India@75 Road to public health has more miles to travel

India’s life expectancy at birth has grown to 70.8 years, from 32 years in 1947. It is a remarkable achievement, when we consider the current global average of 73.3 years.

India@75 Road to public health has more miles to travel
India could have achieved more, if there was greater and more balanced investment in health. (Representational image: PTI)

As India celebrates 75 years of freedom from foreign rule, there is much to cheer for the health gains achieved during this period. There are also many concerns to be addressed and promises yet to be fulfilled. It would be useful to take stock in terms of key health indicators and identify continuing, emerging and escalating health challenges.

India’s life expectancy at birth has grown to 70.8 years, from 32 years in 1947. It is a remarkable achievement, when we consider the current global average of 73.3 years. However, our neighbours like Bangladesh and Nepal have achieved higher life expectancy, while Sri Lanka is even further ahead and is at a level matched only by Kerala in India. What is of greater concern is that healthy life expectancy (years lived in good health) is only 60.3 years in India, according to the World Health Statistics Report of 2021. This places India last in WHO’s grouping of Southeast Asian countries, in that measure of population health. This is a reminder that our health system must not only treat advanced disease but prioritise health promotion, disease prevention and early care of illness.

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India could have achieved more, if there was greater and more balanced investment in health. For several decades, public financing of health stagnated around 0.9-1% of GDP and only in recent years it has moved to 1.35%. While this is short of the 2.5% target set in the National Health Policy of 2017, the economic survey of 2022 computes that the Covid-19 response has raised the share of government spending to 2.1% of GDP. Recent health budgets have included water, sanitation, nutrition and air pollution under the budget head for health, accounting for part of the rise in government health expenditure. Apart from increased capital expenditure on healthcare infrastructure, we must also spend on improving the operational outreach and efficiency of delivering all essential health services.

As India’s life expectancy rose, it has experienced a marked health transition, wherein the epidemiological profile of major public health challenges has changed over the past three decades. Between 1990 and 2019, India’s health transition has been marked, pushing non-communicable diseases (NCDs) to the top, with doubling of attributable disease burden. NCDs now account for 65% of deaths. Nearly two-thirds of those occur below 70 years of age. The pre-transitional disorders declined steeply, with halving of attributable disease burden. Mental health disorders and injuries too presently contribute to high levels of disability.

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Eradication of small pox, yaws and polio have been signal successes for India’s public health. Other infectious diseases like HIV-AIDS and malaria are responding to control programmes, though they remain an active threat. Tuberculosis, with drug resistant strains, is a worrisome challenge. The government’s avowed intent to eliminate tuberculosis by 2025 has been hindered by the Covid-19 pandemic which has heavily consumed the health system’s attention and resources since 2020. We must aim to achieve the elimination of TB by the global timeline of 2030, if not by 2025. A variety of vector borne diseases will grow in menace with global warming, while extreme climatic events will increase the threat of water borne infections. There will be continued need for attention to communicable diseases, even as NCDs are on the ascendant.

Health of women and children has been an area of great concern as the rates of infant, child and maternal mortality were extremely high for several decades. The decline was markedly accelerated after the initiation of the National Rural Health Mission in 2005. Maternal mortality rate is still 113 per 100,000 live births, with six states exceeding 150, while the global goal set for 2030 is 70. The current trajectory of decline in maternal and under-5 child mortality rates appear capable of taking us close to the 2030 targets set by the Sustainable Development Goals (SDGs) but neonatal mortality rates still need energetic action by health and social systems. The high rates of child malnutrition (with stunting still at 35%) and anaemia (67% in children under 5 and 57% in women aged 15-49 years) will impact child and maternal mortality rates.

Women’s health calls for greater attention to other health problems across the life course, not just pregnancy related problems. Adolescent health bridges many areas of health concern, from high risk behaviours and addictions to mental health problems and accidents. Adolescence is also the gateway to non-communicable diseases in adult life and calls for stepped up health promotion and disease prevention programmes.

We should strengthen the capacity of the health system to deliver primary healthcare led universal coverage (UHC). A limiting factor, for efficient and equitable delivery of health services is the inadequacy of the health workforce – in numbers, skills and distribution. Mid-level healthcare providers will be needed aplenty, in the form of nurse practitioners and community health officers. AYUSH practitioners of non-allopathic healing systems too need to be appropriately utilised. Public health and managerial expertise too must be infused into the health system. The recent move to create such dedicated cadres must be advanced with alacrity.

Health is constitutionally mandated as a state subject. Apart from centrally sponsored programmes, state governments too must increase health budgets, invest in health workforce expansion and advancing programmes for UHC. Marked inter-state disparities that exist in health system capacity and major health indicators must be reduced, even as we collectively march towards the SDG targets. That is the commitment we must make on August 15, 2022.

The views expressed are personal

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