Covering the needs of the world’s largest population calls for a robust public health system. Ayushman Bharat has elements of the health system design needed.
Accelerated economic growth is expected to be propelled by the demographic dividend of a mostly young population over the next three decades.
By K Srinath Reddy
India’s population recently crossed 1.4 billion and is projected to overtake China’s in 2023, making it the world’s most populous country. This is ahead of earlier forecast transition time of near-2028. India’s position at the top will stay unchallenged for many decades, even though the total fertility rate (TFR) has fallen below 2.1 in most states. China’s recent push to incentivise more children, to atone for the folly of its one-child policy, is unlikely to succeed in bringing it back to the pole position of the baby race.
Accelerated economic growth is expected to be propelled by the demographic dividend of a mostly young population over the next three decades. That will materialise only if a healthy, educated and skilled population is productively employed. Commitment to create a healthy society must take into account not only the health services needed by the population but also the social, economic, environmental and commercial determinants of health. Poverty, gaping income and gender inequalities, lack of assured access to education and employment are major barriers to promotion of population health and protection of individual health.
Threats to health security include microbial infections that can lead to epidemics or even pandemics or become menacing in an endemic form (TB, malaria, etc). This is aggravated by anti-microbial resistance. Even as we appear to be slowly escaping from the python-like coils of a prolonged pandemic, new microbial threats—epidemic or endemic—confront us, demanding greater alacrity in prevention, efficiency in surveillance and effectiveness of treatments.
Climate change poses health threats due to severe heat, extreme weather events, water and nutrition insecurity, escalated threat of vector-borne and water-borne infections, a wide spectrum of non-communicable diseases, mental health disorders caused by climate stress and forced migration (climate refugees).
Food and agriculture systems that promote nutritionally-inappropriate diets—high consumption of ultra-processed foods, with less affordable fruit, vegetables and good protein sources—endanger population health by escalating cardio-metabolic risks and eroding innate immunity, Environmental pollution is another threat that operates at the societal level. Lack of road safety threatens individual health when inadequate or inefficient social safeguards create poor roads, permit unregulated traffic flows and condone high-risk behaviour by vehicle users and pedestrians while denying them safe travel tracks. Conflict endangers physical and mental health. A weak health system worsens health insecurity at the population level, unable to provide easily accessible, affordable and high-quality services.
These population-level determinants are amplified by social determinants operating at the individual level—education, income, occupation, gender, health and nutrition, literacy, social status and participation in social networks. The interplay of population- and individual-level determinants of health shapes personal vulnerability to communicable and non-communicable diseases, different forms of malnutrition, mental health disorders and high-risk behaviour like tobacco addiction and alcohol abuse. India is experiencing a progressive health transition where non-communicable diseases are by now the leading causes of death and disability, often striking in the prime of productive mid-life. Accidents too are contributing to a rising health burden, while infectious diseases as well as maternal and child health challenges still demand committed health system responses.
Covid-19 has delivered several clear messages: (1) we need an efficient, equitable and empathetic health system functioning in the steady state, to generate a swift, strong and sustained response to a public health emergency; (2) comprehensive primary health care (CPHC) is the foundational base of competent health services; (3) CPHC must be community-centric, delivering services at home/close to home (4) primary care must be bidirectionally and seamlessly connected to secondary and tertiary care through efficient referral systems, telemedicine and emergency transport; (5) universal health coverage (UHC) must make quality-assured care widely available and easily accessible, combining horizontal equity (common services to all people) and vertical equity (additional services or additional cost coverage to vulnerable sections of the population); and (6) a multi-skilled, tech-enabled and well distributed health workforce is essential for delivering entitled services.
The Ayushman Bharat programme has elements of such a health system design. CPHC is led by rural and urban Health and Wellness Centres (horizontal equity). The Pradhan Mantri Jan Arogya Yojana (PMJAY) provides cost coverage for hospitalised secondary/tertiary care to vulnerable sections (vertical equity). Financial protection for healthcare now must be extended to other sections of the population vulnerable to catastrophic health spending. The Health Infrastructure Mission aims to strengthen primary care, build a countrywide pathogen and disease surveillance system, create capacity for critical care at secondary and tertiary levels, and boost research. Upgradation of district hospitals as training centres for doctors, nurses and allied health professionals will help reduce regional disparities. The Digital Health Mission seeks to energise tele-health services, invigorate data collection and analysis while enabling ‘point of care’ diagnostics. When cohesively connected across the country, this composite architecture can create an efficient health system.
Higher levels of public financing are needed to achieve this. Strengthened public provision, together with health insurance, will couple service entitlements with promise of financial protection. Strengthening all elements of the health system (infrastructure, work force, drugs & equipment, technology, information and management systems and community connectivity) will help to create the delivery vehicle for UHC. Multi-sectoral action on social determinants of health will, along with UHC, provide holistic health assurance to India’s 1.4 billion+ population. This needs political will and professional skill. Crossing the 1.4 billion mark in the 75th year of India’s Independence should inspire us to make that commitment.
(The writer is cardiologist and epidemiologist, and president, Public Health Foundation of India. Views are personal.)