Date: 14/12/2022

Relevance: GS-2: Issues Relating to Development and Management of Social Sector/Services relating to Health.

Key Phrases: Population perspective, Public Health, Public Sector Healthcare, Functional Epidemiology, Pradhan Mantri Jan Arogya Yojana (PMJAY), National Sample Survey Organisation, Atomistic fallacy.

Context:

• There is a strong tendency in public health to prioritize individual-oriented interventions over societal oriented population-based approaches, also known as individualism in public health.
• A failure to examine and interpret public health problems from a population perspective is leading to ineffective and unsustainable solutions as far as complex public health problems are concerned.

Evidences of individualism in Indian public health system

1. Pradhan Mantri Jan Arogya Yojana (PMJAY) falls under Ayushman Bharat is the classic example of individualism in public health.
   • PMJAY is the largest health insurance scheme in the country covering hospitalisation expenses for a family for ₹5 lakh a year.
   • The goal is to ensure ‘free’ curative care services for all kinds of hospitalisation services so that there is no financial burden to the beneficiary.
   • Individualism Issues in PMJAY:
     • It is not talking about the need for hospitalisation services per year for any population.
     • Instead, every individual is given an assurance that if there is a need for hospitalisation expenses, the scheme will cover the expenses, highlighting the risk/probability of every individual facing hospitalisation in a year.
     • This is an individualistic response to the problem of hospitalisation expenditure faced by populations.
     • Data from the National Sample Survey Organisation (75th round) show that on an average, only 3% of the total population in India had an episode of hospitalisation in a year.
     • Thus, ideally, the Government needs to ensure health-care facilities to only 3%-5% of the population to cover all the hospitalisation needs of a population. This is population-based health-care planning.
     • Instead, PMJAY giving an assurance to every individual without ensuring the necessary health-care services to the population is not really helping in a crisis.
2. The approach to vaccination for COVID-19 has also been an example of individualism in public health.
   • It was evident that a COVID-19 vaccine cannot prevent people from getting the disease but only reduce hospitalisation and deaths in the event of contracting COVID-19.
   • It was also evident that around 20% of the total COVID-19 positive cases needed medical attention, with around 5% needing hospitalisation and around 1%-2% needing intensive care (ICU) or ventilator support.
   • Thus, to effectively manage COVID-19, what was needed was to have primary, secondary, and tertiary health-care facilities to manage the above proportion of cases.
   • Individualism issues in COVID health plannings:
     • Most of the deaths due to COVID-19 are a reflection of the failure to offer ventilator and ICU support services to the 1%-2% in desperate need of them.
     • Curative care provisioning is never planned at an individual level as epidemiologically, every individual will not necessarily need curative care every time.
     • The morbidity profile of a population across age groups is an important criterion used to plan the curative care needs of a population.
     • What it means is that for population-level planning, the need of the population as a single unit needs to be considered.

What are the three main reasons for the dominance of individualism in Indian public health policies?

1. Firstly, dominance of biomedical knowledge and philosophy in the field of public health with a misconception that what is done at an individual level, when done at a population level, becomes public health.
2. Secondly, the aspect of ‘visibility’ of health impacts among the general public.
   • Health effects are more visible and appear convincing at the individual level, wherein improvements at the population level will be clear only after population-level analysis.
   • This needs a certain level of expertise and orientation about society — an important skill required for public health practitioners.
   • Atomistic fallacy in public health: The public who take individual experiences at face value, will make the same mistake of judging a population’s characteristics based on individual experiences popularly known as atomistic fallacy in public health.
3. Thirdly, the market’s role and the effect of consumerism in public health practice.
   • The beneficiaries for a programme become the maximum when 100% of the population is targeted at individual level.
   • On the contrary, from a population perspective, the actual beneficiary will reduce to only 5%-10% in case of population perspective for treatment needs.
   • Thus, market forces would prefer to cast a wide net and cover 100% of beneficiaries.
   • Therefore, propagating individualism has always been a characteristic feature of a capitalist society as every individual can then be a potential ‘customer’ in the face of risk and susceptibility.

Way ahead:

• Sustainable approaches such as a strengthening of the Public Distribution System, supplementary nutrition programmes, and the health services should be encouraged.
• In the case with chronic disease control, wherein early diagnosis and treatment is the most popular solution should done through organised community action.
• An evaluation of publicly-funded insurance schemes, which points to the low proportion of population that benefited from the scheme annually.
• From an individualist perspective, any individual can be at risk for hospitalisation anytime but from a population perspective, one can confidently argue that each year, the maximum proportion of population in need of hospitalisation will be in the range of 5% of the total population.This is why a population-based approach should be focusing on.
• Much efforts should be on adequate health-care infrastructure to ensure the necessary primary, secondary and tertiary care services.
• All forms of individualistic approaches in public health need to be resisted to safeguard its original principles of practice, viz. population, prevention, and social justice.

Source: The Hindu

Mains Question

Q. India’s policies on healthy demography are very high in objectives, ambitious on intent but ineffective on outcomes. Discuss this statement with special emphasis on phenomenon of predominance of individualism in Indian health policies. (15 marks).