Policy paralysis, a weakened public health sector

• The public health sector in India has faced significant challenges over the past decade, with recent critiques focusing on inadequate attention and resources in the recent Union Budget. This scrutiny highlights a broader issue of misalignment between public health needs and policy responses.

Categories of Public Health Needs

1. Diseases of Poverty:

• These include tuberculosis, malaria, undernutrition, maternal mortality, and food and water-borne illnesses such as typhoid, hepatitis, and diarrhoeal diseases.
• Addressing these issues is crucial as they affect the poorest and most vulnerable populations. These needs are fundamental and require comprehensive, rights-based interventions.

2. Environmental and Lifestyle-Related Issues:

• This category includes problems related to air and water pollution, waste management, and inadequate drainage and food safety.
• These issues are more prevalent among the middle class and are driven by poor infrastructure and market regulations. Additional concerns include road traffic accidents, climate change, and the rise of chronic illnesses.

3. Curative Care:

• Curative care is divided into three levels: primary, secondary, and tertiary. The poor and vulnerable largely depend on primary health-care institutions for affordable and accessible care.
• Secondary care has historically been neglected, leading to inadequate infrastructure and a shortage of professionals. Tertiary care needs are somewhat addressed by the Pradhan Mantri Jan Arogya Yojana (PMJAY) under Ayushman Bharat, which provides coverage for high-cost treatments.

Historical Context of Public Health Policies

Over the past decade, significant policy shifts have occurred:

• National Rural Health Mission (NRHM), initiated in 2005, and later the National Health Mission (NHM) in 2013, marked a departure from the National Health Policy of 2002, which emphasized commercializing healthcare.
• The NHM aimed to strengthen public sector health care through architectural reforms, focusing on primary health care and building trust in public health systems.
• Despite these efforts, the shift towards publicly funded health insurance schemes like PMJAY since 2018 has shifted focus away from strengthening secondary and tertiary public sector care.
• Instead, it has facilitated the growth of the private health care sector, which benefits from government contracts at market rates, thus monopolizing the market and leaving those outside the insurance schemes to depend on costly private care.

Issues with Current Policies and Structures

1. Outsourcing to the Private Sector:

• The reliance on private health care under PFHI schemes has led to an imbalance, where private hospitals dominate and public sector care is sidelined. This has created a situation where the public health system is weakened, forcing a large segment of the population to seek expensive private care.

2. Transformation of Primary Health Care Facilities:

• The transformation of sub-centres, PHCs, and CHCs into Health and Wellness Centres (HWCs) in 2018, and their recent renaming to ‘Ayushman Arogya Mandir’ has been criticized.
• This shift prioritizes curative care over preventive and promotional activities, undermining the original intent of these institutions to provide holistic primary care.

3. Loss of Trust:

• The current public health infrastructure suffers from overcrowding, inadequate resources, and poor infrastructure, which has led to a loss of trust in both private and public health providers.

Moving Forward

To address these challenges, the government needs to:

• Strengthen secondary and tertiary public sector care to create a more balanced health care system.
• Focus on preventive and primary care, aligning health institutions’ roles with their intended purposes and ensuring they are adequately resourced.
• Reassess and recalibrate health insurance schemes to better integrate with and support the public health infrastructure rather than undermining it.
• In summary, India’s public health policies have struggled to address the diverse needs of its population effectively. There is an urgent need to re-evaluate and realign these policies to ensure a more equitable and functional health care system.