Public Health reforms post-Independence and new challenges – A need for strengthening public health care system in India : Dr SAMEER Ul HAQ

Public Health reforms post-Independence and new challenges – A need for strengthening public health care system in India

Dr SAMEER Ul HAQ

India is a big country and is currently passing through demographic, economic, epidemiological and environmental transition. During independence India was left with crippled economy, devastated health care system and over-population. But post-independence, there has been development in various fields like economy, healthcare, communication, transport and connectivity etc. In the public health, there were developments since independence starting with formation of Bhore Committee, a health survey and development committee, which emphasized integrating preventive health measures such as hygiene, sanitation, and waste management into all sectors and recommended the development of Primary Health Centres, particularly in rural areas, along with reforms in medical education. In 1956, the Indian Public Health Association was formed to support policy development and promote public health research and practice. Medical education reforms continued with the creation of the Medical Council of India in 1960, later replaced by the National Medical Commission in 2020 to strengthen regulation and curriculum standards. The National Institute of Health and Family Welfare, established in 1977, contributed to training and research in health administration, epidemiology, and family welfare. In 2006, the Public Health Foundation of India was set up to enhance public health education, research, and policy capacity. To expand healthcare access, the National Rural Health Mission and National Urban Health Mission were launched and later integrated into the National Health Mission in 2013, focusing on reducing IMR and MMR, improving child health, strengthening sanitation, and ensuring universal access to comprehensive healthcare services.

Major Achievements in Public Health post-Independence

Since independence, India has achieved substantial progress in public health indicators, with life expectancy rising from around 50 years to nearly 69–72 years, a marked decline in Infant Mortality Rate, and a reduction in Total Fertility Rate to about 1.9 births per woman. The expansion of Primary Health Centres and Community Health Centres has strengthened rural healthcare delivery, while improved institutional deliveries and skilled birth attendance have significantly reduced maternal mortality. Nutrition initiatives under the National Food Security Act have supported better child health outcomes. India was declared polio-free in 2014, and disease control efforts targeting malaria, tuberculosis, and HIV/AIDS have been reinforced through structured programs, including the work of the National AIDS Control Organization and the DOTS strategy for TB. Environmental sanitation improved with the launch of the Swachh Bharat Abhiyan in 2014, while access to safe drinking water expanded under the Jal Shakti Abhiyan. The National Immunization Programme has reduced under-five morbidity and mortality, and the National Action Plan on Antimicrobial Resistance (2017) addresses emerging drug resistance through surveillance and rational prescribing. Public–Private Partnerships have enhanced service delivery, and universal health coverage has been strengthened through the Pradhan Mantri Jan Arogya Yojana, which provides financial protection to economically vulnerable populations in line with Sustainable Development Goals.

There is strong evidence that economic inequality and disparity among people is related to worse health outcomes.

India is presently going through a state of transition environmentally, economically, demographically and epidemiologically in terms of health. Since last decade, unprecedented economic development particularly in terms of Gross Domestic product (GDP) is significantly visible, but unfortunately this progress has created disparities between the rich and the poor. There is correlation between economy and health outcomes. There is strong evidence that economic inequality and disparity among people is related to worse health outcomes. This in turn widens the gap between the rich and the poor and has damaging health and social consequences. Financial and social security measures are being implemented by the Government to bridge economic inequalities but there is need to do more.  Presently India is having a triple burden of disease;

Some unfinished Infectious diseases and their disease burden like TB

The challenge of non-communicable Diseases (NCDs) which are linked with lifestyle changes and behaviour

Emergence of new infections due to population growth causing epidemics and pandemics. 

In addition to these, the health care system is already substandard and needs to be strengthened to enable it to confront these challenges. In the health sector, India has made remarkable progress over the past decades. The life expectancy reached 67 years in males and 69 years in females, and infant as well as under-five mortality rates have declined subsequently over the years. Diseases, like polio, tetanus have been eradicated due to successful vaccination programs and effective community participation. In spite of this progress made, communicable diseases and their burden is expected to continue and to remain a major public health problem in the coming decades. Besides endemic diseases such as HIV/AIDS, Tuberculosis (TB), Malaria, and neglected tropical diseases, the communicable disease outbreaks will continue to challenge public health. Also vector-borne diseases, such as dengue and acute encephalitis syndrome, are of particular concern and need effective intervention. Antimicrobial resistance is one of the biggest public health challenges currently. This has arisen due to uncontrolled drug policy and it must be tackled with all efforts in upcoming years. In addition, non-communicable diseases are now the leading cause of death in the country, contributing to 60% of deaths. NCDs like Heart disease, cancer, diabetes, and chronic pulmonary diseases are leading ones. Approximately 80% of all deaths are due to these four diseases. These diseases have multiple causal factors like smoking, alcohol, unhealthy diet, and lack of exercise. Also, important concern is the maternal mortality ratio and infant mortality rate (IMR) which still remain unacceptably high as compared to other South Asian Neighbouring countries except Pakistan. The IMR, which was 81 in 1990, according to the World Health Organization (WHO), declined to 30 Per 1,000 live births as of 2019. According to the sample registration system (SRS) report as of 2018 the IMR is 36 per 1,000 live births. Since mortality rates have declined significantly but the rate of incidence is still high, compared to that being achieved by other South Asian neighbours with exception of Pakistan.

A Framework To Strengthen Public Health Sector: Covid-19 Fallout

COVID-19 pandemic caused deleterious effects and is devastating nations and has incapacitated the health systems of nations globally. Nations weren’t fully prepared and the pandemic has been carried out with great losses both physically and economically. On one hand Developed nations were bearing the after effects of COVID-19 while on other hand developing countries are still taking steps to control the pandemic while facing economic hardships. Universal health coverage is needed more than ever to recover from the effects of the current pandemic more importantly in developing countries like India. Post pandemic lessons need to be learnt which I already have mentioned especially for developing economies like India where the public healthcare system is not up to the mark. COVID-19 pandemic has emphasized the need for strengthening public health care systems globally. The fate of COVID-19 pandemic in countries with well-established health systems stresses on the need for a strong public health system that goes beyond hospitals and health establishments. Government should take measures to develop sustainable capacity to respond to rapidly spreading epidemics and must recognize overlooked public health services as vital, and adequately finance them as part of the UHC model. The current framework is aimed to highlight the key concerns in the public healthcare system of India and areas that need prioritization learned from the pandemic.

WHO LEADERSHIP; An Important Element to Support Developing World

The World Health Organization, the world’s health body, has emphasized the importance of national health, works on its planning and monitors critical functions to improve health systems globally. There should be a sophisticated and robust approach to deal with any kind of pandemic without political interests and WHO should work on this uniquely and be autonomous. Developed nations need to fund this organisation without any interests and more focus should be emphasized to developing countries (South East Asia, Middle East and Africa). WHO needs to adapt a policy to fund the developing countries with economic packages to counter economic hardships due to pandemic. A national action plan for pandemic preparedness should be formulated for developing countries while taking all the key factors (economy, geography, climate change, population, health system) in account. India has already enforced many acts like Epidemic Diseases Act, Disaster Management Act, Essential Commodities Act, Healthcare Establishment Act, etc. as part of the action plan. Unfortunately, many of such acts have their own drawbacks and these need to be modified for the current scenario.

HEALTH CARE SYSTEM and its FINANCING 

The healthcare model in India was designed and aimed to provide basic health services as primary care to the population (prioritizing women’s and children’s health). But it came out more as an “Out of Pocket model” where the rich acquire high quality health care services and the poor suffer due to economic hardships and unreasonably high cost of private hospitals. To support the health care system and services, the Government of India launched Ayushman Bharat Scheme under National Health Policy 2017. It is aimed at two core issues, free accessible Health services under Health and Wellness Centres and free access to health insurance coverage under National Health Protection Scheme (NHPS). Health and Wellness Centres are working as foundation of the health system to provide basic primary care, free essential drugs and diagnostic services to all the citizens, whereas National Health Protection Scheme is working on to provide financial services to poor and vulnerable families which arises due to high costs at secondary and tertiary care hospitalization. The National Health protection Scheme should ensure financial protection also for marginal people when they seek treatment during pandemics. The Indian government’s expenditure on health is merely around 2%, one of the lowest in the world. More than 60% of households in urban areas, and 50% of households in rural areas consult private hospitals when they need medical attention. During the pandemic, health expenditures rose because of the high cost offered by the private healthcare system which is unfortunately not regulated by the government. Health care budget should be given priority along with the education sector (prioritising maternal education). Policies should be made to invest in the health care sector, priority should be made to rural areas, up-gradation of hospitals to modern levels, all technological advancements should be made available and easily accessible and finally there should be Public private partnership which is an important step to formulate sophisticated modern health care system.

The country’s public healthcare system should have technological advancements with an easy accessibility and applicability to people.

STRENGTHENING PUBLIC HEALTH SYSTEM 

There is an immediate need for strengthening the public health system in India with priority focused on building public health professionals. Healthcare workers need to be strengthened by continuous capacity building and training in public health fields. There should be public health laws to ensure active participation of the private health sector and other health related sectors. The country’s public healthcare system should have technological advancements with an easy accessibility and applicability to people. There is a need for cooperation between local and state public health agencies with the centre, in order to apply guidelines at its first phase and on priority basis. There should be robust and sophisticated mechanisms for data sharing especially during outbreaks. This will prove beneficial during challenging times.

HEALTH CARE WORKFORCE 

Manpower is important for every system to work properly. Public health care system can’t cope with the current challenges without a health care workforce. India has had a shortage of healthcare workers from the beginning and it still persists, as was visible during the pandemic. In order to cope up with the current challenges and a future policy, the government of India should come up with a policy to educate, train other health care workers (AYUSH, Nursing). The training should be focused mainly on modern medicine skills. Alternatively, these professionals can be posted at rural areas to cope up with the shortage of health care workers and can also prove handy in challenging times like during pandemics. Pandemics like COVID-19, Influenza, HIV have timely reminded us that public health systems are core social institutions for any country. The government has already made policies to overcome the issues in the public health system through schemes like the National Medical Commission Act, 2019, Pradhan Mantri Jan Arogya Yojana etc. However, there is more to be done to sophisticate the public health care system like in developed countries. First step is to go with an adequate investment in health care for creating a health system that can withstand any kind of public health challenges, can deliver universal health coverage at all levels by all means and can meet the targets of the Sustainable Development Goals.