Medical workers in PPE gesture as they arrive at an ICU treating COVID-19 patients at a Delhi hospital. Photo: Reuters/Danish Siddiqui
- India’s healthcare concerns are focused narrowly on improving the quality of medical care and education, but not public health itself.
- Public health approaches healthcare as a social problem whose solutions are collective in nature.
- Despite a multi-crore allocation, the new Ayushman Bharat Health Infrastructure Mission seems destined for spectacle more than actual transformation.
Public health is not simply medicine. Taking the wood for the trees, India’s healthcare concerns are focused narrowly on improving the quality of medical care and education.
Medicine refers to the scientific discipline of identifying the aetiology of a disease in a patient and curing it. In common parlance, medicine would refer to the job profile of a doctor extending to a surgeon. A training in medicine, however, is not sufficient to deal with public health.
This is because a social group such as a community, a village or a city is not just a collection of individuals. The social collective has emergent properties that we can’t predict by studying the level of individual elements – a fact that is well established across the social sciences. For instance, within economics, macroeconomics is distinct from microeconomics. One can’t reach macro phenomena by adding up properties observed at the micro level.
Public health approaches healthcare as a social problem whose solutions are collective in nature. Curing a disease for an individual patient is never the same as dealing with an epidemic. Medicine and pathology, together with statistical modelling, sociology and anthropology, economics, finance, mass psychology and an understanding of communications makes for an integrated approach to public healthcare. Doctors and hospitals are only one part of a public health system and increasing only their numbers and funding will go only so far in dealing with health emergencies of a public nature.
More money, less imagination
An example of this lack of governmental vision is the latest multi-crore project that the Narendra Modi government has announced: the Ayushman Bharat Health Infrastructure Mission. With an allocation of Rs 64,000 crore, this project seems destined for spectacle more than any actual structural transformation of the country’s ailing health infrastructure.
The government has touted this mission as the “largest scale up of health infrastructure in the country”. In an October 26 press conference, Union health minister Mansukh Madaviya claimed that it would provide healthcare access to every citizen of the country while also preparing everyone for all possible emergent public health threats.
However, dealing with public health requires a distinctive approach that continues to be lacking.
India’s healthcare spending remains trapped in an archaic division between primary and secondary/tertiary healthcare. Chronic ailments such as diabetes have taken on epidemic proportions and need to be tackled at the level of individual patients and social groups. The specific requirements of public healthcare including data and surveillance systems, a pool of dedicated public health experts, technical capacity for epidemic modelling and social scientists for health communication and social impact assessments are either absent in healthcare policies or present as an afterthought.
Present but ill-conceived
There can be no argument against an increase in government spending on primary healthcare. The mission aims to increase the number of health and wellness centres in urban and rural areas. These centres are conceptualised as an improvement over the previous primary healthcare centres.
Over and above the basic facilities of first aid, family planning services and maternity care, the centres will screen for non-communicable diseases such as diabetes, provide ground-level surveillance for infectious epidemics and even provide basic mental healthcare. All this falls on the shoulders of a basic staff consisting of doctor(s), nurses, auxiliary midwives and ASHA workers. There is no provision for appointment of public health specialists, programme coordinators or managers and data analysts who can provide key public health inputs.
Another component of the mission is the expansion of government-run diagnostic labs. This too is a much-required investment. However, government-run diagnostic labs are a minority in the country. There is in fact no singular government database that lists all private diagnostic labs in the country. The Clinical Establishment Act, which is meant to govern this sector, has been adopted by only 11 states. Accreditations are voluntary and so are audits.
In an environment where private diagnostic labs operate outside state regulation, acquiring any clear picture of the spread of an epidemic is a Himalayan task.
On a related note, the mission aims to expand and improve the IT-enabled health surveillance infrastructure of the country. India already has a disease surveillance institution – the Integrated Disease Surveillance Programme (IDSP), created in 2004. However, its functioning has been found lacking on many levels. Its capacity to collect data is severely curtailed as India’s healthcare infrastructure relies heavily on private providers who are poorly regulated. It also lacks the ability to gather any data from pharmacies and chemists. Such data is used globally to track disease movements across regions, as people tend to self-medicate all ailments when the symptoms are mild.
In the midst of India’s first COVID-19 wave in 2020, 216 districts in 11 states didn’t have an epidemiologist to analyse data collated by the surveillance system. Assam was willing to hire persons trained in homeopathy and Ayurveda while Karnataka offered only temporary positions. Studies have found that the IDSP system produces poor-quality data that is rarely subjected to audits. To improve disease surveillance in the country, we need a thorough overhaul of health regulation and policy instead of throwing more money at a system riddled with holes.
The mission also includes the creation of National Institutes of Virology, new biosafety level 3 labs, regional centres for disease control and public health units at international entry points for improved surveillance. All of these are excellent measures on paper. However, there is still no overarching public health policy laying out the guidelines to share data, coordinate action, ensure data collection is transparent and timely, and install a functional hierarchy to guide their operation during a pandemic. It is likely these institutions will end up functioning in silos instead of producing any coherent public health impact.
In line with global trends, the Indian government has also announced the creation of a ‘National Institute for One Health’. ‘One Health’ refers to a global healthcare paradigm in which health infrastructure expands its focus from just human health to an integrated concern with animal health, food safety and crop health. While the exact structure of this new institute is yet to be revealed, we can safely argue that it will be a mere nod in the direction of One Health.
Currently, multiple schemes for livestock health and vaccination are operational under the animal husbandry ministry. Crop health falls under the agriculture ministry and issues related to genetically engineered crops and food fall under the environment ministry. Diseases among wildlife populations also fall under the environment ministry. Without thoroughgoing structural changes in these functional divisions between the ministries, any attempt to move towards the ‘One Health’ paradigm will remain a paper tiger.
The government has missed an excellent opportunity to create a dedicated public health cadre for India. The Mudaliar committee recommended this in 1959, as did the National Health Policy 2017. Currently, medical doctors hired by states to undertake clinical work also implement large-scale public health interventions. Their training is woefully inadequate to deal with the many challenges of such large social projects, which include everything from personnel management to accounting.
Tamil Nadu is the only state with a functioning public health cadre, and its excellent performance on all health indicators is testimony to the cadre’s importance.
Next, the supply of public health experts in the country is lacking. There are only a handful of colleges that offer master’s degrees in public health. Medical colleges do offer courses in community health and epidemiology, but these lack the interdisciplinarity of public health. We need courses that draw students from both medical and non-medical backgrounds and curricula that integrate scientific components with the social sciences.
Finally, the country’s healthcare interventions will benefit immensely from health communications departments under the health ministries. Health communication is a specialised discipline that neither untrained bureaucrats nor medical professionals can handle. Communicating information and using media platforms to create trust and reassurance instead of confusion and panic is of utmost importance during a pandemic.
The destruction that COVID-19 visited on India has provided us an opportunity. We must reimagine how we think of and practice healthcare. It doesn’t suffice to increase expenditure without reconceptualising how we think of healthcare.
Anirudh Raghavan is an independent researcher working on issues of medicine and public health in India. He is trained in medical anthropology and sociology from the Delhi School of Economics.