Universal Healthcare & Nationwide Public Health: A tale of two declarations from one city

Demand for universal healthcare

The demand for universal healthcare coverage in India has recently gained momentum. From January 2011, The Lancet published a series of 16 articles and commentaries, all by Indian authors, culminating in a “call to action” advocating universal healthcare coverage as an imperative if India should progress socially and economically1. In February 2011, the Ninth Calcutta Group Workshop, chaired by the Nobel Laureate economist, Professor Amartya Sen, announced the Kolkata Declaration which demands universal healthcare coverage provided through the public sector2. Both groups stressed the need to increase the government's budget for healthcare.

Providing equitable access to quality healthcare for all citizens is the moral responsibility of every government. In a few countries governments fulfill this responsibility by providing medical coverage in the public sector – examples are the National Health Service in the United Kingdom and the healthcare systems in Cuba and Sri Lanka. On the other hand, many countries allow substantial private sector participation in healthcare, but both quality and cost are carefully monitored and regulated. In such countries universal coverage is largely achieved through social health insurance as in Canada, Germany and the Scandinavian nations. Universal healthcare is essential and imminently feasible through either approach in India, but medical care is only one determinant of the overall health of the people. Achieving a healthy population will require not only greater levels of public investment in healthcare but also fundamental improvements in our health system design.

Two components of health management: prevention and treatment

The health management system in all countries that provide universal healthcare, either directly or via social health insurance, has two components – public health and healthcare. Public health prevents a wide range of diseases through community level interventions, covering the entire population at risk; hence, as everyone benefits, public health is a true public good and should receive priority for public funds. The more we spend on public health the less will be needed for healthcare.

Preventable illnesses are a frequent cause of heavy out-of-pocket expenses that may push families into debt and even penury1,3. Functional and efficient public health minimizes healthcare expenditures, particularly for easily prevented infectious diseases that still plague our nation. Good health improves productivity; so investment in disease-prevention is not only poverty-alleviating but also wealth-generating. Thus, both economic arguments and social justice demand that diseases driven by social and environmental risks must be targeted by public health for prevention and control.

Until recently, higher public spending on health was perceived as unaffordable under the excuse that India was a poor country with low national revenue. During the last decade or more, the economic scene has changed drastically, and India has become the fourth largest economy in the world. Millions of Indians have been lifted out of poverty. Economic growth itself improves some health parameters through numerous mechanisms. However, improvements in social indicators have not kept pace with what is feasible for, or what is necessary in, improving population health. Unacceptable disparities remain in social development within and between States. For example, the prevalence of undernutrition has not declined in the absence of health specific interventions4 and exhibits wide inter-State inequalities5.

In summary, achieving optimum health in the population can no longer be neglected. India cannot afford to delay the establishment of public health while it strives to provide universal healthcare. We must reinvest some of the dividends of economic growth to meet the basic governmental obligations to citizens. In every country that has achieved a high level of health, both public health and healthcare are well established and intimately interactive. While India has a healthcare system, albeit with inequitable coverage and quality, the glaring deficiency is the lack of public health.

Public health, the missing component

Organized public health addresses and redresses determinants of ill health at the community and environmental levels. It also protects health by ensuring all diseases are continuously monitored, and by deploying appropriate interventions for the timely prevention and control of those that pose a threat to people's health. These functions require the implementation of biomedical, environmental, and social interventions such as immunizations, vector control, environmental protection, child nutrition, and safe water and sanitation. While some interventions cut across several administrative departments and ministries, public health itself is the overarching system that unites these in support of disease prevention. From that vantage point public health can make full use of data from vital registrations, case-based reporting of legally mandated notifiable diseases, and other epidemiological intelligence to combat the transmission of infectious diseases and reduce risk factors of non-communicable diseases and injury. In the absence of public health, the healthcare service is burdened with preventable disease, crowded hospital beds, and overstretched healthcare workers.

If healthcare is personalized service under market justice, public health will be societal infrastructure under social justice6. Public health structures will be visible to the public eye but their achievements invisible. A public health success is when disease does not occur. No one can observe the disease or the outbreak which was prevented; consequently, public health will neither be recognized by the media and the government, nor rewarded by the medical profession. On the other hand, the impact of healthcare on the individual is immediate and visible to the public and political leadership. So when healthcare and public health compete for attention in a single system, the needs of public health are neglected as is obvious in India. Yet, as for other items of infrastructure, public health is a long-term investment that must be constructed and expanded to realize the social and economic benefits alluded to above6. Nationwide public health will be essential for achieving equity in health.

In 1999, a large group of health management experts met together in Calcutta (now Kolkata). They took note of the absence of public health infrastructure in India and other South Asian countries and identified its critical importance in protecting people's health7. Their call, known as the Calcutta Declaration7, identified public health as essential for health and development, emphasized its leadership role in improving health, and advocated for the creation of a structure separate from healthcare to support public health. The group of experts made a strong plea to their governments to urgently establish organized public health. To provide health security to all people India will require a dual component health management system. Public health must have full departmental status, administrative structure, and an adequate budget within the Ministry of Health. This was the vision of the Calcutta Declaration made a decade ago.

Moving the agenda forward

The agenda for India must be the establishment of public health infrastructure alongside the provision of universal healthcare coverage. For both public health and healthcare, the management unit ought to be the district as already emphasized under the National Rural Health Mission. One forward step is to organize public health and universal healthcare supervision within the district under trained managers – preferably within a framework such as the Indian Health Service, parallel to the Indian Administrative Service and Indian Police Service. Indeed these three services are fundamental to the administration of and maintenance of legal and social well-being. Training of personnel for public health and healthcare management, with well defined careers to follow, is necessary to provide for the needs of both systems. All these and other elements of a reformed health management system will have to be enumerated.

A national commission on public health and healthcare is long overdue8. In the past such an exercise had been done twice – in the pre-independence period of 1944-1946 under the leadership of Sir Joseph Bhore and later during 1964-1966 under the leadership of Sir A.L. Mudaliar. Since then India has not conducted a comprehensive review and analysis of our health needs, strategies, and organizational structure. Broad public input along with considerable effort from dedicated experts will have to be harnessed to (i) describe the present situation, (ii) analyze the barriers to achieving the best possible health status of the people, and (iii) design the two-component health management system needed for our future. We hope such a national commission will accept the spirit of the Calcutta and Kolkata declarations towards achieving the goal of health security for all.