisages "health security for all", the meaning and content of which are undefined and vague (3). It also states that the National Rural Health Mission (NRHM) will be implemented with "greater sense of urgency"; every family living below the poverty line will be covered under health insurance within 3 years; and every District Headquarters Hospital (DHH) will be upgraded to "provide quality health facilities for all" (3). These are welcome moves in themselves, but are too little in the face of the gross inadequacies faced by the health sector, as pointed out with a few examples below. These statements of intention are indicative of the value assigned to equitable access to quality healthcare, but the proposed steps are insufficient to achieve it. "Health security for all" is also apparently the expression of a desire for equity. Even if NRHM is fully implemented and all DHHs are upgraded, access to healthcare will not become equitable or quality-assured for the rural and urban poor. No concern about the low quality of available healthcare in the public sector or about the lack of regulated/assured quality (and high cost) of healthcare in the private sector is evident in the manifesto. Moreover, no importance is given either to disease prevention through public health or to health system reform. Therefore, health system reform will not evolve from the election manifesto of the ruling political party. An alternate pathway is necessary.

One such pathway is through legislative resolve, exemplified by the Draft 2008 National Health Bill (4). A re-examination and assertion of the legal framework for enabling and empowering people on their constitutional rights regarding health is good in itself, but it is not the solution for the deficiencies of the system. Hope for the future is always welcome but what India needs is structural and functional improvements of the health system beginning in the present. Thus, in addition to what is promised under the manifesto and whatever promises the Draft Bill holds, the deficiencies of the health system deserve diagnosis and remedial measures starting from now. How and where should they begin?

Globally, modern medicine has advanced on two fronts--public health and healthcare. Health systems in all progressive countries subsume these as two sub-systems. Independent India's health system does not include public health as a result of the uncorrected regressive steps taken soon after achieving independence from British Raj. The post of the "Public Health Commissioner" in the central government was abolished and the concept of "Indian Medical Service" was discarded (5). They were not replaced by better public health organization; thus the baby and the bathwater were thrown out together (6). The GoI must now address health system reform in order to re-establish organized public health and to provide quality healthcare with equity. Since these elements are not envisioned in the election manifesto or clarified in the Draft Bill, and since the system-design with reform will be complex, the need of the day is for detailed stock-taking, analysis and synthesis of all the elements of the health system. One way to achieve this is through the establishment of a National Commission on Public Health and Healthcare, with the governmental commitment to implement its prescriptions (7). The purpose of this article is to advocate for such a visionary and bold forward step.

The first such Commission (Health Survey and Development Committee) was established by the British Raj, in 1943, under the chairmanship of Joseph Bhore. Its report, submitted in 1946, reviewed the health system under the following sub-heads: Public health; Medical relief; Professional education; Medical research; and International health (5). The present organization of the health system is patterned after the Bhore Committee report. While it recommended the integration of public health and healthcare at the local level, what happened post-independence was the abolition of the public health sub-system. It is only through public health that health benefits can be equally shared by all (6).

Towards the end of the period of the second 5-yr plan, in 1959, another Commission (Health Survey and Planning Committee) was appointed under the chairmanship of A. Lakshmanaswamy Mudaliar, to review progress since independence and to provide guidelines for national health planning in the context of 5-yr plans (5). The Mudaliar Committee recommended several steps to improve the national health system, but those were not implemented except in part in Tamil Nadu. Accordingly there is a separate Department of Public Health, under a technically qualified Director of Public Health and Preventive Medicine in Tamil Nadu. Also, public health services in units of 2 or 3 districts are supervised by a Deputy Director of Public Health, also technically qualified. The proposed National Commission will do well to analyse the achievements of Tamil Nadu in public health to identify what elements should be adopted in all other States. A structured career pathway for those trained in public health is an obvious element that should be established both in the central Ministry of Health & Family Welfare (MoHFW) and in all States. The establishment of public health training institute in every State, as in Tamil Nadu, is another element for providing trained officers in public health.

The Mudaliar Committee reiterated the need for an Indian Health Service on the pattern of Indian Administrative Service or the Indian Medical Service under the British Raj (4). Both Bhore and Mudaliar Committees recommended the upgradation of DHHs to streamline the referral system; thus the recent election manifesto has merely re-stated what was said way back in the 1940s and 1960s. The inability to implement these is indeed a system weakness--unless re-designed the system may not be able to implement the proposal even today. In Tamil Nadu, every district hospital has already been upgraded into a medical college hospital. This has ensured, within every district, both the referral need of specialties and also a steady supply of doctors to work in the rural areas, compensating for the migration of doctors to towns, cities and other States as well as overseas. For contrast, there are about 70 districts in Uttar Pradesh, but only 7 government medical colleges--so it is not surprising that the State is finding it virtually impossible to fill all vacancies of doctors to work in rural areas.

West Bengal has recently passed a Bill to train health workers for 3 yr and to post them in primary health centres, to overcome the shortage of doctors (8). What primary health centres need are doctors trained in "family medicine"--not half-baked health workers, not even fresh medical graduates, but well-trained family doctors as the first level physicians to care for all members of the family, neonates to grandparents. Ask one simple question: will you take your sick family member to be treated by the 3-year diploma holder or even a fresh medical graduate without experience? The medical graduate is well trained to function within a hospital set up; short 'exposure' to rural conditions is insufficient for developing reasonable quality competence in a fresh graduate, sufficient for entrusting the health and lives of people. The principle is: do unto others what you would want them do to you. Improving healthcare delivery in rural areas is an essential element in ensuring the empowerment of people to enjoy the constitutionally enshrined Rights to Health and Life, whether or not the Draft National Health Bill gets passed. India should aim for nothing less. Equity and quality should begin at the primary care level and continue up along the referral pathway.

There must be a clear policy on public-private participation in healthcare. The national tuberculosis (TB) control programme has already pioneered successfully public-private partnership, but it is confined to TB diagnosis and treatment. There has to be careful auditing of the quality of care in both public and private sector institutions. There are several private but not-for-profit healthcare institutions in the country. If the public sector would partner with them for providing care equitably, and share the basic costs of running them efficiently, this model can spell win-win situation for the local population, the government and the philanthropic institutions. This approach requires innovative policy framework.

The MoHFW works within the National Health Policy that was enunciated in 2002 and not revised since then9. While the Draft Bill referred to above desires revision of health policy every 5 years, nothing has prevented the GoI from revising the policy now, without waiting for the Bill to be passed. According to the current policy, only the following infectious diseases are meant to be controlled: polio and yaws (eradication by 2005); leprosy (elimination by 2005); kala azar (elimination by 2010); lymphatic filariasis (elimination by 2015); HIV/AIDS (zero growth by 2007); TB, malaria, other vector-borne and water-borne diseases (50% mortality reduction by 2010). Of these, the targets regarding yaws, leprosy and HIV/AIDS have been fully or partially achieved, but all others have failed or are failing. To illustrate, the failure of TB control is briefly presented below.

The National Tuberculosis Control Programme (NTCP) was launched in 1962 but found to have failed when evaluated in 1990. It was modified as the Revised NTCP (RNTCP) and the tactic of directly observed treatment, short course (DOTS) adopted in 1993 (10). It took 13 more years to expand DOTS programme in all districts (10); RNTCP has not been comprehensively evaluated. There is no reliable evidence that the incidence of Mycobacterium tuberculosis infection or the burden of clinical tuberculosis (especially the infectious form of pulmonary disease) has perceptibly declined in spite of 47 yr of efforts at tuberculosis control (10,11).

The Expanded Programme on Immunization, the flagship project of the Department of Family Welfare under MoHFW was established in 1978 and enlarged in 1985-1990 as Universal Immunization Programme (UIP). It is a relatively straightforward and result oriented public health programme; yet India has failed to achieve equity in the prevention of the 6 targeted vaccine-preventable diseases of children (4,12). The performance is grossly deficient without reliable monitoring of data on inputs efficiency, total performance or outcome achievements (12). The results of the third National Family Health Survey in 20052006 showed that only 44 per cent of children (12-23 months) had received the recommended vaccines (13). In 1988 India resolved to eliminate wild poliovirus transmission by 2000, but has failed until 2009, while every other country of the South East Asia Region of the World Health Organization succeeded by 2000 or earlier. The quintessential reason is the glaring gaps in the health system (14). Diphtheria has re-emerged in this decade as a result of poor vaccination coverage (15). India is the only country in the world that has not been able to provide a second dose of measles vaccine in UIP (16).

While India's burden of infectious diseases remains huge, the gathering clouds of other diseases like diabetes, chronic renal failure, cardiovascular and cerebral-vascular catastrophes, etc. are in urgent need of comprehensive public health responses for control (17). Our health system that has no formal public health sub-system and has not learned the basic lessons of disease control is no match for this challenge. Health system reform is not a luxury, but an urgent imperative --if not for humanitarian reasons, at least for poverty alleviation and wealth creation and conservation, both at the family level and at the national level (17).

Health system reform will not originate from within the MoHFW whose function is to translate policies to action and to administer and manage the public sector component of the health system. It has not succeeded in achieving satisfactory results in disease-control, providing adequate diagnostic support services for healthcare and public health, hoped for reduction of mortality in vulnerable age groups such as infants, under-5 children and parturient mothers, and in nutrition security. Action towards health system reform has to be initiated at the highest level of the GoI. To want reform is a policy shift--unless a policy for the need to re-invigorate the health sector comes from the political party in power or the Prime Minister of the Central Cabinet, the journey will not even begin. The pragmatic beginning is for GoI to appoint a Commission as soon as possible during the early part of the tenure of the current UPA government which has the clear mandate of the people to lead the country on the path of progress. The GoI will still have, within its tenure, time to implement the reform.

References

(1.) United Nations Development Program. Available at: http:// www.hdrstats.undp.org/en/countries/country_fact_sheets/ cty_fs_IND.html, accessed on December 29, 2009.

(2.) Sarva Siksha Abhiyan, Government of India. Available at: http://www.educationforallinindia.com/RighttoEducation Bill 2005.html, accessed on December 29, 2009.

(3.) Lok Sabha Elections 2009. Manifesto of the Indian National Congress. Available at: http://aicc.org.in/new/manifesto09eng.pdf, accessed on December 29, 2009.

(4.) Ministry of Health and Family Welfare. Available at: http:// www.mohfw.nic.in/nrhm/draft_bill.htm, accessed on January 1, 2010.

(5.) Park JE, Park K. Health planning and management. In: Park s textbook of preventive and social medicine, 13th ed. Jabalpur: Banarsidas Bhanot; 1991. p. 470-86.

(6.) John TJ, Muliyil J. Public health is infrastructure for human development. Indian JMed Res 2009; 130 : 9-11.

(7.) John TJ. Lessons from the challenges of polio eradication in India. Natl Med J India 2009; 22 : 4-8.

(8.) The Telegraph, Kolkata, 18 December 2009. Available at: http://www.telegraphindia.com/1091218/jsp/bengal/ story_11880892, accessed on January 1, 2010.

(9.) Ministry of Health and Family Welfare. National Health Policy. Available at: http://www.mohfw.nic.in/NRHM/Documents/ National_Health_policy_2002.pdf, accessed on December 28, 2009.

(10.) Ministry of Health and Family Welfare. Available at: http://www.tbcindia.org, accessed on December 9, 2009.

(11.) John TJ, John SM. Paradigm shift for control of tuberculosis in high prevalence countries. Trop Med Int Health 2009; 14 : 1-3.

(12.) John TJ. Quo vadis, expanded programme on immunisation? Indian J Med Res 2007; 125 : 13-6.

(13.) National Family Health Survey-3. Available at: http://www. nfhsindia.org/india2.html.

(14.) Polio Eradication Committee, Indian Academy of Pediatrics. Universal immunization programme and polio eradication in India. Indian Pediatr 2008; 45 : 807-13.

(15.) John TJ. Resurgence of diphtheria in the 21st century. Indian J Med Res 2008; 128 : 669-70.

(16.) John TJ, Choudhury P. Accelerating measles control in India: Opportunity and obligation. Indian Pediatr 2009; 46 : 939-43.

(17.) Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1744-9.

T. Jacob John

Formerly

Departments of Clinical Virology & Microbiology

Christian Medical College

Vellore 632 002, Tamil Nadu, India

tjacobjohn@yahoo.co.in
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