From Sustainable Change to Changing Sustainability in Healthcare: Indian Perspectives
The word sustainability conveys several connotations such as “maintain”, “support”, or “endure”. Brundtland Commission of the United Nations elucidates “sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs”. While economy, society and environment have been identified as the three pillars of sustainability, Health is a subject that should be considered a key contributor and a foundation for these three pillars. For, in absence of health the needs of present or future could not be met to achieve sustainable development.
In this era of increasing prevalence of debilitating illnesses from communicable and non communicable diseases, food safety issues and impending environmental threats, it may be difficult for us to achieve this goal of sustainable development in India from health perspective.
The World Health Report, 2000, ranked India as 112th among the 191 countries in terms of healthcare system measures, much lower than the neighbouring countries of Srilanka, Indonesia and Bangladesh. A key reason for this a overburdened and fragmented system of healthcare in our country. This healthcare system which includes private clinics, nursing homes, medical colleges, government aided hospitals and corporate hospitals are currently being sustained in a rather unplanned and disorganised manner. The current proliferation rate of medical care providers is in disequilibrium with disease patterns, geographic vulnerability or accessibility. This results in a situation with no clear denominators available to guide or plan a clear vision for health and medical care provision and strengthen the resilience of these health care systems.
The Government’s recent decision to cut the budget on healthcare by approximately 20%, due to fiscal constraints adds a new dimension to this deteriorating problem.India spends about 1% of its gross domestic product (GDP) on public health, one of the lowest in the world. This curtailment is speculated to derail several ambitious programmes, which were to be launched.
Thus in our search for a sustainable change in healthcare, we today stand at cross roads of myopic vision of changing sustainability itself in healthcare focused on “disease” care alone rather than delivering “health”.
At this juncture, it may be time for us to reshape our views and our perspective on healthcare and look into the possible interventions to provide comprehensive healthcare measures for the society – especially keeping the focus on underprivileged. To achieve such a goal we would also need to address the social, environmental and policy determinants of HEALTH for the overall society to achieve a sustainable goal.
“Healthcare” is often confused with medical care. Medical care is only a part of healthcare and comes into picture whenever there is deviation from health. Healthcare is treating the cause and not only the effect, where diseases form only the tip of the iceberg. Not only should our healthcare initiatives focus on providing medical care, but they must also address the social determinants of health. It has aptly been said – a healthy society should have less illness and less hospitals and our goal should be to have a healthy society. Hence, while spending less on health may be a utopian dream, it could be achieved by adequate treatment of existing illness and working in parallel towards preventive health.
While we are filled with optimism to acknowledge that we have overcome several hurdles to improve health indices such as life expectancy, maternal and infant mortality rate over the last few decades, it still stands to fact that we do not have a credible and established healthcare system. Only the developed, industrialized countries — perhaps 40 of the world’s 200 countries — have well established healthcare systems. Most of the nations are too poor or too disorganized to provide any kind of mass healthcare system, with the result that the affordable get medical care; the rest have limited access or receive poor quality services.
It has been observed that in India, general government expenditure on health as a percentage of total expenditure on health constitutes just 18% and the remaining 82% is private expenditure. Moreover, nearly all the private spending in India is out-of-pocket at the point of service use, which is an inefficient way to finance health care that leaves people highly vulnerable.
Our country needs to devise its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills. Out-of-pocket model practiced in India is a poorly effective model of health care which further burdens the citizens of this country, compared to the different health care models used in industrialized nations, such as the Beveridge model in UK, the Bismarck model in France or the National Health Insurance in Canada. These universal insurance programs tend to be less expensive and have lower administrative costs than American-style for-profit insurance plans or the out-of-pocket model. It is estimated that more the thirty million people each year fall below poverty line because of out-of-pocket payment on healthcare.
Furthermore, there is a serious need to incorporate the outlook of preventive healthcare and thus focus on reducing the diseases rather than increasing the number of doctors and hospitals in present healthcare system outlook. The present day health concerns of non-communicable diseases are largely an offshoot of life styles and habits – such as consumption of tobacco, alcohol etc., which can be more effectively dealt with preventive healthcare policies. The recent milestones achieved, such as the ban on gutka (chewing tobacco) in many States of India, is one such example. India is world capital of oral cancers. This is primarily owing to use of chewing tobacco, hence a purely preventable cancer. Almost thirty percent of the population in India (above 15) consumes tobacco, of which 20% is in chewing form. Banning this product is a wise step than to increase the medical care facilities or providers to deal with increasing burden of this cancer. While a ban on a harmful substance may not necessarily be synonymous with eradication of a disease; it is still an important step towards prevention of such disease and may be the best form of control.
Communicable diseases can be tackled effectively through hygiene and sanitation measures. Tangible goals could be achieved towards these two broad aspects of health by working towards effective implementation of hand wash awareness programs and making toilets available for each family (such as ECO sans toilets recommended in UNICEF projects which are not dependent on water supply). These are simple and equally powerful approaches that have the potential to change the indicators in communicable diseases significantly if well planned and implemented.
In addition although several diseases in India are notifiable, the process of notification is extremely poor. The linking of medical doctors and hospitals to the health department needs a complete re-look and overhaul. This is significant information that is skewed; and if rightly collected, can serve as an important denominator to systematically and wisely direct the resources to prioritize health management strategies and programs. Also, as recommended by the Indian Council of Medical Research, it would be useful to incorporate cancer (the new age illness) to the list of notifiable diseases, which has already been done by more than 50 countries worldwide.
Lastly, health is profoundly, often adversely, affected by policies made in non-health sectors. For the Ministry of Health, Government of India and the health ministries of various States, to work towards achieving the goal of sustainability in healthcare, the disease prevention policies require population-wide interventions. This is largely beyond the power of the health ministries alone and requires a “health in all policies” approach. For example, public policies dealing with urban development and municipalities need to look into water and sanitation issues. Further, the Panchayat Raj system, the policies on education, environment, agriculture and industrial production, all have important ramifications for health of the Indian population. These departments need to strongly view health as an inclusive priority under their activity list and thus move forward to achieving the collective goal of health.
Health is largely a state subject, hence with the current stand of reducing the health care budgets by Union Govt, the state governments would need to shoulder greater responsibility and have a renewed outlook on their health care goals and approach. There is a strong need for change with a inclusive and holistic perspective of health, taking into consideration social and environmental determinants of health, with health in all policies approach to achieve a sustainable health goal.
Dr.Vishal Rao U.S,Consultant – Head and Neck Surgeon, Department of Surgical Oncology,HealthCare Global Enterprises Limited and Member High Powered Committee- Tobacco Control, Government of Karnataka