Public health needs a public revolution

People need to play a larger role for public health care schemes to bear fruit

The World Health Organisation came in to being 70 years ago with the objective of “attainment by all peoples of the highest possible level of health”. A few months earlier, India had turned independent. At the time, the average life expectancy of Indians was 32 years, a figure which has doubled. Infant mortality rate and maternal mortality rate have decreased since Independence by one-fourth, and one-eleventh, respectively. Of late, there is a growing focus on health in mainstream public discourse courtesy the National Health Protection Mission, which was approved by the Cabinet in March. The Aspirational Districts Programme, and the NITI Aayog Health Index Report have further galvanised the public health sector.

While these endeavors move four of the five policy levers of health which are key for policy specialists to improve health systems -- financing, payment, organisation, and regulation; the fifth lever, which is behaviour, still needs to gather momentum. Behaviour in this context “includes efforts to influence what individuals do in relation to health and health care, including both patients and providers”. This should be further extended to the realm of engaging patients, beneficiaries, and constituents to actively participate in ensuring health delivery, especially from the government.

The right to health is not grounded in a particular enactment, like it is for the right to food in National Food Security Act, 2013, or for the right to transparent governance in the Right to Information Act, 2010. However, in the Paschim Banga Khet Mazdoor Samity versus State of West Bengal (1996), the Supreme Court held that it is the constitutional obligation of the state to provide adequate medical services to the people. All three National Health Policy documents, the latest one released in 2017, focus on health systems strengthening, but little has been written about the professed centre of the health ecosystem — the patient.

To make efforts in public health count, a public revolution is required, wherein the people demand for the “quality” services mentioned in the National Health Mission (NHM), and in the future, in the Ayushman Bharat Scheme (comprising the National Health Protection Mission, and Comprehensive Primary Health Care). There is a provision for Patient Welfare Committees or Rogi Kalyan Samities in NHM, which are registered under the Societies Registration Act, 1860. These Samitis, numbering over 32,000, are associated with all three tiers of government health centres (primary health centres, community health centres, and district hospitals). The purpose is to act “as a group of trustees for the hospitals to manage the affairs of the hospital”. 

A Samiti is headed by the district collector (DC) and has representation from panchayati raj institutions, NGOs etc. The DC can appoint two eminent citizens to the Samiti as well. Funds of Rs 1,75,000 to Rs 5,00,000 are provided per annum, by the government, for the Samitis to take measures to improve the facility and services offered. They can also charge user fees to expand their corpus. While this platform can be used by active citizens, as it also provides for the membership of people who make donations to the Samiti, the platform is facility-centric.

A patient/beneficiary representing body which can demand their health rights from the government has not been seen up. There are disease-focused groups such as the Cancer Patients Aid Association, or small organisations at the level of metro cities such as in Gurugram, Bengaluru, and Pune. All-India or state level organisations need to be set up to ensure that schemes and programmes are implemented successfully. An active, participatory citizenry can lead to improvement in delivery of public health services.

Comprehensive Primary Health Care (a part of the Ayushman Bharat Scheme) will transform 1,50,000 sub-centres — the first point of contact of a patient with the government health system — into health and wellness centres. This will entail an expansion of services from the current focus on reproductive and child health to a package of 12 services that will include geriatric and palliative care, as well as control of non-communicable diseases. This mammoth task can only be successful if demand for the same is voiced — a jan andolan for jan swasthya.

The government's public health system provides for a plethora of behaviour change communication strategies, but the system still needs people to play a larger role. As with all sectors, health needs an active citizenry that will hold the government accountable, only in this case, it is all the more crucial as it is really a matter of life and death. 

The author is a physician, and part of the Young Professional Program, NITI Aayog