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Strategy for New India at 75:Inclusion- Public Health Management and Action

  • On 15th August 2022, independent India will turn 75. In the lifespan of nations, India is still young. The best is surely yet to come. India’s youthful and aspirational population deserves a rapid transformation of the economy, which can deliver double-digit growth, jobs and prosperity to all.
  • The purpose of this, ‘Strategy for New India @ 75’, is to define clear objectives for 2022-23 in a  diverse range of 41 areas that recognize the progress already made; and challenges that remain; identify binding constraints in specific sectors; and suggest the way forward for achieving the stated objectives. 
  • The Strategy document has disaggregated the 41 sectors under four sections: drivers, infrastructure,  inclusion, and governance. 
  • The first section on drivers focuses on the engines of economic performance – in macroeconomic terms with chapters on growth and employment.
  • The section also discusses strategies for the doubling of farmers’ incomes; boosting Make in India; upgrading the science, technology and innovation ecosystem; and promoting sunrise sectors like fintech and tourism.
  • An annual rate of growth of 9 per cent by 2022-23 is essential for generating sufficient jobs and achieving prosperity for all. Four key steps, among others, have been spelled out for achieving this GDP growth rate. These are:

a. Increase the investment rate as measured by gross fixed capital formation (GFCF) from present 29 per cent to 36 per cent of GDP by 2022. About half of this increase must come from public investment which is slated to increase from 4 per cent to 7 per cent of GDP. Government savings have to move into positive territory. This sharp increase in the investment-to-GDP ratio will require significantly higher resource mobilization efforts as elaborated in the chapter on Growth.

b. In agriculture, emphasis must shift to converting farmers to ‘agripreneurs’ by further expanding e-National Agriculture Markets (e-NAMs) and replacing the Agricultural Produce Marketing Committee  (APMC) Act with the Agricultural Produce and Livestock Marketing (APLM) Act. The creation of a unified national market, a freer export regime and the abolition of the Essential Commodities Act are essential for boosting agricultural growth.

c. A strong push would be given to ‘Zero Budget Natural Farming (ZBNF) techniques that reduce costs,  improve land quality and increase farmers’ incomes. This is a tested method for putting environmental carbon back into the land. Therefore, ZBNF allows India to significantly contribute to reducing the global carbon footprint.

d. To ensure maximum employment creation, codification of labour laws must be completed and a massive effort must be made to upscale apprenticeships.

  • The second section on infrastructure deals with the physical foundations of growth. A lot of progress has been made across all infrastructure sectors. This is crucial to enhancing the competitiveness of Indian business as also ensuring the citizens’ ease of living. Three key steps, among others, are:

a. Expediting the establishment of the Rail Development Authority (RDA), which is already approved. RDA  will advise or make informed decisions on an integrated, transparent and dynamic pricing mechanism for the railways. Investment in railways will be ramped up, including by monetising existing railway assets.

b. The share of freight transported by coastal shipping and inland waterways will be doubled. Initially,  viability gap funding will be provided until the infrastructure is fully developed. An IT-enabled platform would be developed for integrating different modes of transport and promoting multi-modal and digitised mobility.

c. With the completion of the Bharat Net programme in 2019, all 2.5 lakh gram panchayats will be digitally connected. In the next phase the last mile connectivity to the individual villages will be completed. The aim will be to deliver all government services at the state, district, and gram panchayat level digitally by  2022-23, thereby eliminating the digital divide.

  • The section on inclusion deals with the urgent task of investing in the capabilities of all of India’s citizens. The three themes in this section revolve around the various dimensions of health, education and mainstreaming of traditionally marginalized sections of the population. While there are multiple dimensions and pathways  contained in the chapters in this section, four key steps, among others, are:

a. Successfully implementing the Ayushman Bharat programme including the establishment of 150,000  health and wellness centres across the country, and rolling out the Pradhan Mantri Jan Arogya  Abhiyaan.

b. Upgrading the quality of the school education system and skills, including the creation of a new innovation ecosystem at the ground level by establishing at least 10,000 Atal Tinkering Labs by 2020.

c. As already done in rural areas, affordable housing in urban areas will be given a huge push to improve workers’ living conditions and ensure equity while providing a strong impetus to economic growth.

d. Implementing strategies to achieve regional equity by focusing on the North-East region and successfully rolling out the Aspirational Districts Programme.

  • The final section on governance delves deep into how the tasks/business of government can be streamlined and reformed to achieve better outcomes. It involves a sharp focus on ensuring accountability and a shift to performance-based evaluation.
  • The government will revamp its data systems and analysis so that all policy interventions and decision-making are based on evidence and real-time data. This will yield efficient and

targeted delivery of services and justice to those who need them the most.

  • Three key steps, among others, are:

a. Implementing the recommendations of the Second Administrative Reforms Commission as a prelude to appointing a successor for designing reforms in the changing context of emerging technologies and the growing complexity of the economy.

b. A new autonomous body, viz., the Arbitration Council of India, may be set up to grade arbitral institutions and accredit arbitrators to make the arbitration process cost-effective and speedy, and to pre-empt the need for court intervention.

c. The scope of the Swachh Bharat Mission may be expanded to cover initiatives for landfills, plastic waste and municipal waste and generating wealth from waste.

  • To achieve the goals of New India in 2022-23, it is important for the private sector, civil society and even individuals to draw up their own strategies to complement and supplement the steps the government intends to take. With the available tools of 21st-century technology, it should be possible to truly create a mass movement for development. With the Sankalp of all Indians, India will have Siddhi.

Check out our previous blogs on the Strategy for New India at 75:

Objectives

To revamp radically the public and preventive health system in the nation through the following strategic interventions:

  • Mobilize public health action through an integrated, inter-sectoral, and pan-stakeholder approach, targeted at communities and individuals as well as grassroots organizations, aimed at creating an unprecedented people-led movement for health and wellness.
  • Operationalize vital enablers –

a) public health and management cadre,

b) public health agency with capacitated supporting institutions

(c) municipalities and Panchayati raj institutions

.

Current Situation

  • Public health, i.e., the science of keeping communities healthy through the prevention of disease and promotion of health and wellness, has historically been a low priority in India. Of the total current expenditure on health classified by healthcare functions, preventive care accounts for 6.7 per cent. The money spent on curing people, on the other hand, is 51 per cent of the expenditure with the remaining money being spent on pharmaceuticals, other medical goods and patient transportation.
  • Although India accounted for only 18 per cent of the global population in 2016, we accounted for 34 per cent of the global tuberculosis burden and 26 per cent of the premature mortality due to diarrhea, lower respiratory and other common infectious diseases.
  • At the same time, non-communicable diseases (NCDs), including cardiovascular conditions, chronic obstructive respiratory diseases, diabetes, mental health conditions and cancers are now the leading cause of health loss, with 55 per cent morbidity and premature mortality attributable to these conditions. The range of health loss across states is wide. Kerala and Goa have the lowest rates while Assam, Uttar Pradesh, and Chhattisgarh have the highest rates.
  • Public health action and management is a scientific and professional endeavour that should not be left to untrained employees relying on common sense alone.

A suboptimal public health system:

  • Makes it challenging to tackle NCDs, which, in the first place, is all about prevention and early detection.
  • Causes us to resort to high-cost secondary and tertiary health care in many cases.
  • Diminishes our preparedness for new and emerging threats such as bioterrorism.
  • Compromises our ability to harness the demographic dividend.

The nations with whom we compete or aspire to emulate have achieved health and wellness outcomes on the foundation of strong public health systems. Thus, it is an absolutely essential

ingredient for building a New India.

During the last four years, the government has taken several steps to strengthen public health

in the country including the launch of Mission Indradhanush and Intensified Mission

Indradhanush as well as the National AYUSH Mission. Efforts have also been intensified for eliminating Neglected Tropical Diseases like Kala-Azar and Lymphatic Filariasis.

Further, the war against Tuberculosis has been escalated through the launch of the National

Strategic Plan in 2017.

Constraints

  1. Diseases need to be prevented first, a concept that has historically been inadequately acknowledged in India. The large burden of NCDs requires lifestyle and community-level interventions. Ensuring people eat right, sleep right, maintain good hygiene, exercise, and adopt a healthy lifestyle necessitates concerted interventions at various levels of the system.
  2. In most states, population health management positions are staffed by doctors, trained primarily in the provision of curative services, or by generalist civil servants. They have limited public health training, which includes an understanding of the causes and linkages between risk factors and diseases as well as disciplines including epidemiology, biostatistics, social and behavioural sciences, and management of health services. Likewise, hospitals are run by clinicians with little expertise in managing health facilities.
  3. The following preventable risk factors are causes for a major proportion of diseases in the country: maternal and child malnutrition, air pollution, unhealthy diets, high blood pressure, high blood glucose, tobacco consumption, unsafe water, and poor sanitary practices; of these, nutrition, environment, water and sanitation are outside the purview of the health ministry. Therefore, accountability for ensuring vital public health actions is spread thin.
  4. There is no single authority responsible for public health that is legally empowered to enforce compliance from other public authorities and citizens, even though several factors may require inter-sectoral action to achieve a measurable impact on population health.

Way Forward

  1. Mobilize public health action at multiple levels
  • Public funding on health should be increased to at least 2.5 per cent of GDP as envisaged in the National Health Policy, 2017.
  • Create an environment, through appropriate policy measures, that encourages healthy choices and behaviours:

O Make the practice of yoga a regular activity in all schools through certified instructors.

O Increase taxes on tobacco, alcohol and unhealthy foods such as soda and sugar-sweetened beverages.

O Co-locate AYUSH services in at least 50 per cent of primary health centres, 70 per cent of community health centers and 100 percent of district hospitals by 2022-23.

  • Strengthen the Village Health Sanitation and Nutrition Day platform to cover a broader set of health issues across various population groups instead of only focusing on child health.
  • Activate multiple channels (schools, colleges, women’s groups, traditional events like fairs, social media platforms, National Cadet Corps, etc.) and prepare communication materials for catalysing behavioural change towards greater recognition of preventive health care.
  • Make nutrition, water and sanitation part of the core functions of panchayati raj institutions and municipalities.
  1. Institute a public health and management cadre in states

Incentivize state governments to invest in creating a dedicated cadre for public health at the state, district, and block levels:

  • Characteristics of the cadre

O Train officials in public health-related disciplines including epidemiology, biostatistics, demography and social and behavioural sciences.

O Provide training in hospital management to suitably equip personnel responsible for managing large facilities.

O Create a career pathway up to the highest levels within the state health departments for those trained in public health, as well as for those with clinical specialties.

O Allow mid-level providers responsible for managing health and wellness centres delivering comprehensive primary healthcare to rise to higher-level positions within the cadre. Similarly, allow public health functionaries at the block and district levels to enter the cadre.

O Mandate a master’s level qualification, in addition to specified training, for officials taking on leadership positions.

  • Institutional mechanisms

O Develop a model public health and management cadre by drawing upon best practices and engage with states to adapt, refine and institutionalize the model.

O Formulate guidelines to create the cadre, primarily by re-aligning the requisite skill sets of existing functionaries with service conditions.

  1. Create a focal point for public health at the central level with state counterparts
  • Create a designated and autonomous focal agency with the required capacities and linkages to perform the functions of disease surveillance, information gathering on the health impact of policies of key non-health departments, maintenance of national health statistics, enforcement of public health regulations, and dissemination of information to the public. An appropriately empowered and capacitated National Centre for Disease Control may be considered to play this role with support from relevant organizations.
  • Create a counterpart Public Health Agency in each state, where they do not already exist.
  1. Miscellaneous
  • Explore the need for a Public Health Act to legislatively empower and, if necessary, institutionalise the Public Health Agency discussed above.
  • Redefine the role of the technical directorate (Directorate General of Health Services) and create a Directorate of Public Health.
  • Develop a comprehensive MIS including baseline data for NCDs.