Context

The health needs of a population are varied and can differ significantly across different social groups. Public health policies are formulated by the government based on available resources to address these needs. These needs include those directly experienced by individuals (felt needs) and those identified by experts (projected needs) who design public health policies. Recent critiques of the Union Budget highlight its insufficient emphasis on the social sector, particularly public health. Over the past decade, government public health policies have been criticized for their lack of effective solutions to address the genuine needs of the population.

Overview

• India’s health expenditure has increased from 1.4% to 1.9% in 2024 budget.
• In 2021 Bhutan's spending on health was 2.5 times more than India's while Sri Lanka's was three times more. Many BRICS nations (old list) spent 14-15 times more than India.
• India has the highest medical inflation rate of 14%, followed by China (12%), Indonesia (10%), Vietnam (10%), and the Philippines (9%).
• The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors. According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas.

Needs in Public Health

•  Diseases of Poverty
  • Includes tuberculosis, malaria, undernutrition, maternal death, and illnesses from food and water-borne infections (e.g., typhoid, hepatitis, diarrhoeal diseases).
  • Primarily affect the poor and vulnerable.
  • Addressing these issues involves tackling livelihood challenges and is critical from a rights perspective.
•  Issues for the Middle Class and Affluent
  • Problems related to environmental pollution, including air and water pollution, waste management, inadequate drainage, and unsafe food and eateries.
  • Other concerns include road traffic accidents, climate change, and chronic illnesses.
  • These issues also affect the poor but may not be prioritized as highly.
• Curative Care Needs
  • Primary Care: Most affordable and accessible for the poor, provided by public sector institutions.
  • Secondary Care: Historically neglected, with inadequate infrastructure and health professionals, continues to be a problem.
  • Tertiary Care: Addressed by the Pradhan Mantri Jan Arogaya Yojana (PMJAY) under Ayushman Bharat.
• Historical Context of Public Health Policies
  • National Rural Health Mission (2005): Aimed to strengthen public sector health care, deviating from the National Health Policy of 2002 which promoted commercialization.
  • National Health Mission (2013): Focused on improving primary health care and public sector institutions, enhancing trust in public health services.
  • Infrastructure Growth: Increased number of sub-centres, primary health centres (PHCs), and community health centres (CHCs).
  • Shift in Focus (2018 onwards): Emphasis shifted to publicly funded health insurance schemes (PFHI) like PMJAY under Ayushman Bharat, rather than further strengthening secondary and tertiary care in the public sector.

Private Health Care: The Real Beneficiary

• Limited Coverage of PFHI Schemes
  • India’s health insurance schemes, such as PMJAY, cover only hospitalization expenses, not all health-care costs.
  • With 12 crore households enrolled in PMJAY, only about 2.5 crore people are expected to need hospitalization annually based on epidemiological data.
• Outsourcing to Private Sector
  • The government outsources secondary and tertiary-care services to private providers at market rates.
  • This outsourcing indicates a failure to strengthen secondary and tertiary public sector health care.
  • The 100 crore population not covered by government schemes is forced to seek expensive, commercialized medical care.
• Impact on Private Sector
  • Private hospitals dominate the market, offering services at market rates.
  • By undermining public sector health care, private hospitals ensure that a significant portion of the population relies on their services.
• Transformation to Health and Wellness Centres (HWCs)
  • In February 2018, sub-centres, PHCs, and CHCs were rebranded as HWCs, with a claimed establishment of 1,50,000 new institutions.
  • Many of these were already in existence (RHS 2015).
  • Community health officers, who receive minimal training, are expected to provide curative care, reducing the role of these centres to basic treatments.
• Problems with HWCs
  • HWCs have transformed from outreach institutions to providers of basic curative care.
  • The new model risks undermining public trust in these institutions due to inadequate care.

Threats to the Public Health System

• Diverse Public Health Challenges

India faces varied public health challenges that need to be addressed across all social groups.

• • Infectious Diseases:
    • Tuberculosis, malaria, and other vector-borne diseases.
    • Food and water-borne illnesses like typhoid, hepatitis, and diarrhoeal diseases.
  • Chronic Non-Communicable Diseases (NCDs)
    • Diabetes, hypertension, cardiovascular diseases, and cancer.
    • Increasing prevalence of lifestyle-related conditions.
  • Access to Health Care
    • Disparities in access to quality health care between urban and rural areas.
    • Insufficient health infrastructure in underserved regions.
  • Health Financing and Insurance
    • Limited coverage and inadequate funding for public health insurance schemes.
    • High out-of-pocket expenses for medical care.
  • Emerging and Re-emerging Diseases
    • Threats from diseases such as COVID-19 and other emerging infections.
    • Challenges in managing and controlling outbreaks.
  • Mental Health Issues
    • Growing prevalence of mental health disorders with limited mental health services.
    • Stigma and lack of awareness around mental health care.
  • Health Inequities
    • Socioeconomic and geographic disparities affecting health outcomes.
    • Barriers to accessing care for marginalized communities.
• Felt Needs of the Vulnerable and Poor
  • For vulnerable and poor populations, basic primary and secondary curative care are essential.
  • Prevention and health promotion become secondary when basic livelihoods are not secured.
• Historical Role of Primary Health Care

Primary health care institutions historically provided preventive and promotional services close to home, tailored to local cultural and contextual needs.

• Loss of Trust in Health Care Providers

Trust issues arise due to:

• • Private Sector: Driven by commercial interests.
  • Public Sector: Overcrowding and inadequate infrastructure.
• Government's Role in Weakening the System
  • The government has failed to strengthen secondary and tertiary public sector care.
  • There is a preference for expanding the private sector.
•  Weakening of Primary Health Care Institutions
  • Primary health care institutions, essential to India’s public health system, are now being repurposed as curative care centers.
  • This shift undermines their original role in health programs and their connection to grassroots health care.

Conclusion

The Indian public health sector is experiencing severe policy paralysis, marked by a critical underinvestment in strengthening secondary and tertiary care facilities within the public sector. This has led to overcrowded and inadequately resourced health services. The government's reliance on the private sector for curative care exacerbates this issue, leaving many to bear high out-of-pocket costs and weakening the public health system. Additionally, the transformation of primary health care centers into curative care providers dilutes their effectiveness in delivering preventive and promotive services. Publicly funded health insurance schemes like PMJAY, which cover only hospitalization, fail to address the broader spectrum of health needs. This misalignment of policies, combined with the erosion of public trust due to both the inefficiencies of public facilities and the commercial motivations of private care, results in a fragmented and ineffective public health system that struggles to meet the comprehensive needs of the population.

Source: THE HINDU