Karnataka state recently celebrated the 61st Rajyotsava day on November 1st. While the state has made great strides in different areas of human endeavor, one needs to use this occasion to learn from the past and think through and strategize for the next 40 years. One of the critical elements for the progress of any state or country is the status of health of its citizens. It is here that we need to understand that the state of Karnataka could have done better keeping in mind what we as a people and a state are capable of. The human capital of the state is extremely critical for overall progress and we need to ensure that public expenditures from the current levels of less than 1% today is substantially increased. The State needs a health policy that is evolved from a systems thinking and an approach that takes into account all elements of the health care eco-system in order to ensure health care of its citizens decades from now.
De-medicalizing the health care system: Medical care is only a sub-set of health care and the perspective and practice that medical professionals should be at the helm of all health programs must be changed. Health is an area which has ample scope and in dire need for non-medical professionals with different skills and knowledge to participate in. For instance, a campaign on safe drinking water could be better managed and led by officers with skills in mass communication and in handling logistical challenges than physicians. ‘De-medicalization’ of health care by introducing people from disciplines and backgrounds in the ambit of public health must be a priority. This move can solve the problem of shortage of doctors while at the same time bring down the cost of providing health care too. The state should also consider bringing in an alternate model of training Physician Assistants who can be an intermediary service provider and reduce the dependency on a clinician.
Promotion of Integrative medicine: There are more than 70,000 traditional healers in Karnataka and the State’s health care delivery system must be based on knowledge that is inherently embedded in communities. We must look at traditional medicine systems and practices of AYUSH at par with other systems of medicine like Allopathy. Mutual respect for different streams of medicine with a view to genuinely understand the strengths and limitations must be promoted at all levels. Instead of having separate hospitals and health centers for Allopathy and Ayurveda, the state should start having Centers that promote and practice Integrative Medicine.
Streamlining Insurance Schemes: Schemes and programs towards making health care accessible to poorer sections of our population through insurance coverage have been introduced over the past years. However studies indicate that the poor families still have to bear out-of-pocket expenses and not all ailments are fully covered. There are evidences of gaps in pro-poor targeting mechanisms of programs such as Rashtriya Swasthya Bima Yojana and Yashasvini Scheme. This indicates that health coverage is implemented primarily from an insurance provider perspective and not the user’s perspective. Health coverage schemes must be designed with ‘eliminating the possibility of any individual being denied medical treatment for want of funds’ as their core objective and multiple insurance schemes of the state must be integrated into one master scheme.
Addressing regional disparities: Despite the efforts of the Govt., we still lack equitable distribution of health care services and regional disparities exist at all levels. Planning mechanisms must take into account disease burdens and other health characteristics of the districts or regions so that the resultant plans reflect the disaggregated focus that allows lagging or vulnerable districts to improve. A change in the funding pattern to the districts is needed, especially in terms of moving away from ‘facility-based’ funding to ‘need-based’ funding. As a result of facility-based funding, districts with greater needs and lesser facilities end up getting lesser funds than districts with lesser needs but higher number of facilities. The southern districts of the state have more than the required number of PHCs while the northern ones have significantly lesser numbers. Rationalizing the location of the PHCs based on the population and usage criteria will help reduce the inequity in infrastructure and also bring down the total number of PHCs from 2200 today to the required number of 1750.
Limiting the ‘verticalization’ of health department: We must put an end to the process and practice of creating disease-focused verticals in the health department and adopt an integrated approach to disease control. While there is no denying that prevention and control of diseases such as HIV/AIDS, TB, Malaria, etc. are huge challenges on their own and special emphasis is needed on them, disease-focused programs also create functional and administrative stress on a system. Disease control mechanisms can be effective only when convergence is established at the macro level and implemented through the existing primary care delivery system.
Strengthening community monitoring: The National Health Mission places a great emphasis on community participation in health, but the efforts to support it on the ground is a mixed affair. There is evidence to suggest that a sustained effort in strengthening community monitoring results in greater transparency and accountability at the grassroots level and generates local, cost-effective solutions to issues. Community monitoring and social accountability processes must go beyond the customary lip-service and should be integrated into the health care system itself.
Preparing for the ageing population: Currently, India can boast of its demographic dividend, but the increase of ageing population resulting in higher dependency ratios are a prospect Karnataka will face in the not-so-distant future. The burden of non-communicable diseases is also increasing and this coupled with the problems of aging needs special focus and attention.
Emphasis on Palliative Care: Palliative care is also a huge public health challenge and the recently announced Palliative care policy is a welcome move. One must recognize that palliative care is not just cancer care, but includes all chronic, incurable and progressive neurological, cardiac, respiratory, AIDS and other diseases. With the rise in ageing population, patients needing palliative care will only increase and the public health care delivery system must be prepared for this.
Integrating mental health into mainstream public health: WHO has predicted that 20% of the state’s population will suffer from some form of mental illness by 2020. There is a great need for pooling together resources to address mental health issues, awareness creation, and capacity building both in terms of curative and preventive aspects as well as breaking taboos and stigma.
Reforms and regulation of private sector participation in health: With less than 20% of infrastructure in their hands, private medical establishments are catering to more than 60% of people in need of medical care. This poses a huge quality challenge and appropriate regulation of the private sector accompanied by strengthening of public health care institutions is needed. At the same time, private sector contribution to health care must not be undermined and efforts must be made to include private sector players in dialogues on the nation’s health priorities and enhance their role in addressing the same.
A good policy with a long term strategic focus will be meaningless if the existing system is not geared up to deliver on the same. The capacities of the people in the public health system needs to be built and people should be held accountable for not delivering on key milestones that will have to be fixed for the short, medium and long terms. The need of the hour is to have an Ombudsman who can oversee and monitor this and ensure that the future of the people is both healthy and in safe hands.