Public health experts share their views on the challenges in India’s public health sector and recommend measures for improvements, with Express Healthcare
‘Addressing challenges in the implementation of the health policies is most important’
Public health refers to all organised measures to prevent disease, promote health and prolong life among the population as a whole (WHO). Public health also includes assessing, monitoring and prioritising the health needs of the community and the population at risk. Public health policies should resolve the identified local and national health problems and secondly, ensure that the population has easy access to appropriate and cost-effective care in order to prevent diseases and promote health. These core values of public health should be shared between all the stakeholders of the public health. Public health is a social responsibility, hence it is the role of the stakeholders to respond timely to the community’s health needs along with the primary healthcare providers, as they themselves are the beneficiaries of these health policies.
In order to make public health a shared value between all stakeholders, it is important to consider making the public health concerns a top priority. Not only policy makers and public health professionals but also the rest of the stakeholders should join in implementation of educational programmes, recommending health policies, administering services and conducting research in contrast to clinical professionals who primarily focus on treatment rather than prevention.
Accordingly, addressing the challenges in the implementation of the health policies is an important initiative for the better health of the society. The most common challenges that need to be addressed include: lack of skilled personnel, inadequate funding, inadequate resources, limited buy-in form leadership, decentralised local and state public health services.
Hence it’s high time that each stakeholder and every individual worked towards a healthier nation.
– Dr G Srinivas Rao, Chief Programme Officer, NHM, Telangana
‘There is a need to revitalise the public healthcare system with sufficient manpower and funds’
Public services are vital for country’s development, yet they face problems like shortage of manpower and shortage of funds. Forcing the doctors obtaining the degree from Government Medical Colleges to enter in the public health services arena will not improve the quality of the services. Doctors can’t be forced to examine the patients and treat them. Hence, manpower shortage needs to be tackled by offering various incentives like facilities for postgraduate study, additional remuneration, early promotion etc. There are many public health activities where sufficient fund is available but they do not reach the target population due to insufficient manpower.
Apart from the National Health Programme (NHP), health is also a state subject. Most of the activities are carried out with the funds from the state government. Yet, only 1-1.5 per cent of the state budget is being allocated to the health department. Unless this percentage is increased the goals of achieving universal health cannot be achieved. Several private organisations offer funds for specific health activities with an intention to make profits. These private organisations provide funds one time and then burden of carrying out these activities fall on the government machinery. Private healthcare providers are nowadays participating in public health activities through PPP models, but many are in the pursuit of mere profits. Hence, there is a need to revitalise the public healthcare system by providing sufficient manpower and sufficient funds.
– Dr Pravin Shingare, Director, Directorate for Medical Education and Research (DMER), Maharashtra
‘Information for transaction intensive discretionary healthcare is a concern needing a remedy’
Public health is a cross-cutting subject wherein all stakeholders and various government departments are required to address the issue of healthcare in the state and the nation.
The community members or the users of health facilities are the end major stakeholders of public health. Further moving up, any intervention can never be implemented successfully without the help of frontline health functionaries who are a part of their respective community and are directly involved in the public health programme implementation at the village level. Then, other primary stakeholders of public health are service providers at the health facilities including the district hospitals, rural hospitals, sub-district hospitals, primary health centres and sub-centres. The managers at facility level or district level or state level also have a role in ensuring uninterrupted logistic supply and operation maintenance to make the service encounter meaningful. Therefore, at state headquarters, the policy makers can design policies for the benefit of general public. But these policies can never be successful without the effective and efficient implementation by various stakeholders and the frontline workers as they are the backbone of the entire system. The information among various stakeholders, particularly for transaction intensive discretionary healthcare, is a concern needing a remedy.
In lieu of this, Maharashtra has introduced two programmes through which information is being exchanged by various stakeholders like community members, doctors and healthcare providers, front line workers etc., at the same time i.e. Health Advice Call Center (HACC) which is a 104 call center to provide health advice free of cost and on 24X7 basis. Another programme that runs on the same concept is the RGJAY helpdesk which gathers grievances and suggestions from network hospitals, users and potential users. Here, various stakeholders including the general public can access the information about the treatments provided, coverage amount, eligibility and nearest empaneled hospitals on 24X7 basis.
– I A Kundan, Mission Director, National Health Mission, Maharashtra
‘We need to implement an Infection Control Surveillance programme in all public health institutes’
BHOR Committee report in 1946 had estimated that bulk of healthcare was being delivered from government hospitals and only eight per cent services were with private (trust) hospitals. The report strongly recommended that healthcare services should continue to be with the government. With the time and with growth of population, government however could not keep pace in terms of opening of new hospitals and that paved the entry of private/ corporate sector in to healthcare. Today, the government investment in the health systems is limited to 1.1 per cent whereas the private sector was incurring 3.8 per cent of GDP. As of now more than 70 per cent of OPD and 60 per cent of IPD services are with private sector.
Government is committed to provide health for all (UHC). But, it does not have adequate capacity of its own to provide UHC. Setting up of new hospitals at this stage would call for huge expenditure and government was not in position to do that. The only option available with government is that it procures health services from the private sector and delivers to the community. Such an arrangement has been proved successful by government health insurance schemes in Andhra Pradesh, Tamil Nadu, Karnataka, Telangana, Gujarat and Maharashtra and more recently in Rajasthan. These services are made available to BPL families through cashless options from empanelled private hospitals and therefore are largely confined in urban settings.
The rural population however continues to depend on a network of PHCs/ CHCs and district hospitals. These institutes suffer with inherent problems associated with government establishments. For e.g., we do not have specialists posted at CHCs. We need to strengthen the systems by improving efficiency and safety. We need to implement ‘Infection Control Surveillance programme’ in all public health institutes and monitor the key clinical outcomes. We need to train clinicians for undertaking clinical audits. We need to train nurses on infection control. This will make the public health system robust, safe and efficient, besides it will introduce an
element of accountability within the system.
– Dr Girdhar J Gyani, Director General, Association of Healthcare Providers (India)
‘A realistic national policy for medical education is needed’
The health sector revolves around human life. The right to health is upheld as a basic human right by the UN. But do we have adequate doctors, nurses and paramedical health workers to ensure this right to our populace?
Medical education and health policies discuss doctor to population ratio. However, the ratio considers only allopathic doctors for the purpose of calculations while in reality along with allopathic doctors, AYUSH doctors are also catering to the healthcare needs, which is approved by GOI too. (Maharashtra has 80,000 allopathy doctors and 120,000 AYUSH practitioners)
If so, why are they excluded from the ratio? Yet, AYUSH doctors are permitted to prescribe modern medicines which results in unwarranted treatment and antibiotic abuse. Therefore, we need to develop a realistic approach while developing rational policies.
Medical education is also divided between the goverment and the private sector. Both sectors are riddled with certain drawbacks. The government sector has a large number of patients who are unaware about their rights (Drug Trials!). Lack of trained teachers, advanced amenities for diagnosis are some of the other challenges. On the other hand, private medical colleges charge capitation fees alongwith exorbitant tuition fees. Hence, there is a need to streamline medical education with better policies.
The bottom line of drug procurement is low price. However, due to doubtful efficacy of these drugs, the patients end up spending double on drugs. Stringent regulations on pharma is the solution, but the industry itself can lower the prices by cutting down on promotional activities and favours to doctors! Self discipline, coupled with a code of conduct for the industry will change the scenario.
Long term planning for procurement of equipment in government set ups is also essential. Better treatment protocols also need to be developed to improve healthcare delivery in India.
– Dr Alka Deshpande, Director General, Association of Healthcare Providers (India)
‘Good population health is essential for developments in the economy and community’
Public health has traditionally been perceived as the responsibility of the government, by way of providing infrastructure facilities, personnel and materials for the population. The new concept of shared value recognises the common benefit derived by individuals, communities, groups, local bodies, businesses and governments when there is active participation of all the concerned stakeholders in public health efforts and initiatives. This improves the quality of life of the population while simultaneously reducing the healthcare costs. The most important stakeholders are those most dramatically affected.
In order to gain stakeholder participation and support, it’s important to understand not only who potential stakeholders are, but the nature of their interest in the effort. With that understanding, it should be possible to invite their involvement, address their concerns, and demonstrate how the effort will benefit them.
Stakeholder analysis is used to identify and assess the influence and importance of key people, groups of people, or organisations that may significantly impact the success of an initiative. As public participation becomes increasingly embedded in national and international public health policy, it becomes ever more crucial for decision-makers to understand who is affected by the decisions and actions they take, and who has the power to influence their outcome.
The motivations for degree and depth of involvement of any stakeholders in the public health efforts vary widely. Some may have a truly altruistic outlook and volunteer because they feel it’s the right thing to do.
In the case of governments this may well be improvements in public health, the creation of a healthy society etc. Poor health is both a symptom and a creator of inequality. Preventable disease reduces people’s ability to work, removes valuable resources from society and reduces economic performance at both country and organisational level. Good population health is essential for developments in the economy and community. Employment opportunities and inward investment are facilitated by a labour market that is characterised by high levels of fitness and health. Funding relevant research to understand what can be done to improve health, and equity in health outcomes, is a priority as is making the best use of that research as part of government objectives.
But, this will not be a legitimate reason for other stakeholders to become involved.
Businesses, companies and trade unions may see benefits in terms of reducing loss of productivity due to sickness, reducing healthcare expenditure because of effective prevention and also as a part of their corporate social responsibility. At times businesses may participate just because their competitors are doing it, thus they must do the same to maintain their market position. The government can create opportunities for employers to participate in health promotion initiatives through national and local health campaigns, accreditation/ award schemes and capacity building.
For a few stakeholders it’s a matter of compulsion e.g. doctors serving in rural areas as a compulsory part of their curriculum and bonds with the government. The significant risk with this approach is that stakeholders might not willingly participate in the activities and will do the absolute minimum expected from them.
Promoting and supporting the development of a healthy society must include disease prevention and health promotion and through their legitimate roles NGOs are ideally placed to facilitate this process. NGOs can hold government and employers to account on issues relating to the public health, the provision of information and access to facilities/ products relating to diet and physical activity and the prevention of lifestyle related diseases.
Research associated bodies are sources of evidence, expertise and innovation. They include academia, respected expert national and international entities, and research and development corporations.
Media has a powerful role in influencing culture and opinion and is a key partner in strategic communications. It has a formal role in educating and creating interest and readiness for change through strategic communications. The media is also able to draw attention to issues from the public’s perspective.
As with any community building activity, work with stakeholders has to continue for the long term in order to attain the level of participation and support needed for a successful effort. New stakeholders may need to be brought in as time goes on.
Stakeholder engagement is not about giving the public a list of options to choose from – it’s about drawing them in right from the start, so that their views, needs and ideas shape those options and the services that flow from them.
There are three levels of stakeholder engagement. The lower levels, (manipulation, therapy, informing) relate to situations in which the organisation is merely informing stakeholders about decisions that have already taken place, although these levels represent bad practice if done in isolation. They are often among those most affected by an effort, and thus have good reason to work hard for or against it, depending on how it affects them. Often, the stories of those who have or will benefit from the effort can be effective motivators for people who might otherwise be indifferent.
At middle levels, (explaining, placation, consultation, negotiation) stakeholders have the opportunity to voice their concerns prior to a decision being made, but with no assurance that their concerns will impact on the end result. Providing whatever information, training, mentoring, and/ or other support they need to stay involved is always helpful. Maintaining their enthusiasm with praise, celebrations, small tokens of appreciation, and continual reminders of the effort’s accomplishments goes a long way in achieving full participation.
The highest levels, (involvement, collaboration, partnership, delegated power, stakeholder control) are characterised by active or responsive attempts at empowering stakeholders in decision-making. Employing them in the conception, planning, implementation, and evaluation of the effort from its beginning usually assures full participation.
Coordinated and committed participation of the stakeholders is key to impact and success of a public health initiative.
– Dr Ramesh Bharmal, Dean, BYL Nair Hospital and TN Medical College Mumbai
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