FOSTERING HEALTH EQUITY & HEALTH LITERARCY FOR EFFICIENT HEALTH GOVERNANCE
Dr.Zubair Ahmed khan
Dr.Priti Ramani Nayyar
Public Health Infrastructure (HPI) of India
Since independence, the Indian public health policy towards building a robust and sustainable infrastructure has been pragmatic in its approach. India has made a significant improvement in building the health of the Indian population. Out of 30 million children born in India, 2 million used to die within one year till 1991 and thereafter, the Indian health policy has taken a turn and in 2015, the children born are expected to live 10 years longer than the children of 1991. And, the credit of this success goes to the Governments, who have been able to build a sustainable PHI in India. India came up with a credible, quality and economically sustainable drug manufacturing, which not only covers the long waiting space of fulfilling the demand of the medicines, but it has also made India a leading name in the sector of drug manufacturing. Evidently, India is supplying 20 percent generic medicines to the world and India is at forefront, when it comes to medical tourism.
Despite achieving the various milestones, Indian Public Health Infrastructure is still facing various long and short-term challenges, such as,
Malnutrition amongst the masses, especially in girl children
Increasing pollution levels in urban centres,
Lack of institutional support in providing pre-natal and neo-natal vaccinations,
Problem of open defections,
Problem of Tuberculosis, Dengue, Malaria, etc.
Other than the above problems, there are many other issues which have a direct bearing on the PHI of India, such as,
Lack of education
Lack of clean water
Lack of nutritional intake among the low-income groups
Increasing number of persons living below poverty lines, etc.
In short, Indian Public Health care was suffering from various primary level infirmities, such as,
No knowledge about one’s health status,
Irregularity in sharing information between the doctor and the patient and
Unpredictable cost of the health care expenditure.
Sometimes, lack of knowledge about the cost of expenditure becomes the major impediment in going for the urgent medical attention.
There are various schemes and programmes launched by the Government to tackle the above referred issues, for building a sustainable public health infrastructure, such as launching of National Rural Health Mission (NRHM) 2005, whose aim was to come up with various programmes to strengthen the PHI. Janani Suraksha Yojana (JSY) is one such scheme, which has the provision for providing cash to the marginalised persons, so as to encourage them for institutional delivery of the child. This has led to the phenomenal growth in public institutional delivery system, which further led to the automatic reduction in the Infant Mortality Rate (IMR). This shift in the public health policy from ‘family planning’ to more resource based ‘child-health’ and ‘maternal-health’ has proved successful. In fact, the growth of private health care has also lessened the burden of the PHI. And, this has led to the boom in insurance sector, with plethora of companies entering into the market to capture the health threat and rising cost of medical attention of the middle class and even Government had also introduced various tax measures to change the behaviour of the persons by providing them tax exemption upto a threshold for investing in Mediclaim Insurance Policies. Though from the Assessment Year 2020-2021, these exemptions will not be available anymore to the Income Tax assesses. In fact, since 1991, India has seen a tremendous growth of big private hospitals, such as, Max, Apollo, Artemis, Venkateshwara hospitals, etc. which led to the increase of Medial tourism in India, and this has also helped in bringing latest medical technology to India. In this way, no doubt, India is in a position to build an excellent Private Health Infrastructure, but, this type of growth has excluded the marginalized persons from the society. Therefore, the present Government came up with the National Health Policy (NHP) 2017, whose objective was to address ‘Social Health Insurance Schemes (SHISs) and therefore policy’s focus is on Universal Access to Comprehensive Services (UACS)’. The objective of NHP, 2017 is to either re-model the existing primary health care or completely revamp it, which is completely free for all the citizens of India. The objective is also to provide quality ‘preventive and curative’ public health care. There are various other health related programmes launched by the Government to strengthen the PHI with the assistance of indigenous way of practicing the medicines, such as promotion of AYUSH. A whole Ministry of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy) was established.The purpose of NHP is to promote private investment in the health sector, especially for secondary and tertiary care.
Building Public Health Infrastructure for a self-reliant India, a Post-COVID Priority
Covid 19, has affected the developing countries the most, as they lack both public and private infrastructure to tackle the pandemics and India in this regard is not an exception, yet India has shown determination to not only handle this situation well, but also in a very short time, It has been able to work on the weaknesses of its PHI, so as to arrest the spread of deadly Covid and in this way, provided a model to the developed nations. India is already committed to attain Sustainable Development Goals (SDGs) by 2030 and for the fulfillment of these goals, it is necessary to work on the agenda of developing the social sector, both because it can be instrumental in building India a self-reliant nation and it also helps India in making intrinsic developments, necessary for attaining long term goals, such as, building strong public health infrastructure for all.
Achieving Nourishing Nation: Public Health Policy targeting Chronic Malnutrition for Building Healthy Citizens
There is no doubt in the fact that nourished nations will automatically build ‘healthy citizens’ which can take the challenge of pandemics in a better way. The pandemic has affected the livelihood of the most, especially of those, who live their lives at the ‘margins’ and this has led further to the disruption in the supply chain of the Government nutritional programmes and due to which, one can see the reduction in food consumption amongst the marginalised persons. As a prime objective, the health policies should first address the issues related to malnutrition, rather than reacting and responding at the times of pandemics. By addressing malnutrition, the policy makers are actually building strong citizens of India. This is the right time to address the operation of National Nutrition Policy, 1993. Already available data clearly shows 40 percent dietary deficit amongst all the age groups of India. Present policy initiatives are inadequate to bridge the deficit of protein and calorie – micronutrients. The condition is more alarming in regard to the foetal malnutrition and maternal dietary deficits. The issue is further aggravated when we look at the nutrition level of the lower income households. The policy intervention is necessary here at two levels. First, at the level of imparting and dissemination of the information to the households towards approaching the nutritional levels necessary for a healthy and nutritious life, and second, inequitable market conditions, which provide expansive energy diets for the elite and middle class but no substitute for the lower income groups.
Strengthening Health System
The worst part of the pandemics like, Covid 19, is that they are neither the first and nor are the last in the list. And, therefore a lot many States are already working towards strengthening their PHI with the help of digital technology, by creating a dedicated Public Digital Health Infrastructure to not only tackle the present outbreak of Covid 19, but also to check the spread of such viruses and diseases in the future.Not only this, the pandemic has shifted the focus of the Government health policy towards strengthening of the domestic manufacturing sector in essential components and medical instruments such as, ventilators, medical masks and sanitizers, etc., so as to build the foundation of a strong and self-reliant India. We are aware of the fact that the war against the virus is not won yet, rather the findings of new strain of Covid 19 in United Kingdom (UK) and South Africa proves the fact, that the future roads are not safe and there is a constant need to work on the PHI. The strain of UK’s Coronavirus is proving dangerous because it not only transmits much faster than the previous Covid 19 strain, but it also impacts the most. And, now there are reportings of other mutant strains of Coronavirus too reported from different parts of the world.
Covid19 and Public Health Infrastructure
It is not an easy task for the vast country like India to, firstly, tackle pandemics like Covid 19 by a state-run vaccination drive and then secondly, to check the transmission of the virus within the community. India has successfully tackled both the issues, with the help of the state-of-the-art digital public health infrastructure (DPHI) where, digital technology is used to generate real time data for effective evaluation and implementation of State-run programmes with the help of the team of Covid health workers. But, while implementing the lockdowns, no one has realised its far-reaching consequences. Lockdown has left millions without any means of livelihood and most them were also not carrying the shelter.
According to the World Health Organization (WHO), Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society”.1 Public health refers to all organized measures (whether public or private) 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.‖2 Public Health being a science for protection and improving health of people and communities is achieved by researching Disease, Promotion of Healthy lifestyle, Prevention of injury and Detection, Prevention and Responding to diseases.3 These Populations may differ and it may be small as a Neighborhood or can be as big as an entire country or any particular or specific region of the World. It deals with delivery of the services based on scientific techniques and methodologies. The core of Public Health Law relies upon Law and Science and the Law must Prohibit the Person who causes the situation for others suffering. The Public Health Actions are not implied for punishing however to screen and improve the health status in the community. General Health Law manages the Study of Legal Powers and structures obligations upon the state to guarantee the conditions for people to be sound, and restricting the force of the State to constraint the independence, privacy, freedom, or some other legitimately ensured interests of the Individual and for advancement and protection of community wellbeing4. The term ‗Public‘in Public Health refers to a group of people. It refers to the collective action and not an individual‘s action. Individuals must work in a synchronized manner, in order to have impact on public health. Thus public health is collective action of State or any agency that focuses on health of a community.
The above has been stated in the Preamble of Constitution of the World Health Organization. It is indeed true that the progress of a nation depends on the well-being of its citizens. Apart from education and food, health is an essential factor, the provision and maintenance of which is supposed to be ensured by any welfare State. The right to good health is basic and must be made available, affordable and accessible to all. However, the working of healthcare delivery system in India and the implementation of various healthcare policies pose a question as to whether the State is equipped enough to promise this basic right to its citizens. Through this study, an attempt is made to understand the intricacies and merits of and the loopholes in the healthcare delivery system in order to formulate an opinion about the recommendation made by a High-Level Group on the health sector constituted by the 15th Finance Commission in September 2019. The recommendations, among others, are that the right to health must be declared a fundamental right and the subject of ‘Public Health’ be shifted to the Concurrent list. Right to health has been recognized by the Indian Constitution as well as by the Indian judiciary. Certain Articles of the Directive Principles of State Policy contained in Part IV of the Indian Constitution reflect the importance that the Constitution envisages to give to the right to health. Article 39 inter alia provides that the State shall, in particular, direct its policy towards securing that the health and strength of workers, men and women, and the tender age of children are not abused (clause e) and that children are given opportunities and facilities to develop in a healthy manner (clause f).Article 42 requires the State to make provision for securing just and humane condition of work and for maternity relief. Article 47 makes the provision that the State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall Endeavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health. Apart from the Directive Principles, Entry 23 of Schedule 11 read with Article 243 provides that the State legislature may, by law, endow the Panchayats with powers and authority with respect to implementation of schemes in relation to health and sanitation, including hospitals, Primary Healthcare Centres and dispensaries.
Similarly, Entry 6 of Schedule 12 read with Article 243W (added by 74th Amendment of the Constitution) provides that the State legislature may, by law, endow powers and responsibilities upon Municipalities with respect to public health, sanitation conservancy and solid waste management. The Supreme Court of India, through its various judgments over the years has maintained that the right to health is an integral part of the fundamental right to life contained under Article 21 of the Indian Constitution. Some of the pioneering judgments upholding the State’s obligation to secure the right to health by virtue of it being a welfare State are Vincent Panikur Langara v. Union of India , Consumer Education and Research Centre v. Union of India , Paschim Bange Mazdoor Samiti and Ors. v. State of West Bengal and Anr.3 , People’s Union for Democratic Rights v. Union of India4 and Mangesh Salodkar v. Mansanto Chemicals of India Ltd.
Right to health has been given importance under various articles of Part IV of the Indian Constitution. However, V.N. Shukla in his book, Constitution of India, provides that since the “directive principles are not enforceable by any court, it has been advocated that they are not law, much less constitutional law and, therefore, their non-observance by the State does not entail any legal consequences. For the same reason, a law giving effect to directive principles must satisfy the constitutional limitations such as the fundamental rights and distribution of powers between the Centre and the States. In case it violates these limitations, it must be held unconstitutional.
Newton’s third law of motion stated that for every action there is an equal and opposite reaction. Natural disasters are a reaction to man’s cruelty to Mother Nature. The newest addition to the corona virus can be seen as one of the gravest disasters faced to the detriment of life, statehood and stability. Unfortunately, COVID-19 is a human creation to the world’s detriment. Once again, humanity has out-proven itself for the worse. In the wake of the continually mutating strands of the coronavirus, the inefficacy of the Health Sector in India has taken the nation by storm. As of May 2021, there has been a steep increase in cases with 27 lakh active cases.279 India has continued to see mass shortages in oxygen access, beds for critical patients and COVID tests.
India‘s constant tussle between the Economy and the Health Sector was just picking up pace in 2019. The public health care budget had seen a substantial raise in order to cater to the growing population. But the year 2020 acted as a wakeup call to the Government to make substantial increases in the Health Budget with the outbreak of the coronavirus in India. The expenditure rose by 3.9% and yet it proved to be insufficient with mass demand of testing, medications, beds, oxygen among many more. Adding on, most of this burden was solely handled by the Government hospitals and frontline healthcare workers as private hospitals dealt with less than 10% of COVID patients. This is a stellar anecdote on its own to prove why Government should be in-charge of public healthcare rather than the private sector. With many new policies such as the Aatmanirbhar Swasth Bharat Yojana, many beneficiaries were benefitted such as the senior citizens and salaried taxpayers.
However, when the health budget was read upon in detail, one can‘t help but point out the vast one-time expense of Rs.35, 000 Crores towards the vaccination with no other valid policies in place apart from this. While the healthcare budget proudly claims to have had a significant increase from the previous years, a deeper look shows that Rs. 36,022 Crores of the total healthcare budget are used for water and sanitation, and it has been wrongly put under the healthcare division, instead of its spending from a separate department. All these intricacies indicate a real‘ decrease of 10% in the healthcare budget from the previous years when adjusted to inflation. Furthermore, the Centre has devised a 6-year long healthcare plan for the country which aims at developing primary, secondary and tertiary healthcare service sectors. However, the current Government would stay in office for the next three years only and that does not give it the freedom to formulate a 6-year long policy such as this. Upon observing, the means and methods adopted by India to tackle the pandemic, i.e. the International Monetary Fund (IMF) advised India to increase investment in human resource rather than capital in the future as one of the greatest threats to India‘s ease of doing business ranking‘ is health. Therefore, overcoming this issue would definitely improve the ease of doing business in India.
Suggestions with Conclusion
The Government is moving in the right direction through implementation of National Health Policy (NHP) 2017. But the problem is of effective implementation of the policies. There is an urgent need to address Public Health Infrastructure, because, even today, the majority of Indian population lives below the poverty line and there is a large number of low-income groups which, forget about the nutritional diets, are not even in a position to have two meals a day. It is therefore essential to synthesize various schemes and programmes for effective management of building health of the nation. The primary step in this regard can be the effective interface and integration of National Health Policy 2017 with that of National Nutrition Policy 1983 and National Plan of Action on Nutrition 1995. This will not only help in addressing the issue of widespread malnourishment amongst the masses, especially children and women, but it will also make them an important stakeholder of National Health Policy 2017.It is essential for a good policy to have following four objectives, (i) Clarity in Objectives, (ii) Strategic design, (iii) Financing, and (iv) Outcomes, and all-in sync with each other. Secondly, it is necessary to provide Government support for public health issues, as it would automatically address the health issues of the persons living at the margins. Covid 19 has certainly created both, a challenge and an opportunity. There is no doubt in the fact that now, when the cities will be opened more for the public, they will be more hygiene and clean and certainly would carry the habits of maintaining virus free-zones. But there are administrative lapses also, which need to be addressed such as non-detection and non-reporting of the infections. Evidently, a “robust disease surveillance system backed with active testing, contact-tracing, and isolation or quarantine”, can prevent the spread of deadly pandemics like the present one. On priority basis, an expert group NEGVAC (National Expert Group on Vaccine Administration for COVID-19) has been constituted in India to urgently address the challenge of vaccine distribution. The Indian initiative of building a robust Public Health Infrastructure is in line with making India a self-reliant nation in the 21st Century.
The reason why Scandinavian Nations have much better health facilities than India is because of their responsiveness to a Public Health Emergency. A country responds better to a health crisis when they have adequate resources. India lacks awareness and knowledge about Public Health. Although laws and legislations are in place, unawareness restricts implementing basic Human Rights. A document can be how so ever well drafted, it may not be good on ground unless the executors are learned and people are willing. International health law, conventions as well as treaties are important fields with enormous potential in developing the standards of living at the global stage. Huge challenges lie ahead in terms of strengthening the existing standards and addressing the responsibilities of non state actors in the health field. The enforcement and implementation of these international legislations remain a huge hassle.
Considering the terrible wave of the COVID-19 pandemic that has affected India, the health sector is in dire need of growth and development. Such developments need extensive resources like finance and expertise. Such resources can be accessed immediately through public-private partnerships. However, it is pertinent to understand that a public-private partnership will not work in a country like India with the current model it is following. There need to be better incentive structures to motive the parties to perform efficaciously. Further, there also needs to be a more rigid standard of performance that ensures that the quality of services offered is never compromised. In a field as complex and important as the health sector, there can be no room for negligence or error. Therefore, quality of service is of great importance. Public-private partnership schemes often raise a cause for concern among public health activists as district hospitals are often the targets. To increase the efficacy of public private partnerships in the health sector, there needs to be a higher threshold of accountability on the government. Dr Alex Thomas, president of the Association of Health Care Providers India recommends an equal division of responsibility in the managerial and administrative level of the public-private partnerships. 315 This ensures shared accountability, wherein the public and private sector entities are responsible to each other for functioning efficaciously. Further, when the public sector will be involved in the operations of a facility, there will exist a mandate of transparency. Therefore, the likelihood of corruption in working and reduced aggregate accountability is lower as the public is aware of the functioning of the public-private partnership.
Focus need be given to rural and remote areas with more skilled doctors, good quality health services, where in India currently, quality health services, Telemedicine are only concentrated in private hospitals which are accessible only to the privileged class and few government hospitals in urban areas. Our biggest challenge remains that we are not able to meet the demands of the majority of population and that is where quacks come in and take advantage. The BNI also shows that there is concentration of doctors in a particular region and that there is dearth in many regions especially in the rural heartlands. Rebuilding the trust between doctors and patients instills primary healthcare centres to provide humane care closer to home. Stricter regulations regarding the quality of medicines and an efficient monitoring mechanism will also ensure that fake doctors and quacks do not operate.
 See NachiketMor, Diva Dhar and Sandhya Venkateswaran, “Healthcare in India: A Fork in the Road” in Rakesh Mohan (ed), India Transformed: 25 years of Economic Reforms, First edition (2017, Penguin India) p.384.
Section 80D of the Income Tax Act 1961 provides exemption from tax in case of investment made in Mediclaim policies. This exemption is in addition of Section 80C where life insurance premiums are already subject to exemption upto rupees one and a half lakh only.
Ambarish Rai, Srijita Majumder and Dipa Sinha, “The right to Education and Health: Is the State giving up”, in Nikhil Dey, Aruna Roy and Rakshita Swamy, We the People: Establishing Rights and Deepening Democracy (Rethinking India Series)”, First edition (2020, Penguin) pp.41-52 (48-49).
 See Ministry of AYUSH (https://main.ayush.gov.in/, last accessed on 13.01.2021, at 11:05 PM).
 S Mahendra Dev, “The post-Covid Priority”, The Indian Express, Saturday, January 9. 2021, p. 11.
 The National Monitoring Bureau’s, (NMB) third repeat survey of 2012.
 Veena S Rao, “Nourishing the Nation: Improving diet of low-income households is only way to address chronic malnutrition”, The Indian Express, Saturday, January 9, 2021, p. 11.
 Amitabh Sinha (Science Editor), “Lessons from a Pandemic”, The Indian Express, Wednesday, December 30, 2020, p. 15.
See Bloomberg, Sunday, January 10, 2021 (https://www.deccanherald.com/science-and-environment/now-japan-says-it-found-new-coronavirus-variant-similar-to-uk-strain-937495.html, Last accessed on 15.01.2021 at 10:55PM).
 See Vinay Lal, The Fury of Covid-19, The Politics, Histories, and Unrequited Love of the Coronavirus”, First edition (2020, Macmillan) pp. 68-78 (71). It is found that the migrant workers were left out of the mainstream public health planning, therefore, they start moving towards their home States, and due to lack of means of livelihood, they suffered both at mental and physical level.
 K Sujatha Rao, “Care and Caution: Peoples confidence is a must for a successful roll out of the Covid-19 vaccine”, The Indian Express, Thursday, January 14, 2021, p. 10.
 See T. Sundararaman, “Challenge and Opportunity”, Frontline, January 15, 2021, p. 4-5. The administrative challenges and introduction and administration of the vaccines discussed extensively.