GS Notes

22. Social Justice Notes 04

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Elaborate Notes

Concept of Good Health

The understanding of health has evolved from a purely biomedical model to a holistic, socio-ecological concept.

  • World Health Organization (WHO) Definition: In the preamble to its constitution in 1948, the WHO defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition was groundbreaking as it broadened the scope of health beyond the absence of illness to include positive well-being across multiple dimensions.
  • Manifestations of Good Health:
    • Economic Good: Good health is a critical component of human capital. A healthy workforce is more productive, leading to economic growth.
      • Historical Context: Economists like Amartya Sen in his work “Development as Freedom” (1999) have argued that health is a fundamental “capability” that enables individuals to achieve their potential and contribute to the economy.
      • Example: A healthy population reduces the economic burden of disease through lower direct costs (medical treatment) and indirect costs (loss of workdays). Studies by the World Bank have consistently shown a strong positive correlation between public health expenditure and GDP growth in developing nations.
    • Social Good: Health is intrinsically linked to social development and equity.
      • Explanation: A healthy society fosters better social cohesion and development. For instance, healthy children have better cognitive development and learning outcomes, as researched by scholars like Jean Drèze and Amartya Sen in “An Uncertain Glory: India and its Contradictions” (2013). Improved health reduces social inequalities, as ill-health disproportionately affects marginalized communities, pushing them further into poverty.
    • Political Good: Health is a prerequisite for a functioning democracy.
      • Explanation: A healthy citizenry is more likely to participate in political processes, from voting to community engagement. Poor health can lead to political apathy and marginalization, weakening democratic institutions. Ensuring health for all is also a key responsibility of a welfare state, reflecting its political commitment to its citizens.
    • Ecological Good: This modern perspective, often termed the “One Health” approach, recognizes the interconnectedness of human health, animal health, and the health of the ecosystem.
      • Example: The emergence of zoonotic diseases like COVID-19 and Nipah virus underscores how environmental degradation and unsustainable consumption patterns can directly impact human health. The health of the population is dependent on a healthy environment providing clean air, water, and food.

Issues with respect to the Health Care System in India

India’s healthcare system is a complex mix of public and private players, plagued by systemic challenges that hinder the goal of universal health coverage.

  • Lack of Infrastructure and Workforce:
    • Doctor-Population Ratio: While the Ministry of Health and Family Welfare states the ratio is 1:834, surpassing the WHO recommendation of 1:1000, this is a national average that masks severe disparities.
    • Rural-Urban Divide: A NITI Aayog Report highlighted that approximately 80% of doctors, 75% of dispensaries, and 60% of hospitals are concentrated in urban areas where only about 30% of the population resides. This creates a critical lack of qualified medical professionals in rural India.
    • Qualification Crisis: A WHO report (2016) pointed out that in 2001, 57.3% of allopathic doctors in India did not have a medical qualification. This highlights the widespread issue of unqualified practitioners or “quacks,” particularly in rural and semi-urban areas.
  • Dominance and Under-regulation of the Private Sector:
    • Scale: The private sector caters to about 70% of outpatients and 60% of inpatients.
    • Regulatory Gap: The Clinical Establishments (Registration and Regulation) Act, 2010 was enacted to regulate standards in both public and private health facilities. However, since ‘Health’ is a State Subject under the Seventh Schedule of the Constitution, the adoption and enforcement of the Act have been inconsistent across states, leading to a lack of uniform quality and pricing standards.
    • Out-of-Pocket Expenditure (OOPE): Due to the high cost of private healthcare and low insurance penetration, India’s OOPE on health is around 47.1% (National Health Accounts Estimates 2019-20). This is one of the highest in the world and a primary driver of medical-induced poverty, pushing millions of households below the poverty line each year.
  • Systemic Weaknesses:
    • Weak Primary Healthcare: The foundation of the healthcare system is weak. This leads to an increased burden on secondary and tertiary hospitals, which are often overcrowded with patients suffering from conditions that could have been managed or prevented at the primary level. This reflects under-investment in promotive and preventive care.
    • Implementation Gaps: Schemes like Pradhan Mantri Jan Arogya Yojana (PM-JAY) face challenges due to the poor state of public health infrastructure, especially in rural areas, forcing beneficiaries to rely on private hospitals.
    • Absence of Medical Ethics: Issues like ‘provider-induced demand’ (unnecessary tests, procedures, and medications) and the preference for prescribing expensive branded medicines over cheaper generic ones are rampant. A report by the Central Drugs Standard Control Organisation (CDSO) found that about 4.5% of all generic drugs tested were substandard, raising quality concerns that deter their prescription.
  • Pharmaceutical and R&D Issues:
    • API Dependence: India’s pharmaceutical industry, often called the ‘pharmacy of the world’, is critically dependent on China for about 70% of its Active Pharmaceutical Ingredients (APIs) or bulk drugs. This dependency creates supply chain vulnerabilities, as witnessed during the COVID-19 pandemic.
    • Low R&D: Investment in pharmaceutical and medical research and development remains low compared to global standards, hindering indigenous innovation.
  • Operational and Social Challenges:
    • Lack of Integrated Systems: The absence of a robust, integrated Health Management Information System (HMIS) prevents effective data collection, planning, and monitoring. The Integrated Disease Surveillance Programme (IDSP) has often been dysfunctional due to a lack of manpower and resources, limiting its ability to detect and respond to outbreaks effectively.
    • Low Insurance Penetration: As per the Insurance Regulatory and Development Authority (IRDA), a significant portion of the population lacks health insurance coverage (pre-Ayushman Bharat data indicated around 80% uninsured).
    • Emerging Health Issues: The system is ill-equipped to handle the growing burden of non-communicable diseases (NCDs), geriatric care, mental health issues, and lifestyle diseases.
    • Health-related Taboos: Social stigma surrounding issues like mental health, sexual and reproductive health, and HIV/AIDS prevents people from seeking timely care and perpetuates superstitious practices.

Tiers of Healthcare Systems

India’s public healthcare system is structured in three tiers to provide a continuum of care.

  • Primary Healthcare: This is the first point of contact for individuals and the community with the health system.
    • Historical Context: The vision for primary healthcare was globally articulated in the Alma-Ata Declaration of 1978, which called for “Health for All” and emphasized community participation, appropriate technology, and inter-sectoral coordination.
    • Components: The focus is on preventive and promotive health. The UNICEF-promoted strategy GOBI-FFF encapsulates key elements: Growth monitoring, Oral rehydration therapy, Breastfeeding, Immunization, Family planning, Female education, and Food supplementation.
    • Challenges in Primary Healthcare:
      1. Underfunding: The National Health Policy, 2017, recommends that at least two-thirds of government health expenditure be allocated to primary care, but this target remains unmet.
      2. Epidemiological Transition: PHCs were designed primarily for communicable diseases and RCH, but they are now facing a rising burden of non-communicable diseases (e.g., diabetes, hypertension) without adequate training or resources. Ayushman Bharat Health and Wellness Centres (AB-HWCs) are an attempt to address this gap.
      3. Trust Deficit: Poor infrastructure, absenteeism of doctors, and lack of medicines have created a deficit of trust, leading people to bypass PHCs and go directly to private providers or higher-level public hospitals.
      4. Governance: A top-down, bureaucratic approach often ignores local needs and social determinants of health, leading to ineffective planning and implementation.

SDG 3: “Ensure healthy lives and promote well-being for all at all ages.” It sets specific targets to be achieved by 2030.

  • Key Targets:
    • Reduce the global Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births.
    • End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases.
    • Reduce premature mortality from non-communicable diseases by one-third.
    • Strengthen the prevention and treatment of substance abuse.
    • Halve the number of global deaths and injuries from road traffic accidents.
    • Ensure universal access to sexual and reproductive healthcare services.
  • Government Efforts Aligned with SDG 3:
    • Maternal and Child Health:
      • Pre-Natal: Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) for antenatal care.
      • Peri-Natal: Janani Suraksha Yojana (JSY) to promote institutional deliveries.
      • Post-Natal: Janani Shishu Suraksha Karyakram (JSSK) to provide free care to mother and infant.
      • Comprehensive Strategy: The RMNCH+A (Reproductive, Maternal, Newborn, Child, and Adolescent Health) strategy adopts a life-cycle approach.
    • Universal Health Coverage (UHC): Ayushman Bharat, with its two pillars—Health and Wellness Centres (HWCs) for primary care and PM-JAY for secondary/tertiary care hospitalization insurance—is India’s flagship program for achieving UHC.
    • Communicable Diseases: Swachh Bharat Mission (improving sanitation) and Jal Jeevan Mission (safe drinking water) address the root causes of many water-borne diseases. The National AIDS Control Programme is another key initiative.
    • Affordable Healthcare: Pradhan Mantri Bhartiya Janaushadhi Pariyojana promotes the use of generic medicines to reduce costs.

Digitalization of Healthcare Infrastructure

Leveraging technology is seen as a key strategy to overcome systemic gaps.

  • Prospects:
    • Bridging Resource Gaps: Telemedicine can connect specialists in urban centers with patients in remote areas, optimizing the use of the existing workforce.
    • Evidence-Based Policy: The Ayushman Bharat Digital Mission (ABDM) aims to create a longitudinal Electronic Health Record (EHR) for every citizen, which can provide valuable data for policymaking and research.
    • Portability & Efficiency: Digital health IDs and records ensure that a patient’s medical history is accessible to any provider across the country, ensuring continuity of care.
    • Examples: Platforms like eSanjeevani (telemedicine), e-pharmacies, and the CoWIN portal for vaccination have demonstrated the potential of digital health.
  • Challenges:
    • Federal Structure: Since ‘Health’ is a state subject, ensuring nationwide adoption and interoperability of digital systems is a major challenge.
    • Digital Divide: Lack of internet access, digital literacy, and smartphone penetration, especially in rural and remote areas, can exacerbate existing inequalities.
    • Data Security and Privacy: Storing sensitive health data requires a robust legal framework for data protection and privacy, which is still evolving in India.

Mental Healthcare

Mental health has long been a neglected area in Indian public health discourse.

  • WHO Definition: Mental health is “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.”
  • Burden of Disease: The WHO estimates that mental illness accounts for about 15% of the total disease burden globally. In India, the National Mental Health Survey (2015-16) revealed that nearly 150 million Indians needed mental health interventions, but the treatment gap was over 70%.
  • Legislative Framework: The Mental Healthcare Act, 2017, marked a paradigm shift from a custodial to a rights-based approach. It decriminalized suicide, guaranteed the right to access mental healthcare, and mandated the provision of a wide range of services. However, its implementation remains a challenge due to a severe shortage of mental health professionals and inadequate funding.

Prelims Pointers

  • WHO Definition of Health (1948): A state of complete physical, mental, and social well-being, not merely the absence of disease.
  • Doctor-Population Ratio: WHO recommendation is 1:1000. As per the Indian Health Ministry, the ratio in India is 1:834.
  • Private Sector Dominance: Accounts for ~70% of outpatient (OPD) care and ~60% of inpatient (IPD) care.
  • Out-of-Pocket Expenditure (OOPE): Stands at 47.1% of total health expenditure in India (NHA 2019-20).
  • Key Legislation: Clinical Establishments (Registration and Regulation) Act was passed in 2010.
  • Constitutional Provision: ‘Health and sanitation’ is a State Subject under the Seventh Schedule.
  • Substandard Drugs: As per the CDSO, 4.5% of all generic drugs are identified as substandard.
  • Insurance Penetration: According to IRDA, before the launch of PM-JAY, only about 17% of the population had some form of health insurance.
  • National Health Policy (2017): Recommends allocating at least two-thirds of the government health budget to primary healthcare.
  • Alma-Ata Declaration (1978): A global declaration on Primary Health Care, with the goal of “Health for All.”
  • GOBI-FFF: A primary healthcare strategy focusing on Growth monitoring, Oral rehydration, Breastfeeding, Immunisation, Family planning, Female education, and Food supplementation.
  • SDG for Health: SDG 3 aims to “Ensure healthy lives and promote well-being for all at all ages.”
  • Ayushman Bharat Scheme:
    1. PM-JAY: Pradhan Mantri Jan Arogya Yojana.
    2. Insurance Cover: Provides health insurance of ₹5 lakh per family per year.
    3. HWC: Health and Wellness Centres, the primary care pillar.
  • ABDM: Ayushman Bharat Digital Mission, aimed at creating a unified digital health infrastructure.
  • Mental Healthcare Act: Enacted in 2017, it decriminalized suicide and adopted a rights-based approach to mental healthcare.
  • Key Government Schemes:
    • JSY: Janani Suraksha Yojana (maternity).
    • JSSK: Janani Shishu Suraksha Karyakram (mother and child).
    • RMNCH+A: Reproductive, Maternal, Newborn, Child, and Adolescent Health.

Mains Insights

The Curative vs. Preventive Healthcare Dichotomy

  1. Cause-Effect Relationship: India’s healthcare system has historically been “curative-focused,” with a majority of public spending directed towards tertiary care hospitals in urban centers. This underinvestment in preventive and primary healthcare (clean water, sanitation, nutrition, immunization, basic clinics) leads to a high burden of preventable diseases. Consequently, secondary and tertiary hospitals are overburdened, leading to inefficiency and poor outcomes.
  2. Economic Angle: As per the Economic Survey, investing in preventive healthcare is more cost-effective. Every rupee spent on Swachh Bharat Mission (sanitation) is estimated to yield a significant return in terms of reduced disease burden and health costs. A shift towards a “wellness” model from an “illness” model is economically prudent.
  3. Way Forward: The establishment of 1.5 lakh Health and Wellness Centres (HWCs) under Ayushman Bharat is a policy shift towards comprehensive primary care, including screening for non-communicable diseases. The success of this initiative is crucial to rebalancing the healthcare system.

Challenges of Universal Health Coverage (UHC) in the Indian Context

  1. The UHC Model: Universal Health Coverage means all individuals receive the health services they need without suffering financial hardship. Ayushman Bharat (PM-JAY) is an insurance-based model to achieve UHC.
  2. Prospects: PM-JAY aims to provide financial protection to over 50 crore beneficiaries, potentially saving millions from catastrophic health expenditures. It leverages the private sector’s capacity to expand service delivery.
  3. Challenges & Debates:
    • Infrastructure Deficit: An insurance scheme is only as good as the healthcare infrastructure available. In many parts of rural India, there are no empanelled hospitals, making the insurance card useless. Strengthening public health infrastructure is a prerequisite for the success of PM-JAY.
    • Regulation of Private Sector: Without strong regulation of prices and quality in the private sector, there is a risk of cost escalation, unnecessary procedures, and fraud, which could make the scheme financially unsustainable. The implementation of the Clinical Establishments Act is critical.
    • Exclusion of Primary Care: The insurance model primarily covers hospitalization (secondary and tertiary care), neglecting the crucial aspects of outpatient care and preventive services, which form the bulk of health needs and OOPE. While HWCs are meant to address this, their integration with PM-JAY needs to be seamless.

Federalism and Health Governance

  1. Constitutional Challenge: Since ‘Health’ is a State Subject, the Central government’s role is largely advisory and financial. This creates significant challenges in implementing uniform national health programs. States have varying capacities, political will, and health priorities.
  2. Historiographical Viewpoint: The centralizing tendency of some national health schemes has been criticized for adopting a ‘one-size-fits-all’ approach, ignoring local contexts. Conversely, complete decentralization can lead to widening regional inequalities in health outcomes.
  3. Path Forward - Cooperative Federalism: A collaborative approach is essential. The Centre can focus on providing funds (e.g., through centrally sponsored schemes), setting standards, and fostering technology adoption. States should have the flexibility to adapt programs to their specific epidemiological and socio-economic contexts. Institutions like the NITI Aayog can serve as platforms for Centre-State dialogue and knowledge sharing.

Digital Health: Prospects and Perils

  1. Analytical Perspective: The Ayushman Bharat Digital Mission (ABDM) is a transformative initiative with the potential to create an efficient, transparent, and patient-centric healthcare ecosystem. Evidence-based policymaking, continuity of care, and telemedicine are significant benefits.
  2. Associated Risks (GS Paper II/III):
    • Right to Privacy: The collection and storage of sensitive personal health data raise profound privacy concerns. The Supreme Court’s verdict in the Puttaswamy case (2017), which declared privacy a fundamental right, forms the legal backdrop. A robust Data Protection Law is imperative.
    • Exacerbating Inequality: The ‘digital divide’—disparities in access to technology and digital literacy—could mean that the benefits of digital health accrue primarily to the urban and educated elite, leaving the most vulnerable behind. A strategy to ensure digital inclusion is necessary.
    • Data Security: The risk of data breaches and cyber-attacks on health databases is a significant national security and individual safety concern. Robust cybersecurity infrastructure is a non-negotiable prerequisite.

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