Arguably the worst health crisis in recent memory, Covid-19 has had some major fallouts. If economies have been shattered, societal disruption has not remained untouched either. But beyond that, “a collective lack of preparedness and an inability of the systems to defeat outcomes” has perhaps been the “greatest failure”. The reason perhaps is that despite being warned of an impending pandemic for long now and despite claiming to have enough analytical capabilities and artificial intelligence tools to make better predictions, we were unable to change the outcome of the current pandemic to a large extent. However, despite the stated failure and despite continuing massive losses, we must be thankful that we somehow got lucky this time as Covid-19 pandemic, if not anything else, has been a human and healthcare disaster. The stroke of luck may not be on our side next time if we are not creating an ability to protect ourselves against future pandemics and healthcare disasters.
Creating structures and systems that enable us to better deal with pandemics is urgently needed, but creating them in silos or compartments (much like our vertical health programmes) and not as part of a large healthcare systems reform will not serve the purpose. A major part of the effort should go into taking care of the processes and building a system resilient enough to meet all foreseeable challenges.
For the start, a lesson that this pandemic taught us will need to be incorporated in developing such a system and that lesson is “Notwithstanding the advancement in technology and centralisation of health around disease and illness, the fundamental premise on the basis of which battle against this pandemic is being fought is the usually less involved healthcare component of “Human behaviour”. So, developing a healthcare system answering to the more complex science of health and disease and not just human–disease interaction needs to be worked out. Does this health system exist anywhere in the world? Or do we need to develop our own? More importantly, what outcome do we want from the system we consider good? The expectation is to have a robust public health, backing comprehensive primary and secondary health care, led by research- and academic-focussed tertiary care.
Where does health and more so public health stand now? It appears that across the world, public health (as a component of the healthcare system) has been discarded into the narrow lanes effectively defeating the very purpose it was supposed to serve as the concepts of public health gained ground at the turn of human civilisational history. Health is more than just disease and the health systems are expected to serve both health and disease; from improving people’s chances of living a healthy life throughout their lifetime to meeting out the incidental eventualities called disease and illness. Unfortunately, however, over a period and especially since the evolution of modern pharmaceutical products and innovative technological advances in diagnostics, the concept of health is being interpreted through the narrow prism of ill health and disease.
The pandemic of Covid-19 may have been a wake-up call. It has shown us that the outcomes of the pandemic that stare us in our faces maybe an outcome of our lack of clarity on public health functions. Public health essentially embraces a range of activities from health protection (and therefore protection from disasters and epidemics), health improvement (policy focuses on improving health parameters) and health service quality. The outcomes of the pandemic appear to have found a further exaggeration because of an absence of a “robust primary care set up”, which is expected to deliver on the eventualities in an equitable and accessible manner.
Greater clarity and focus are required probably to deliver public health and primary care with equal confidence, especially in respect of health improvement and management of illness. And mere coverage through insurance is not going to help. The fundamental principle of public health is health improvement, and without developing a wider agenda involving sectors such as education and nutrition, the public health principle cannot be addressed.
It appears paradoxical that the fundamental principle of public health and primary care is getting seriously eroded at a time when government policy is seeking to advance its cause.
The ministry of health and family welfare constituted a task force on the roll-out of comprehensive primary health care (PHC) in December 2014, and to identify the current challenges in rolling out comprehensive primary health care. The effort again may be reflective of the concept (among policy-makers) that the dominant felt need for individuals across the country is disease and illness and not an overall improvement in health, health policies and health infrastructure. Although it was also tasked to finalise and clarify the components of service delivery, institutional structures and service organisations, the larger change in the landscape of public health thinking remained untouched, making us believe that we are again being subjected to a one-dimensional thinking in health care.
To its credit, the report was clear in its statement “that to reduce morbidity and mortality an effective delivery of primary care is the way to go and that the primary care has the potential to manage health eventualities at lower costs to the system and the individual than any other approach besides significantly reducing the need for secondary and tertiary care”. However, unfortunately, though the promise it held does not seem to have to been realised, much like the “Health for all declaration” emphasising a need for delivery of a comprehensive PHC. The lofty ideals of “Alma Atta declaration” were systematically eroded by the concept of Selective Primary Care paving way for the creation of vertical health programmes as the forerunners of public health in resource-limited settings like India and putting the concept of comprehensive primary care on a shelf, only to be taken out every now and then as a showpiece.
Importantly then, will this report go the “Alma Atta declaration” way and continue to fail to deliver as the current pandemic appears to highlight?
The answer is not simple. But as long as the confusion in the individual functions of primary care and public health is not resolved, we will continue to be at the periphery of both delivering health as well comprehensive primary care.
And this confusion seems to endure as the mere universalisation of healthcare through reduction of out-of-pocket expenditure, implementation of social protection mechanisms and affordable access to secondary and tertiary care referrals may not be a sustainable healthcare model. But that is not the only worry such a system will contain. A larger concern though remains that a larger insurance-backed health care, primary, secondary or tertiary takes away the “health” from the health care delivery as the focus entirely shifts to illness and disease. As also the fact that it puts a premium on one form of healthcare delivery in comparison to others, like the AYUSH, as also pushing the healthy indigenous health practices into dis-favour, a practice not suited to a country like India.
And lastly, it raises doubts in the delivery of care in a country where almost 70% of health is delivered by standalone private healthcare practitioners or private hospitals.
Unfortunately, further, the default setting for assessment of health status in India rests on indicators such as total fertility rate, infant mortality rate, maternal mortality rates etc., and the progress achieved on these parameters is measured in line with the targets established for example under indexes like the Millennium Development Goals.
The improvement in these indicators has no doubt been remarkable since independence, but imaging this improvement in the absence of improvement in the production of food grains or literacy levels will not be appropriate. Similarly, the more recent introduction of the Swachh Bharat Mission or Ujjwala Yojna (both big-ticket public health initiatives of the Government of India) not improving health will again be a wrong conclusion.
The assessment of health in India is not reflective of how healthy an average Indian is and how to improve the same. The fact that the improvement in the default settings being highly skewed across and within states, and between population sub-groups, reflects on the absence of a uniformly accessible and available “health care” and not just “medical care”.
A neglected PHC system, a vastly misunderstood public health system and specialty-driven secondary and tertiary medical care lead to a rapidly rising cost of healthcare, probably a leading cause of impoverishment.
The currently functioning primary health provides very limited services, which represent less than 15% of all morbidities for which people seek healthcare. People have no option but to resort to a local private care provider or travel to the crowded district hospital or government medical college hospital for the rest. If comprehensive primary care is able to take care of even three-fourths of these rest, unnecessary costs and suffering can easily be mitigated.
Probably, the answer lies in the following actions:
- Strengthen structures and organisation for delivery of comprehensive PHC services through development of primary care teams led by resources trained to deliver such services.
- Promote continuity of care for patient-centric services from primary to secondary care.
- Focus on delivery of public health through an understanding of social determinants of health and identifying resources for public health delivery.
- Create community participation as the core for delivery of healthcare and address equity concerns.
- Develop a human resource policy to support PHC.
- Create a specialised secondary care as part of continuum of care.
- Promote an institutional academic and research-oriented tertiary care capable of delivering on academic and policy-specific public health and patient care through geographic-specific solutions.
For these to happen, public health will need to regain its prominent position in the healthcare system in India. Around this core, a partnership between primary care and local communities to develop a primary care team approach delivering comprehensive accessible and quality care needs to be developed. The role of primary care practitioners in the form of family medicine specialists is the key in such a health care delivery system. Family medicine as an independent academic discipline and speciality of medical science needs to lead the delivery of comprehensive primary care. This probably is the only answer to the delivery of medical care catering to the growing demand of the people for personalised, continued and comprehensive care made available and accessible at a quality and premium equitable to every individual in the country. Perhaps, it is also about time to realise the difference between public health and primary care and get rid of the functional confusion between the two. The fact that primary care (whatever form we have in the current system) is being tasked to deliver public healthcare targets set through vertical health programmes is flawed and as flawed as the understanding that the “target culture” established by vertical health programmes is public health. In fact, that this limited PHC set up being diverted to “target culture” public health programme-based public health (as being thought of) from their core operations area of delivering comprehensive care is a classic example of the counterproductive and dysfunctional nature of selective health care delivery system. Contrary to this, the idea of public health rests in its ability to contribute to improving the health of those with the worst health experience (in terms of distribution or determinants of health and disease) and not necessarily to deal with individual disease or illness. Let comprehensive delivery of primary care take care of that while the public health takes care of the health inequalities as also to facilitate the implementation of Government priorities, including health service frameworks as also to tackle the health gap across the socioeconomic divide.
To secure a population that is fully engaged in their health, public health needs to raise levels of health literacy among the public and further create a need for policy engagement on nutrition, education and environment. And for that, public health needs to go beyond unidimensional thinking of “health programmes” and consult the public and develop an ability to strike out a balance between state interventions on the one hand and a person’s right to choose on the other as without this we will not be able to develop a resilient health care delivery system.
It may be that the “downstream” acute healthcare agenda will continue to swamp public health and primary care despite the lessons learned from Covid-19, the practice of the current system of health will make it all but impossible to achieve the gains in health improvement so urgently needed. Only if serious consideration is given to relocating the leadership role to public health and a justified place of practice for primary care, do we see a simple panacea to the health crisis like the one we are staring at now.
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