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The recently presented Union Budget 2024-25 has been critiqued for its inadequate focus on the social sector, specifically the public health sector. Earlier this year, the Supreme Court of India expressed concerns over the rising out of pocket Healthcare expenditure in India, due to the absence of a robust public health sector.
In this article, we will look at what constitutes a public health and the public health sector in India. We will look at the challenges faced by the public health sector in India. We will also look at the significance of a robust public health sector in India and the ways to achieve it.
What constitutes Public Health? What is the structure of public health sector in India?
Public Health- According to WHO, “Public health refers to all organized measures to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.”
Categorisation of Public Health- Public health needs can be broadly categorised into three groups.
| Protection against Diseases of Poverty faced by the Poor and Vulnerable | It includes diseases such as tuberculosis, malaria, undernutrition, maternal death, bouts of illnesses due to food and water-borne infections leading to typhoid, hepatitis, and diarrhoeal diseases. These are faced by the poor and the vulnerable. |
| Protection against Environmental issue related diseases faced by the Middle Class | It includes air, water, waste management, lack of drainage facility, failure to ensure healthy foods and eateries, road traffic accidents, climate change and the rise of chronic illnesses. |
| Curative Public health care | Curative care needs of a population are the most popular needs in public health. Provisioning of curative care is the most critical and controversial policy question in public health. |
Levels of Public Health Sector in India
| Primary | India’s primary health sector consists of sub-centers (SCs) and primary health centres (PHCs), which form the foundation of the public healthcare system. Sub-centers- These are the most peripheral units, serving populations of 5,000 in plain areas and 3,000 in hilly/tribal areas. Primary Health Centers- These are the first point of contact with a qualified doctor, serving populations of 20,000-30,000. Each PHC is expected to have 4–6 beds and provide promotive, preventive, curative and rehabilitative care. The poor and the vulnerable rely on primary health-care institutions of the public sector for primary-level care. It is the most affordable public health service and is closer to their places of residence. |
| Secondary | The secondary health sector in India consists of Community Health Centers (CHCs), which serve as referral units for PHCs. CHCs are 30-bed hospitals providing specialist care in medicine, surgery, obstetrics & gynaecology, and paediatrics. There is one CHC for every 80,000-120,000 population in plain areas and 40,000-60,000 population in hilly/tribal areas. |
| Tertiary | The tertiary health sector consists of district hospitals, medical college hospitals, and other highly specialized facilities. District Hospitals are 100-300 bed facilities providing specialist care, located at the district level. Medical College Hospitals are tertiary care teaching institutions, located in state capitals and major cities. Specialized Tertiary Care Facilities- These include regional cancer centres, mental health institutes, trauma centres, and other super-speciality hospitals. The tertiary sector provides highly specialized care and acts as a referral point for the secondary and primary levels of the health system |
What are the Government initiatives that have been launched for the development of Public Health Sector in India?
| National Rural Health Mission (NRHM) and National Health Mission (NHM) | The NHM and NRHM have focussed on strengthening public sector health care through architectural correction. Efforts have been undertaken to follow the principles of primary health by strengthening the primary health care institutions under these missions. These have led to the development of 1,53,655 sub centres, 25,308 primary health centres (PHC) and 5,396 community health centres (CHC) as per the rural health statistics, 2015. |
| Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) | It is a publicly funded health insurance scheme (PFHI) that provides financial protection to over 100 million families for secondary and tertiary care hospitalization. |
| Health and Wellness Centers (HWCs) | The government is working towards transforming primary health centres into HWCs to provide comprehensive primary healthcare services, including preventive and promotive care. |
| Pradhan Mantri Swasthya Suraksha Yojana | PMSSY aims to enhance tertiary care capacities and strengthen medical education in the country by setting up new AIIMS (All India Institutes of Medical Sciences) institutions and upgrading existing government medical colleges. |
| Jan Aushadhi Scheme | The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) aims to provide quality generic medicines at affordable prices through Jan Aushadhi Kendras. |
| National Digital Health Mission (NDHM) | NDHM aims to create a digital health ecosystem, including health IDs for citizens and the establishment of a national digital health infrastructure. |
What are the existing challenges in the public health sector in India?
1. Inadequate Access to Healthcare- Inadequate access to basic healthcare services remains a critical public health issue, particularly in rural and underserved areas. For ex- Shortage of health Infrastructure and health professionals (shortage of around 600,000 doctors).
2. Myopic focus on short-term results- There has been focus on promotion of initiatives that promise immediate results, such as opening new hospitals, subsidised treatments, and populist health policies. The neglect of the holistic development of primary and secondary healthcare capabilities has led to deterioration of public health sector in India.
3. Low Healthcare expenditure by the Govt- The government (Centre and states put together) spends about Rs 2.8 lakh crore, that is roughly around 1.1% of the GDP. This is extremely low when compared to other government health expenditure in countries like China (3%), Thailand (2.7%), Vietnam (2.7%) and Sri Lanka (1.4%).
4. Lack of adequate emphasis on critical areas- There has been lack of adequate attention to critical areas such as sanitation, disease surveillance, and public health education, which are important to maintain population health and prevent disease outbreaks. For ex- Lack of long-term strategies like understanding vector control or developing effective vaccines in case of dengue.
5. Profit-Driven Pharma Sector- The pharmaceutical industry’s profit-driven nature often sidelines areas such as public health. There has been a loss of trust towards health-care providers (private sector due to commercial interests). For ex- Medical marginalisation of TB patients in India.
6. Lack of a Comprehensive Approach- India’s current public health approach is physician-centric, without adequate focus on expertise from various fields such as environmental science, sociology, urban planning, and economics.
7. Lack of Preventive Care- Preventive healthcare is undervalued in India, despite its importance in reducing disease incidence and healthcare costs. This is especially significant as India faces a ‘triple burden‘ of disease, comprising communicable diseases (like tuberculosis and malaria), non-communicable diseases (such as diabetes and heart disease), and emerging infectious diseases.
What are the advantages of robust public health sector in India?
1. Improved the Access to Healthcare- The Lancet in its latest study ranked India at 145th among 195 countries in terms of quality and accessibility of healthcare, behind its neighbours China, Bangladesh, Sri Lanka and Bhutan. Thus, there is a need to improve the public health sector by making it more accessible by improving the quality of medical professionals and infrastructure.
2. Improved Health Outcomes- Robust public healthcare leads to early detection and treatment of diseases, resulting in improved health outcomes and a decrease in the burden of illness. For ex- Early detection and treatment of Non-Communicable diseases like Cardiovascular Diseases.
3. Reduction of Financial Burden- Improved public healthcare services can alleviate the financial burden and improve household financial stability by reducing the high out of pocket expenditure. For ex- According to the WHO, 55 million people fall into poverty or deeper poverty every year due to catastrophic expenditures on health.
4. Social Justice- Universal healthcare and publicly funded health system provide timely, effective and free care, irrespective of social class. This in turn promotes social justice and fulfillment of DPSP principles.
What Should be the Way Forward?
1. Implementation of the NITI Aayog Action Plan for Health- It has recommended to focus on public health through significantly increasing government expenditure on it (2.5% of GDP) and prioritize preventive care rather than provide curative care.
2. National commission for Health care cost management- The government should appoint a national commission to make recommendations for the spending on healthcare systems and monitor its performance.
3. Separating Health from Political Processes- Public health decisions should be based on scientific evidence and long-term goals rather than short-term political interests.
4. Nutrition Support- Investments in nutrition programmes will have positive long-term implications for health and productivity.
5. Comprehensive Approach- Effective public health management should encompass preventive measures, policy formulation, community health, environmental health, etc.
6. Universal health coverage- State governments should draw up blueprints for universal health coverage and begin experimenting and innovating with pilot programmes.
| Read More- The Hindu UPSC Syllabus- GS Paper 2 Social Justice – Issues relating to Health. |
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