Opportunities for a Health Reform in the 21st Century

Introduction of Health Reform

Given the centrality of health in economic development, a paradigm shift in our approach is needed. The following are some suggestions for consideration:

First, investing more in health and recognizing disease prevention and health promotion as the topmost priorities. Consequently, government health expenditure on health should increase from 1.3% of GDP at present to at least 2.5% before the end of the 13th Five-Year Plan (2013-19). Presently, India has one of the lowest allocations to health among all countries of the world as a percentage of GDP. As a result of such a low investment in health and due to high out-of-pocket expenditure (85.6%, which according to the World Bank is among the highest in the world), nearly 60 million people are pushed further into poverty and into the poverty trap from that they are unable to escape.

Of the total health budget allocation for health, at least 80% of the fund should be earmarked for disease prevention, health promotion, and improving the quality of health services at the primary care level. The new health policy should lay stress on the concept of health as the people’s right and make it mandatory to protect the health budget at all times, including the time of financial crisis. Based on the national health policy, each states should develop a state health policy and drive innovation in program implementation and finding solutions to its health problems.

Second, health system should be strengthened to improve the process of service delivery. In order to make the health services responsive to the need of the community, it is necessary to improve the functioning of the existing government health infrastructure. This can be done in three steps as follows:First, the assessment of existing public health system and facilities, bringing improvements based on the findings of the assessment including augmented human and material resources, and monitoring their performance and fixing accountability in a systematic manner, by setting targets and trying to achieve them through a comprehensive and integrated approach, with full involvement of the community. Improved access to government health services, which are used primarily by the poor and the disadvantaged sections of the society, will go a long way in achieving better health outcomes.

For efficient and effective delivery of services of Health Reform

an efficient public-health workforce is key. India has one of the lowest density of health workforce; with density of physicians (7 per 10 000 population) and nurses (17.1 per 10 000 population) as against the global average of 13.9 and 28.6 respectively (World Health Statistics, 2015). The nurses-to-physicians ratio in India is about 0.6:1, as against the nurses-to-physicians ratio of 3:1 in some of the developed countries. The issue is very serious, particularly in the rural areas, as most doctors and hospital beds are concentrated in urban areas catering to only 20% of the India’s population. Public health planners should make all efforts to fill vacant posts through efficient recruitments, and build skill of the existing staff through training activities and by creating enabling environment including adequate facilities for health workers to stay in rural areas. To enhance skill training activities, health can leverage with and benefit from the national skill development mission launched by the Prime Minister in August 2015.

Third, focusing on evidence, excellence, and equity. An evidence-based policy-making requires data on disease burden and the associated determinants. Focus should be on strengthening a widespread research and innovation culture through out the country and generating homegrown data, obtained through surveillance, research, and monitoring and evaluation (M&E), so that these data can be used for policy and strategy development, priority setting, and evaluating the impact.

Ëmphasizing on excellence is crucial to ensure quality in service provision and in program planning and implementation, especially to ensure that health services are responsive to the needs of the community and are provided efficiently and effectively.

Addressing equity is fundamental because the purpose of public health should be the welfare of the weakest and most vulnerable section of the society. In this regard, the priority should be given to understanding the barriers to equitable access, integrating equity goals in policy and programs, and targeting resources and efforts to reach the poor and vulnerable sections of the society with the needed services. By improving program efficiency, performance and reach, these three “Es” can indeed shape the future of public health in India.

Fourth, leveraging technology to transform public health. Modern technology has great potential in bringing efficiency in service delivery and enhancing the reach of the health services. It can, for example, connect remote areas with national centers of excellence or patients in villages with doctors in hospitals in urban areas through audio or video conferencing. The government is already establishing a network of telemedicine services, mother and child tracking system of weekly voice messages to pregnant women and new mothers, web-based TB registration scheme called Nikshay, and planning mobile app for the training of Accredited Social Health Activist (ASHA) workers. Space research is another area to explore.

Mobile technology holds great promise especially due to its ubiquitous nature. With more than one billion mobile users in the country, the mobile phones offer tremendous opportunities in efficient health service delivery which include: 1) ensuring treatment adherence by sending sms text messages to patients with diabetes or HIV/AIDS reminding them to take their treatment, 2) quick reporting of cases during outbreaks or epidemics, 3) alerting next level of health services regarding emergency situation such as difficult or complicated labor in a remote rural area, or 4) informing populations and creating awareness about emerging health issues or health programs. The internet connectivity is presently being used to enhance e-governance and making patient consultations with experts such a teleophthalmology in Tripura and teleradiology in Assam.(10,11) In addition, low-smoke stoves can help reduce indoor pollution and respiratory infections, and the use of point-of-care diagnostic methods, such as a lab in a suitcase for diagnosis in areas where such facilities do not exist, can be of great help. These examples show that technology already available can enhance the quality and efficiency of the services, and this should be expanded and scaled up rapidly, in order to make health services available and accessible for the people living in geographically remote areas.

Finally, empowering health leadership and governance. It is now clear that most of the risk factors for ill health lie outside of health sector. Therefore, action to combat these risk factors requires an intersectoral and interdisciplinary approach. For a country that has a vibrant civil society and private health sector and an advanced pharmaceutical and biotechnological research capacity, these attributes should be leveraged for the benefit of public health. Besides policy, the programs also should have inbuilt mechanism to ensure transparency and fix accountability.

Uniquely, the role of the government is to formulate policies, plan services, and coordinate activities. It also has a mobilizing and facilitating roles. It should reach out to the sectors other than health sector to develop a consensus on national policies and to build partnership between different sectors for better service delivery based on the comparative advantages of each relevant sector, namely private medical sector (to follow national policies ad treatment protocols), including corporate hospitals (to provide subsidized care to the poor), nongovernmental organization particularly based in the community (for advocacy and service provision), academia and medical colleges, and research organizations (in research and innovation). The self-help groups and cooperative societies, such as Amul, are also contributing to healthcare through innovative approaches.

Private sector can also support the health promotion and disease prevention activities under public–private partnership and through the corporate social responsibility initiatives. Engaging them in a creative and positive manner as partners for health action coordinated by the government can go a long way in addressing health challenges in the next decade and beyond.