Providing essential healthcare
BY: Dr.Tasaduk Hussain Itoo
Universal Health Coverage (UHC) refers to the providing of essential healthcare services to a person while ensuring that the use of these does not expose the user to financial distress. The basic objective is that every person who needs these services should get them and not only those who can pay them. This is required to alleviate the financial costs associated with healthcare while making individual access to these services easier.
According to a report in WHO, at least half of the world’s population do not have full coverage of basic health services. Moreover, around 100 million people are still being pushed into poverty because they have to pay for health care. “UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma Ata declaration in 1978. UHC cuts across all of the health-related Sustainable Development Goals (SDGs) and brings the hope of better health and protection for the world’s poorest.
DEFINITION OF HEALTH
The WHO definition of health is not how health is commonly understood. Health as the absence of disease is a negative definition. The WHO, in the Preamble to its Constitution, defined it positively way back in 1948 and threw a challenge to community workers to construct suitable models of health care. “Health is a state of complete physical, mental and social well-being, and not merely an absence of disease or infirmity.” This definition encouraged researchers to work out positive parameters of health, which they did. For example, the parameters of physical health were (Crew, 1965): “A good complexion, a clean skin, bright eyes, lustrous hair with a body well clothed with firm flesh, not too fat, a sweet breath a good appetite, sound sleep, regular activity of bowels and bladder and smooth, easy, co-ordinated movements. All the organs of the body are of unexceptional size and function normally; all the special senses are intact; the resting pulse rate, blood pressure and exercise tolerance are all within the range of “normality” for the individual’s age and sex. In the young and growing individual there is a steady gain in weight and in the mature this weight remains more or less constant at a point about 5 Ibs. more or less than the individual’s weight at the age of 25.”
MENTAL HEALTH MEANT (Laycock, 1962) :
⚫Freedom from internal conflicts. No internal wars, no self-condemnation or self-pity.
⚫One well-adjusted with others. Who accepts criticism and is not easily upset. Who understands the emotional needs of others and tries to be considerate and is courteous in his dealings with them.
⚫One with good self-control. Not overcome by emotion; not dominated by fear, anger, love, jealousy, guilt or worries. Who faces problems and tries to solve them intelligently.
Social health took account of the social and economic conditions and wellbeing of the individual in the context of his social network, his family, his community and his nation. This definition of social health was modified in 1978 to include the ability to lead a socially and economically productive life (WHO, 1978).
As should be immediately obvious, the WHO definition of health mentioned earlier is idealistic rather than realistic. Ideal health will always remain a mirage. Health in this context is to be considered a potentiality — to be promoted, to be supported, for the maximum good of the maximum number.
“HEALTH FOR ALL” IN INDIAN CONTEXT
The slogan “Health for All” is possible only if All are Mobilised for Health. This meant not just governments and medical establishments, but people themselves. Primary health care is essentially health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost the community and country can afford. And in working for such positive health, the role of health experts or doctors is the same as that of a gardener faced with insects, moulds and weeds. Their work is never done. Primary health care is a health conscious people’s movement. Its implementation depends on knowledge of proper disposal of services and a persistent demand from an active and quality conscious consumer-the public. Strong political will, community participation and inter-sectoral coordination are its basic principles. However, the National Health Policy of India, 1983, was hardly debated in both houses when tabled. Both NHP 1983 and 2002 failed to confer the status of a Right to health, while most other nations are planning newer strategies to put Right to Health and Medical Services into practical use. Community participation in health is an aphorism that awaits genuine realisation in many countries of the world, notably of the third world. India, unfortunately, is no exception. Progressive Five Year Plans in India have reduced percentage spending over health as a part of GDP, which is an alarming state of affairs. Public awareness and activism alone can remedy this alarming condition. The people should not forget that health is not only a commodity that a benevolent government/ institution/ individual bestows on them. It has to be earned and maintained by the individual himself. Health problems cannot be solved in isolation. They will ultimately be part of our struggle for an egalitarian society, because better health care is a sign of a more evolved one.
In sum, as things stand, there cannot be Health for All in this country unless the people unite and raise the slogan All for Health. If the goal is Health for All, the commitment has to be All for Health. They will have to become more aware of their health rights and obligations and will have to stress this need through various social welfare, consumer and political bodies. And we need a government having the political will to put these aspirations into practice. That this is no mean expectation should be obvious considering the apathy, callousness, and cover-up that resulted after the Bhopal tragedy. Moreover the people should not forget that health is not only a commodity that a benevolent government/institution/ individual can bestow on them. It has to be earned and maintained by the individual himself. And for this it is essential both to motivate individuals to accept responsibility for their own health as also to sufficiently de-professionalise medicine so that such motivated laymen can play a greater role in their health care, without jeopardising the legitimate importance of the health care professional in the field. How these could be brought about should engage the attention of at least some of those who have the welfare of this nation’s population at heart. The time for games-playing is past. Only a popular realisation and an active movement of All for Health can ensure the benefits of medicine and Health for All. The WHO in its Preamble(1948) states, “The enjoyment of the highest attainable standard of health is one of the fundamental Rights of every human being without distinction of race, religion, political belief, economic or social condition”
RECOMMENDATIONS TO ACHIEVE UNIVERSAL HEALTH COVERAGE
The first priority for achieving Universal Health Coverage should be “a determined effort to strengthen our public health systems.” Primary health care must be improved, starting with sub-centres, the first health post for the community. By staffing them with well-trained non-physician health care providers, both facility-based and outreach services can be provided without being doctor dependent. District hospitals too should be strengthened to provide high quality secondary care, some elements of essential tertiary care and training to different categories of health care providers. This would also help in relieving unending crowds in tertiary care hospitals.
The second priority should be to improve the size and quality of our health workforce. Without this, the promise of Universal Health Coverage will remain an empty entitlement. Since primary health care is our first priority, resources must be devoted to the production of competent and committed community health workers for the frontline, mid-level health workers or AYUSH doctors for the sub-centres, and general and specialist nurses as well as non-specialist doctors for primary health centres.
More specialists are needed for higher levels of health care including the district hospitals. New nursing and medical colleges should be preferentially set up in districts which presently have very few, linking them to tertiary-care hospitals.
Public health competencies must be increased through inter-disciplinary education which is aligned to health system needs. Improved management of all of these human resources must involve better incentives for recruitment and retention, cadre review and creation of well defined career tracks.
The third priority should be to provide essential medicines and diagnostics free of cost at all public facilities. At the same time, referral linkages and patient transport services should be improved to integrate primary, secondary and tertiary health care in the public system.
Difficult to reach areas and vulnerable population groups should receive special attention, even as the principle of universality must be applied while designing health services.
The fourth priority must be to put in place the necessary public systems for Universal Health Coverage. Regulatory systems need strengthening — from hospital accreditation to health professional education and from drug licensing to mandatory adoption of standard management guidelines for diagnosis and treatment of different disease conditions at each level of health care.
A state inter-operable Health Information Network is needed to improve governance, accountability, portability, storage of health records and management. Community participation must be supported to actively engage people in the design, delivery, monitoring and evaluation of health programmes.
And finally, larger investments should be made in health promoting programmes in other sectors such as water, sanitation, nutrition, environment, urban design and livelihood generation.
The writer is Resident Doctor at Acharya Shri Chander College of Medical Sciences and Hospital Jammu. Email address : [email protected]