TOWARDS A SUSTAINABLE HEALTH GOVERNANCE: Policy Interventions and Strategies

Health remains one of the fundamental pivots of human development alongside education. Health is a force multiplier in the sense that it leads to the overall growth of a country by raising economic productivity, supplying healthy workforce, guaranteeing life longevity and ensuring social cohesion and harmony. A sound health system ensures prosperity for individuals as well as stability in the society and contributes to a peaceful , just and equitable humane community. The United Nations Sustainable Development Goal (SDG) 3, ie. Good Health and Well Being has prioritized the agenda of health in a comprehensive and all inclusive manner to be taken up as a topic of policy discourse at global, national as well as at regional levels. As states aspire to inch closer towards accomplishing the ambitious goals of sustainable development, it is important to reflect upon the broader framework of health governance and how to ensure a paradigm shift in the hitherto approach to health – from isolated and segmented approach of dealing with health crises to a more robust, comprehensive, dynamic approach to health management and strengthening health systems not just from a curative but also a preventive and interventionist perspective. India being home to world’s largest population has its task cut out. Although our country has made commendable strides in the health sector with countless achievements to envy of, there are still some fundamental issues that hinder our march towards ensuring a sustainable health governance and guarantee healthy, diseases-free lives for all our citizens by 2047 – the year we shall be commemorating as the hundredth year of our independence. 

Reorienting and Restructuring Medical Education

Any fundamental reform aimed at revolutionising the health sector must begin from its core, ie. medical education. India has been continuously making strides in this field. The number of medical colleges have increased by about 88 percent in last decade, from 387 to 731 as of August 2024.  The number of MBBS seats have increased by 118 percent, from about 51,348 before 2014 to 1,12,112 at present. The number of PG seats have increased by 133 percent, from 31,185 a decade earlier to 72, 627 now. The doctor – population ratio in the country stands at 1:834 in February 2024 which is better than the World Health Organisation (WHO) standard of 1:1000. Recently, in his Independence Day speech from Red Fort, Prime Minister Narendra Modi has announced addition of another 75,000 medical seats in the next five years.

Although these numbers are encouraging and deserve a semblance of appreciation, the fact remains that the number of postgraduate medical seats in India remain woefully inadequate. Most of the newly opened medical colleges lack specialist postgraduate departments and hence those graduating with an MBBS degree have no option than to compete with their fellow medicos for a small proportion of postgraduate seats, mostly in the government institutions. Lack of specialist care seriously affects the quality of health service delivery in a country confronting a population with significant health burden and life-threatening conditions like diabetes, hypertension, pulmonary disease, heart ailments,cancer, etc. Therefore, while augmenting the intake capacity of medical colleges, we must not lose sight of the quality because at the end of the day it is quality healthcare that counts. The number of postgraduate medical seats needs to be enhanced in tandem with the undergraduate admissions to ensure both, quality medical education and treatment. The syllabus must be periodically revised and updated to equip students with the latest skills and practical knowledge to be able to handle critical care. Recent advances in medical field like Robotics -Assisted Surgery, Artificial Intelligence, Virtual Reality, Nanotechnology and Gene Editing Tools must be made available to aspiring medicos in not just metropolitan cities but also in small towns and rural areas to ensure equitable healthcare. Not just new medical colleges, but atleast one superspeciality hospital equipped with modern amenities and  specialist doctors  in each district of the country must be established to make healthcare most accessible and affordable. Exploring Public-Private partnerships and cross –country collaborations could help achieve  these objectives. 

Strengthening the capacities of Primary and District Healthcare Institutions

Primary Health Centres (PHCs) and District Headquarter Hospitals (DHHs) serve as the basic nodes of healthcare access for majority of people in this country. However, most of the PHCs and DHHs are in dire straits in most parts of the country except for the few southern states which have emphasised on social sector governance for decades. In most of the states, PHCs and DHHs are grossly understaffed, lack even basic medical infrastructure, ill-equipped in terms of availability of beds, medical instruments like MRI machines, CT scan facilities or medicines. If these issues are addressed, not only can these institutions prove to be a boon for majority of poor, underprivileged patients who rely upon state to avail healthcare but also prevent overcrowding at major city hospitals and medical colleges for patients seeking relief from common ailments like flu and other microbial infections that are usually not fatal and can be cured with common medicines. This would reduce the rush for outpatient care (OPD) in hospitals and ease the pressure on our doctors to some extent.

To ensure the smooth functioning of primary health centres and district hospitals, adequate number of medics and paramedics must be posted. It is perhaps with this realisation that the Finance Minister in her budget speech of 2023 has announced that 157 new nursing colleges shall be opened in co-location with the same number of medical colleges established in the country since 2014. Pharmacy education must also be given an equal priority to  make it a lucrative career option for students and  suitable employment opportunities must be generated for B.Pharm and M.Pharm holders in the government sector. Medicine graduates without training in any specialised domains should not be discouraged from practicing at these PHCs and DHHs as it is due to the lack of social prestige and professional pressure for career advancements that a large number of MBBS graduates feel demotivated to join primary hospitals at rural and semi-urban locations. The government should ensure a decent pay scale and other perks to boost their morale. 

Fostering Research in Medical and Life Sciences on New and Emerging Public Health Challenges

WHO defines health as ‘’a state of complete physical, mental and social well being and not just the absence of disease or infirmity.’’. Therefore, it is essential that any effort towards health and well being of citizens must take into account the multifaceted and multidimensional character of human physiology and our health systems should be resilient enough to tackle the emerging threats to human health on account of dramatic changes in lifestyles, socio-economic and cultural patterns and climate change.  Lifestyle diseases like diabetes, hypertension, obesity, cancers, cardiac arrests are becoming increasingly frequent and what is more concerning that unlike earlier times, it is affecting the younger population, especially the age groups of mid-thirties and early forties which ultimately takes a toll on their productivity and exerts significant financial burden on middle and lower middle-class families. Preventive care in terms of early screening and detection, nudging people to incorporate  healthy practices like physical exercises or yoga in their daily lives, quitting unhealthy habits like smoking, drinking, chewing tobacco, eating junk food, etc must be encouraged through community awareness campaigns and involvement of civil society. But at the same time, scientific research and advanced techniques like genetic mapping of populations in selected geographies must be undertaken to discern patterns of disease spread in specific locations, clusters or communities and adequate focus should be given in these areas to prevent its spread.

Antimicrobial Resistance (AMR) has emerged as one of the leading causes of non-communicable disease globally. ‘AMR is a condition in which a pathogen acquires the ability to survive and cause infection even in the presence of an antimicrobial drug.’ It simply means that infections will be difficult to treat if disease causing microbes become resistant to antibiotic drugs. Restricted and regulated use of antibiotics can prevent AMR to a great extent. Medical practitioners should be persuaded to prescribe antibiotics only in cases where the treatment warrants its usage urgently. Climate change and its adverse effects are also manifesting their debilitating impact on human health. Scientists have red flagged the impact of extreme weather events like prolonged heat waves, cold waves, air pollution and/or torrential rainfall and floods on mankind, and more so for people living in the poorer, densely populated regions, facing resource crunch and abysmal health infrastructure or disaster preparedness. Dedicated research and training centres pertaining to these health crises must be established in all leading medical colleges of the country as well as within life sciences departments of major universities. Private sector participation is desirable but public financing is key. Government must step up its health sector expenditure to 2.5 percent of GDP as per the recommendations of National Health Policy, 2017. At least four universities or centres dedicated to the field of Public Health and Management should be established in India and the admissions to these institutions should be opened to  people from Health and Life Sciences, Economics, Sociology, Public Administration and Public Policy, Management, etc since health is a diverse and dynamic field and its governance requires expertise and specialists from across the spectrum. Given the intimate interaction between human, animal and plant species, the idea of One Health Approach should be mainstreamed in policy making and crisis responses pertaining to public health. A dedicated Indian Health Service cadre should be envisaged on the lines of IAS and IPS to induct doctors and scientists specialising in the fields of health and wellness to enrich policy making and their implementation.

Decentralised Health Governance as a Pillar of Public Administration 

As per the constitutional scheme of  distribution of powers under our federal polity, health is a state subject. Thus, the primary responsibility of maintenance, modernisation and upgradation of health infrastructure rests with the state governments. But in the true spirit of federalism, decentralisation of powers and devolution of funds are essential to achieve the desired objectives in health sector, meeting standards, quality and bringing parity between various states. While some states like Kerala and Tamil Nadu have performed historically well on various health parameters and are very close to achieving the targets under SDG 3, some states like Bihar and Jharkhand continue to grapple with even basic healthcare amenities and infrastructure including acute shortage of doctors in their states, especially in rural and backward regions. The outperformers should be lauded for their accomplishments and rewarded in terms of tax concessions and other fiscal measures in order to continue strengthening their resilience in the medical sector. While the laggards should be provided with generous funds and conditional fiscal transfers to nudge them towards improving their performance and ensure quality delivery of healthcare services. 

However, the job doesn’t end here. It is also the duty of the state governments to decentralise and capacitate the local bodies like municipalities and panchayats as healthcare provision is one of the core citizen-oriented services expected from the institutions of local governance. Dispensaries and hospitals run by municipal corporations or healthcare institutions at the gram panchayat levels play an indispensable role in not just primary healthcare but critical preventive care like vaccinations and immunisations. Many of the ambitious healthcare programmes of the government, both at the centre and state depend solely on the efficient and effective health administration of these local institutions. Since local government institutions deal with healthcare at the community level, their political and financial empowerment is crucial. Urban local bodies have a significant role to play in mitigating the outbreak of vector-borne diseases like dengue, malaria, diarrhea, etc. and every year we see our cities and towns reeling under the impacts of these epidemic outbreaks and our civic bodies, grossly incapable of arresting the spread. Civic bodies must be well-equipped to administer basic healthcare and maintain their healthcare facilities. Adequate emphasis should be given to supply of safe potable water and sanitation and hygiene in the surrounding and neighbourhoods as water and cleanliness have a direct impact on health of the population. SDG 6  talks about Clean Water and Sanitation that has a direct bearing on SDG 3.The state of cleanliness, hygiene and civic infrastructure in even some of our bustling metropolises is pathetic and rotten to say the least. This scenario needs to ameliorate. For that holding regular elections, ensuring a steady flow of finances, permanent appointments and timely payment of salaries to municipal staff as well as technological advancements in dealing with issues like sewerage and waste disposal, sanitation and hygiene are instrumental.

Extension of health insurance to the poor households and elderly population is most welcome but what needs attention is also the quality of healthcare delivery at the most basic level. Empowerment of local bodies, community engagement and participation of masses are critical enablers of a decentralised public health administration regime. 

Way Forward

The Constitution of India through its Articles 21 and 47 not only guarantees fundamental right to health and well-being but also widens its ambit and scope by enjoining upon the state to ensure a decent quality of life and enhance the life expectancy of all its citizens. A healthy citizenry is a constitutional imperative in the sense that it broadens the canvass of social justice and deepens democracy by strengthening the foundations of a welfare state. Our dream of a Viksit Bharat or a ‘’Developed India’’ can only be realised if we revisit and revise the hitherto approach towards the governance and administration of the health sector and strive towards achieving the desired targets of sustainable development goals. Till then, it is a work in progress. 

References

• United Nations  Sustainable Development Goals -

https://www.undp.org/sustainable-development-goals?gad_source=1&gclid=CjwKCAjw0aS3BhA3EiwAKaD2ZXC2NJzoiWNSJy_eYVwvmQim3kq9hpOcdQGrpg636Espt59WzUizjBoCma0QAvD_BwE

• Press Information Bureau, press release on Steps Taken to  Increase Medical Colleges and Medical Seats on 30th July 2024 –

https://pib.gov.in/PressReleaseIframePage.aspx?PRID=2039047#:~:text=There%20is%20an%20increase%20of,to%2072%2C627%20as%20of%20now

• The Indian Express,  75,000 new medical seats - https://indianexpress.com/article/education/pm-modi-announces-75000-new-medical-seats-independence-day-speech-9515207

• The Economic Times, Doctor-population ratio in India – https://economictimes.indiatimes.com/news/india/doctor-population-ratio-in-country-stands-at-1834-mansukh-mandaviya-tells-lok-sabha/articleshow/107561323.cms?from=mdr

• The Indian Express, Anti Microbial Resistance –  https://indianexpress.com/article/explained/explained-health/the-grave-threat-from-amr-9561108

• World Health Organisation, One Health Approach - https://www.who.int/news-room/questions-and-answers/item/one-health 

• Moneycontrol ,157 new nursing colleges – https://www.moneycontrol.com/news/business/budget/budget-2023-fm-nirmala-sitharaman-announces-setting-up-of-157-nursing-colleges-9978561.html

• Legal Chronicle, Right to Health - https://uja.in/blog/legal-chronicle/right-to-health-in-indiaconstitutional-perspective.