The third Sustainable Development Goal (SDG-3) pertains to healthcare. “Ensure healthy lives and promote well-being for all at all ages,” it states. This goal is important for several reasons. The economic viability of current healthcare models is under question, even in the world’s largest economies such as the US and China. Health indicators and figures on healthcare access present a picture of widespread inequality. The pharmaceutical industry and medical diagnostic procedures compromise environmental integrity and public health systems do not address the health impacts of environmental pollution. While under-nutrition and communicable diseases persist, non-communicable diseases (NCD) such as cancers, hypertension, diabetes, respiratory problems and injuries are rising.
Universal Health Coverage (UHC) has been adopted as the strategy to attain SDG-3. However, last month, at a meet in Astana, Kazakhstan, the world community acknowledged UHC’s limitations. The Astana Declaration underscored the importance of Primary Health Care (PHC) as an essential complement to UHC. UHC concentrates on ensuring healthcare access through medical insurance “coverage” in order to “prevent catastrophic medical expenditures”. This was a move away from the comprehensive PHC approach that was reiterated by the WHO in 2008.
The Astana declaration (2018) attempts to integrate the two approaches. “We will apply knowledge, including scientific as well as traditional knowledge, to strengthen PHC, improve health outcomes and ensure access for all people to the right care at the right time and at the most appropriate level of care, respecting their rights, needs, dignity and autonomy,” the declaration states. However, what the Astana Declaration leaves unsaid is a matter of serious concern. It is silent on the socio-economic and political conditions (international and national) that lead to malnutrition and ill-health. It does not talk of the complicity of private sector healthcare outfits and the pharmaceutical and insurance industries in creating the problem of unaffordability.
Ivan Illich’s book, Limits to Medicine, published in 1974, brought together a large body of data that demonstrated the negative effects of the doctor-centred medical system. Illich showed how the system disempowers communities and patients. Such evidence has only grown over the decades. Yet, UHC seems to be premised on the belief that increasing access to the “doctor-hospital-centred healthcare” is the solution to the crisis.
The principles of the PHC approach of the Alma Ata declaration (1978) such as healthcare “closest to home” and “appropriate technology” that is effective, safe, cheap, and simple to use, need to be applied to the healthcare system as a whole. The PHC-infused-UHC could facilitate such a shift. People’s experiences, knowledge and practices need to be respected if we are to shift to patient-centred and community-centred healthcare. Binaries of “scientific” versus “traditional” need to be given up by acknowledging the validity and limitations of various knowledge systems.
The women’s movement and Adivasi and indigenous peoples’ movements have asserted people’s rights over their bodies and health. Decentralised and plural healthcare systems, social audits and community monitoring systems have been designed and experimented upon. People across the world are turning to alternative medical systems.
In India, the UHC-PHC complement is embodied in the Ayushman Bharat scheme — the Pradhan Mantri Jan Aarogya Yojana (PMJY) reflects the UHC model, while the health and wellness centres claim to reflect the PHC component at the primary level. This is a shift from the earlier strategy for strengthening public healthcare system, reflected in the National Rural Health Mission (NRHM), 2005-2012 — later the National Health Mission with incorporation of the National Urban Health Mission. NRHM addressed primary and secondary levels, leading to an increase in public health expenditure, from 17 per cent of total health expenditure in 2004-05 to 30 per cent by 2014. It also increased utilisation of public healthcare for out-patient care, especially in the most under-served states. This was no mean achievement, especially at a time when privatisation was the larger policy trend.
With decreasing budgets, however, NHM may well be in decline. Huge sums are being promised for insurance against hospitalisation under the PMJAY. However, evidence from the Rashtriya Swasthya Bima Yojana (RSBY) shows that such insurance schemes distort health provider behaviour, add unnecessary transaction costs and on aggregate do not reduce out of pocket expenditures on health. Thus there is no option but to strengthen public services.
The Health and Wellness Centres bring focus on to non-communicable diseases (NCDs), in addition to the ongoing communicable disease control programmes and maternal and child health programmes. The ambit of services provided has increased and public services at the primary level have been strengthened. However, this is not in sync with the broad SDG of improved well-being. Attaining this goal requires that the environmental, social, and economic conditions are made conducive to health. Economic, agricultural, industrial, rural and urban development policies should all keep people’s health as their central goal.
AYUSH practitioners — who have taken “bridge’ courses” — will be posted at the health and wellness centres to screen NCDs and implement allopathic programmes. Encouraging them to utilise their AYUSH knowledge to prevent and treat diseases will be an opportunity to utilise our indigenous resources for sustainable options.
The PHC-infused UHC provides a window of opportunity for re-visioning and creating sustainable and empowering healthcare. Will we as a country make use of the opportunity Astana provides, or continue to be caught in the trap of over-medicalised commercialised healthcare?