A healthcare reform agenda - focus on public health

Really good article by Jacob John that captures one of the fundamental problems with India's health care system. It is focused on disease care, to the exclusion of public health. In fact, apart from municipalities, we just do not have a professional public health system at all.

I cannot describe it any better,

Nearly all democracies use two modalities of modern medicine to keep citizens healthy—public health and disease-care. Public health is what the state does to prevent diseases and to protect health. In contrast, disease-care includes the different types of biomedical interventions that are carried out to restore health after an individual falls ill. Therefore, disease-care is popularly called “healthcare”. Healthcare is labour-intensive, given by one worker to one client at a time. Clinics and hospitals are visible infrastructure and sought after as a felt need in times of distress. Public health, on the other hand, is invisible infrastructure, working in society to mitigate social determinants of diseases and in the environment to mitigate environmental determinants of diseases. Usually, this is managed by a ministry of public health or at least a separate public health department under the health ministry...

To confuse the common man, the term “public health” has been misappropriated by policy leaders and medical professionals to mean healthcare in the public sector. Healthcare is not and cannot be called public health... Public health must be managed by professionals trained in public health and empowered to work for the health security of all people—urban and rural, poor and rich. Such professionals must be part of a cadre-like structure and career track...

In the absence of a public health framework that can supervise disease prevention, we vaccinate against Japanese encephalitis, but without controlling the disease; we vaccinate against hepatitis B, but without monitoring the benefit; meanwhile, measles continues to kill children even as we have a major measles vaccination thrust. Leprosy is being eliminated but new cases occur unabated. Monitoring of all disease burdens can be done only by public health. Without monitoring by public health, most of our disease-control projects are flying blind.

Not only do we not have a public health focus, we do not even make a pretension to have one. As a reflection, most states call their health departments either Health Department or Health and Family Welfare Department. What we call primary health care is disease treatment, maternal and child health activities, monitoring of various program verticals, and epidemic response either when one breaks out or there is a threat of one breaking out. This pretty much sums up all the activities of the entire health system and its professionals from district upwards. 

Note that there is nothing here about real public health, as defined above. There is no active focus on preventive care. Instead of preventive care, we have reactive scramble or fire-fighting. The medical officers in the Primary Health Centres (PHCs), the nodal field entity for all health care activities, spend the major share of their times either on disease treatment or epidemic response, with virtually not attention to active preventive care (apart from maybe the routine anti-malaria operations).

In some ways, this state of affairs is comparable with education. The preventive care activities are the primary school learning outcomes equivalent in education, with disease treatment being equivalent to the matriculation examinations and professional college entrances. Just as in education, the focus is skewed towards the latter. Naturally, learning outcomes and public health stand out as massive governance failures. 

These preferences are felt across the system. Public health specialty is a very poor and stigmatised cousin of other medical specialties, as reflected in the specialty preferences of candidates in the post graduate examinations. It is not incorrect to say that even within their graduate coursework, medical students largely sleepwalk through their public health courses as a necessary evil. In the marriage market, public health doctors struggle to find place as doctors. The only domain where there is a distinct public health focus is in urban governments, and in many states these are also among the least preferred posting options for doctors (except where the priority is to make money!).  

This misplaced priorities is understandable. Disease care can be reduced to a set of visible, monitorable, and logistics-type (so called "thin") activities. In contrast, preventive care involves invisible, less monitorable, and engagement intensive set of (so called "thick") activities. Systems with weak state capacity, as public agencies are in developing countries, just about manage to get "thin" activities done whereas they struggle with "thick" activities. In due course, such systems gravitate towards the former and marginalise the latter. It has happened with healthcare just as it happened with education. 

This demands, as Dr John argues, a whole new cadre of public health professionals. In fact, as I have blogged on several occasions, we actually do not need a full-fledged MBBS doctor in a PHC. Given the basic nature of primary medical care that is dispensed in PHCs, it is adequate to have them delivered by nurses under the supervision of the public health physician. The treatment doctor can be redeployed to fill the vacancies and supplement resources in our over-stretched secondary and tertiary hospitals. 

In fact, a treatment doctor in a PHC is a very bad use of scarce resource and ends up with worst of all worlds. He is not required to dispense treatment given the nature of primary care, and his focus on seeing out-patients displaces his more important role of co-ordination and management of various sub-centres and field activities. 

In the circumstances, as a practical agenda, it is useful to consider moving disease treatment doctors away from PHCs and replacing them with public health doctors, thereby also shifting the focus of PHCs away from disease treatments towards preventive activities. The public health doctor's major responsibilities should be active and comprehensive preventive care management, co-ordination of the vertical national programs and their integration into preventive care activities, maternal and child health care and related outreach activities, management of the sub-centre and PHC as effective referral centres, and epidemic response. 

Needless to say, there is no need to have a single model for the whole country, though the broad thrust and structure has to be same. In a few states, some of the PHCs do regular maternal deliveries, and it may be useful to have a pool of doctors who travel across a cluster of PHCs and attend to such deliveries. Other variations to accommodate local context would be necessary.

Update 1 (10.09.2017)

Good article in Indian Express highlighting the patient over-load problems faced by the polyclinics in Delhi.