Basic Healthcare: India needs an innovative inter-sectoral response
There is little doubt that the new government in 2014 will inherit a policy landscape infested with challenges. That also means that much can be achieved. Health is an inherently complex sector, and if the new government is brave, it will avoid the trap of dealing with the urgent at the expense of the important. Given the national mood, it would also be fair to say that India, in all spheres, wants greater equity, quality, transparency, and choice.
Much attention is being paid to increasing government expenditure on health (as a % of GDP) and moving towards a system based around universal health coverage (UHC). UHC ensures that all people can use health services without financial hardship. It is hard to argue that inherently either of these is undesirable. However, they are the means to an end – a healthy nation, and that is the focus here. So what is making India unhealthy?
Consider a few statistics. India is home to the greatest burden of maternal, newborn and child deaths in the world: around 309,000 babies die within 24 hours of birth; 56,000 mothers die every year. Non Communicable Diseases (NCDs), which are driven by ageing, rapid unplanned urbanization, and the adoption of unhealthy lifestyles, will account for nearly three quarters of all deaths in India by 2030. They will be responsible for two-thirds of the total morbidity burden and about 53% of total deaths.
At one end of the spectrum, we continue to lose babies and mothers to preventable causes (diarrhea, blood loss, etc). At the other, our growing urban population (including Tier II and III cities) is getting older, making unhealthy lifestyle choices, and dealing with adverse environmental conditions. The demographic dividend that we keep harping on about, especially in urban areas, faces bleak prospects if it is unable to stay healthy. The current health policy framework acknowledges these problems, but the magnitude of the response may be inadequate and misdirected. The good news is that a lot is known about what needs to be done to save precious lives from being lost to these preventable causes, and the government can take several steps immediately which are also consistent with long-term priorities of the health sector.
Earlier this year, the Government of India (Ministry of Health & Family Welfare) adopted an integrated approach for reproductive, maternal, new born, child and adolescent health (RMNCH+A). Its notable feature is its special focus on increasing coverage of essential interventions for vulnerable populations in selected high priority districts (with high burden), and the use of a ‘score card’ system to evaluate performance. It however stops short of setting specific targets for each of the high-focus districts, though there are broad health outcome goals under the 12th five year plan.
However, it would be unrealistic to expect that the average targets would be achieved in the high priority districts, even with the extra support being provided to them under this programme. The integrated approach also fails to establish a timeline or even a process for operationalizing inter-Ministerial linkages, considered critical in addressing gaps in women’s and children’s health. These shortcomings must be addressed immediately.
First, setting clear targets at the sub-state level should be a priority. However, to ensure that targets can be used effectively to hold the government accountable, there is an urgent need to improve health information systems in India. This is a larger problem across the health sector that needs to be systematically addressed. Second, the incoming government will need to articulate a process with clear lines of accountability and management when it comes to coordination actions across ministries. This is critical because several concurrent initiatives of other Ministries will have a critical impact on the outcomes that it seeks to influence.
One such example is the National Sanitation and Hygiene Advocacy Communication Strategy Framework 2012-17 developed by the Ministry of Drinking Water & Sanitation. It calls for “each state to develop its own Information, Education, and Communication strategy (ICE) with a focus on health”, and for it to be “area specific”, i.e. a separate strategy for different administrative levels – district, block, etc. Key priorities for this Ministry include access to improved sanitation and clean drinking water.
Estimates suggest that roughly only a third of India has access to excreta disposal facilities (important for preventing diarrhea in children). Nearly 100 million people in India lack access to improved water supply. There is clear value in linking the work of the dedicated district level support teams under the RMNCH+A strategy to the ICE under the National Sanitation and Hygiene Advocacy Communication Strategy Framework 2012-17, given the strong connect of health, water, and sanitation.
A ‘must do’ for the next government is to conduct a mapping exercise of the initiatives across the various Ministries that impact women’s and children’s health. The information gathered can then be used to reduce duplication, and ensure that the core competencies of different ministries are leveraged to improve coverage of essential interventions for women’s and children’s health in the high-priority districts identified by the Ministry of Health & Family Welfare. The greatest challenge for the next government will be to find an operational mechanism to formalize this inter-Ministerial cooperation, with a clear action plan, targets and an accountability framework.
To tackle NCDs in India, the government plans to scale up the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to cover all districts in the country during the 12th five year plan. The NPCDCS aims at integration of NCD interventions in the National Rural Health Mission (NRHM) framework. The general picture that emerges however is that India has done a better job in screening and management of NCDs than in prevention and awareness.
The former is clearly within the purview of the government. However, while screening and management can be outsourced to external actors through Public Private Partnerships (PPPs), prevention and awareness activities have a strong ‘public good’ nature, and thus it has to be the government that spearheads them. Innovative solutions can be devised to engage the private sector and other stakeholders, but it must be the government that drives this.
Even within the operational guidelines of the NPCDCS, mere lip service is given to the latter. Though “health promotion” is included as one of the services to be made available at different levels under NPCDCS, the focus continues to be on management and treatment. Most of the funding under NPCDCS is allocated to human resources, infrastructure, and diagnostic equipment/testing. Specific funding allocated to prevention through communication and advocacy activities is negligible at the district level and below (except some funding for training of health workers in prevention). It is also unclear how the effectiveness of “behavioral change” strategies will be measured. Another weakness of the current framework is that no clear action points have been identified at the national level to create favorable conditions for adoption of healthy lifestyles.
Thus, it is imperative that the next government take concrete actions vis-a-vis prevention, awareness, and adoption of healthy lifestyle. First, the government must identify and implement priority actions in non-health sectors like trade, taxation, education, agriculture, urban development, food and pharmaceutical production that can allow for substantial health gains, especially for the poor. For example, policy instruments designed to encourage health sensitive urban development should be part of the solution.
Existing mechanisms such as the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) should be modified to enable people to act on healthy behavior messages relayed to them (for e.g. increasing availability of open spaces in urban areas). Secondly, even though prevention is being emphasized, India also needs to incentivize adoption of healthy behavior. For example, strategies focused on urban and peri-urban horticulture need to be promoted aggressively to alleviate the availability and affordability of fresh fruits and vegetables and other nutritious foods for the urban poor.
Business as usual will not suffice, and there is a critical need for a whole slew of innovative measures cutting across sectors. The current framework of NPCDCS is however inadequate to deal with this, and the next government’s performance should be measured in terms of its ability to expanding the scope of NPCDCS such that it empowers people to take positive actions with regards to their own health. A formal multi-stakeholder mechanism led by an inter-ministerial group, with a clear mandate, must be set up immediately to address the gap in India’s NCD response.
Two things are evident when we consider the analysis above. First, the Government needs to strengthen efforts in prevention. Second, the solutions to India’s health problems lie in inter-sectoral efforts and inter-ministerial collaboration. The diarrhea example and the discussion on NCDs, both highlighted earlier, illustrate this well. Unfortunately, India’s current policy framework is ill-suited to this change. The new government will need to demonstrate significant political will and executive action to change India’s approach in tackling the RMNCH+A and NCD challenges.
India has however demonstrated before that it can tackle such challenges, and it is worth reflecting on its success in fighting the spread of HIV and eliminating polio. In dealing with HIV, the government earmarked a majority of the funds for prevention; the government, through its actions, has enabled people to take positive actions for prevention (for e.g. through increased availability of affordable condoms) and empowered people to seek information about prevention and treatment (for e.g. through advocacy efforts aimed at reducing stigma).
The importance attached to thwarting the spread of HIV is captured in a 2002 statement made by India’s then Prime Minister, Atal Bihari Vajpayee, to the Indian Parliament in which he called HIV and AIDS “India’s most important public health problem.” India’s accomplishment in eradicating polio is owed partly to strong political will and a robust surveillance system.
More crucially, India’s polio programme has been characterized by innovation that fixed the inefficiencies in earlier systems; targeted advocacy campaigns, innovative outreach programmes, and strong national coordination provided by the government proved instrumental. The HIV/AIDS and polio programmes are not without their problems, but the success so far provides important lessons for India.
To summarise, the next government must be judged on the basis of its ability to devise innovative solutions that will elevate our response to challenges in RMNCH+A and NCDs. India does not lack the ability to fund this response; we also have the requisite technical experience and knowledge.
However, we are in dire need of a well-designed inter-sectoral response that is appropriate in scale, and backed by strong political will. Innovation will be the key, and we hope that the next government will usher in a period of innovative solutions that can tackle some of India’s health sector challenges head-on.