Social Equality in Public Health

Its often seen that when people meet, almost always, without exception and as a second nature, the first question they ask is about each other’s health. Keeping well and healthy is a central human capability. Yet, good health continues to elude a large chunk of the population in India due to a host of reasons. A host of social conditions produce poor health as well as health inequity and there is a lack of adequate social action to combat these social causes of ill-health. The Chandrakant Patil Memorial Eastern India Regional Health Assembly held at Kolkata recently tried to delve into how issues of health could be made a central democratic priority in India.

Health is not just a private condition or a private transaction between the patient and patient and the doctor, but is a subject of democratic dialogue.

Organised by the Pratichi Trust of Nobel Laureate Dr Amartya Sen in collaboration with the Liver Foundation, West Bengal, ADRI Patna and UNICEF, Kolkata, the health assembly tried to initiate a wider meeting and a dialogue on health in India, something in the line of the National Health Assembly held regularly in Thailand. Named after Dr.  Chandrakanta Patil, who sacrificed his life while serving the flood-hit areas of eastern Bihar, the Assembly tried to tried to take a closer look at ‘what makes good health so problematic for so many people in India’.

It is important to understand the difference between health and treatment. Health is required for people who are not ill and treatment is required for people who are ill. But because of a staunch disease-centric and medicalised view of health, the public health care delivery system is also seen as hospital based infrastructure. This leads to a neglect of the preventive and educative aspects of health.

However, the public health services have been relegated to a somewhat marginalized position in the health system thinking in India. India is a land of curious contrasts. Four of the ten richest persons in the world are Indians, yet India contributes one-fifth of the world’s share of all diseases – one third of diarrhoeal diseases and tuberculosis, a quarter of maternal ailments, and a fifth of nutritional deficiencies. There is a lot India can learn about health from its neighbours, for example, from China and Bangladesh. India can learn particularly about what a massive expansion of public health care can achieve in reducing inequities in health, so also about what reversals in these aspects may occur due to market orientations.

The healthcare system in India is not uniformly weak, implicitly suggesting the critical importance of committed social and policy action in reducing social disparities in health. The lack of public health facilities gives way to a private health market, that in turn promotes a disease-centric view of health, because diseases need curing with medicines. And medicines can be commodified, at very high prices. Thus the primacy given to curative health creates a huge – and almost unregulated drug market. There is a string need for raising voice for the rationalization of the drug policy.

Interestingly the data reveal a relatively promising performance of the several of the states of the states in Northeast India on a number of health parameters. For instance, in a number of north eastern states the prevalence of underweight children is among the lowest in the country. These are also the states that have large percentages of ICDS beneficiaries as well as significant funding for the programme. Several of these states also record low prevalence of anaemia among women. Comparatively speaking, per capita public expenditure on health is sizeable in these states. According to the data collected from ICDS Nagaland’s progress is very high – only six percent of the children being moderately underweight. Sikkim, Manipur and Mizoram show a similarly encouraging show a similarly encouraging performance.

It is important to understand the concept of survival inequality. In a country where more than 50 children per thousand do not even see their first birthday, any public policy on health cannot but take serious note of this in order to improve the chances of survival of the children. Moreover, the children who survive face gross nutritional discrimination leading to poor health of the population. Children belonging to poorer families experience more nutritional deprivation than the relatively well-off ones.

The World Health Organisation (WHO)’s Commission on the Social Determinants of Health states that “Social injustice is killing people on a grand scale”. A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 km away. A girl Lesotho is likely to live 42 years less than another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between – and within – countries result from the social environment where people are born, live, grow and age. Under Sir Michael Marmot’s leadership, this WHO Commission has concentrated on the badly neglected casual linkages that have to be adequately understood and remedied.

On the occasion, the South Asia Women in Media, West Bengal chapter in association with the National Rural Health Mission, West Bengal also organized an important conversation on “Putting the Public Back in Health: Social Equity in East and Northeast India”. The conversation tried to delve into how health, as a concern, has fallen off the map in media as well. While India has been able to bring down its mortality level, its morbidity (or state of ill health) levels have registered a consistent rise. There are many social determinants of health, including larger structural forces and socio-economic inequalities. It was felt that the media ignores the health sector till something new or disastrous happens.

The Pratichi Institute also did a frequency and content analysis of health news in comparison to all other kinds of news during a three-month period preceding the 2011 Legislative Assembly Election in West Bengal. They chose two media groups – The Kolkata edition of The Times of India and Bengali daily ‘Ananda Bazar Patrika’. The chosen period also saw hectic sporting and political activity. Public health being one of the chief agendas of all contesting parties, one could perhaps extrapolate greater emphasis on public health news – on infrastructure, prevention, delivery and condition – during this news cycle. However, this turned out not to be the case. There was an unenthusiastic involvement of the media and legislators regarding key health issues. Another ignored aspect of health is its interaction with entrenched social inequalities.

The very foundation of an effective, efficient and equitable health care system rests on its ability to adequately distribute its health work force. More than shortage, the problem that persists in modern India is the acute imbalance in its allocation of human resources. While the urban centres are being over-staffed, a completely contradictory picture is depicted in their rural counterparts. In India, the largest proportion of medical and paramedical professionals practice in the for-profit private sector, which tend to be concentrated in the urban areas. As a result of the feeble public health infrastructure at the grassroots, the population suffers from certain diseases which could be easily prevented.

Moreover, the exceptionally high burden placed upon households in India reflects the inadequate quantity and quality of public health service delivery. In a context where health insurance is almost absent and the population depend on private health care providers to a large extent, household out-of-pocket expenditure can be a good reflection of their health care consumption. The paucity and unevenness of distribution of healthcare facilities in the country seem to have replaced the popular proverb “health is wealth” to “wealth is health”. In a sense, ill health can deepen poverty as well as increase the number of people living below the poverty line.

It is also important to learn from the patients so that the healthcare system does not remain a one-way traffic. It is important to emphatise with the patient. K.S. Jacob is on the faculty of the Christian Medical College, Vellore stated that it is important to restructure the medical course in such a way that it imparts more practical hands-on expetience to the budding doctors. He says, “The near complete absence of skills and competencies required for practice makes most medical graduates opt for further specialist training. Today's new doctors, with major deficiencies in diagnostic and management skills, would rather apply for post-graduate courses than engage in practice. Yet, competency-based medical curricula seem light years away.”

Health is not just a private condition or a private transaction between the patient and patient and the doctor, but is a subject of democratic dialogue. It’s a time to engage in a critical debate on the whole system in the wake of the beginning of the 12 Five Year Plan. Speaking on the occasion, Prof Amartya Sen emphasized that it was important to have a dialogue on health. Expansion of the Health Assembly will lead to massive medical and healthcare changes in India. Because health is a measure of how well we are doing as a society. It is through the existence of and access to universal public health services that a country can claim to achieve its most basic human development goals.

By arrangement with TeresaRehman.Net


More by :  Teresa Rehman

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