Path to universal health coverage is intrinsically linked to effectively tackling noncommunicable diseases
Foundation for People-Centric Health Systems, New Delhi, India
Foundation for People-Centric Health Systems, New Delhi
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Lahariya C. Path to universal health coverage is intrinsically linked to effectively tackling noncommunicable diseases.J Postgrad Med 2022;68:12-13
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Lahariya C. Path to universal health coverage is intrinsically linked to effectively tackling noncommunicable diseases. J Postgrad Med [serial online] 2022 [cited 2023 Jun 7 ];68:12-13
Available from: https://www.jpgmonline.com/text.asp?2022/68/1/12/336285
A report on the burden of disease in India, released in 2017, noted that––between 1990 and 2016––the noncommunicable diseases (NCDs) had displaced the infectious disease, as a major cause of morbidity and mortality in the country. Fifteen years before that when India's second national health policy was released in 2002, there was barely any focus on NCDs. However, soon after, the epidemiologists and public health experts had started putting evidence together that NCDs was an emerging challenge in India., In 2010, India launched the national program for prevention of cancer, diabetes, cardiovascular diseases, and stroke (NPCDCS). However, the national program remained largely restricted to district level and the plans to roll out the program through primary healthcare facilities did not fully take off. Understandably, the impact of the NPCDCS on control of NCDs in India has been limited, if any.
The reality is that India's health system is not fully attuned to deal with the NCDs. Seven decades ago, infectious diseases were the commonest cause of morbidity and mortality. Alongside, there were very high rates/ratios of infant and maternal mortality and fertility. Understandably, the policy makers started building a health system to tackle infectious diseases; focus upon delivering mother and child health needs and those related to population control. Against this backdrop, it was no surprise that India became the first country in the world to launch a family planning program. To some extent, all of these programs have delivered the results, commensurate with the resources invested.
Over the years, the divide in rural and urban health facilities and services has become starker. The rural health facilities focused mainly on the delivering family planning services; mother and child health-related preventive services such as ante-natal checkups and immunization and on implementing various verticalized national programs. There was very limited curative care for sick people in the rural health facilities. People mostly had to go to district or sub-district level facilities to seek treatment, for the majority of illnesses, be it communicable or NCDs. Without any official distinction, in reality, people started associating the rural government health facilities for public health services and urban hospitals for curative services. With this distinction, the utilization of rural health facilities in India started declining. The situation was compounded when in the mid-1990s, the economic crisis and subsequent liberalization resulted in the entry of the private sector in health services. The private sector started delivering curative and diagnostic services and even those who were attending government facilities drifted to the private sector. The utilization of government health facilities declined further.
Therefore, when the emerging challenge of NCDs was recognized, the Indian health system seemed to be ill prepared. Moreover, the management of NCDs is very different from infectious diseases––which can be treated with single contact with a healthcare provider and many times, through just a single course of medication. On the other hand, the NCDs have risk factors that need to be prevented and once diagnosed, the treatment might have to be continued over a period of time. This essentially means regular interaction with the health facility and providers. The management of NCDs needs a blend of preventive and promotive health services.
In the current issue of the journal, Sivanantham et al., have published a study from rural Puducherry to document the behavioral and biological risk factors for NCDs in the adult population. The authors report that behavioral risk factors were present in 29% to 90% of the population. The findings of this study once again highlight that there is an urgent need in India to re-design health systems to tackle emerging reality and to ensure that happens, all stakeholders need to play their role. As in this study, the academic and research institutions generating evidence on behavioral risk factors can provide useful guidance for health policy makers and program managers to design health interventions. This study also underlines the need for functional institutional mechanisms for collaboration between academic researchers, health program managers and the highest level of decision makers. Such mechanisms would ensure that the findings from community-based research reaches the health policy makers and considered for decision-making.
There is an urgent need to strengthen NCD services being delivered through the primary healthcare system in India. This will be possible through community and citizen participation, who need to adopt healthier behavior that reduces the risk of NCDs. The learnings from the response to the COVID-19 pandemic, where public health and social measures––of face masks, hand washing and physical distancing––identified by health experts were adopted by the citizens. The learnings from this experience should be used to increase adherence to preventive behaviors such as regular physical activity, healthy diet, no smoking and reducing harmful use of alcohol. It also needs to be remembered that the traditional approach of information, education and communication (IEC) in government health programs has to be reconsidered and recasted. Health communication experts and policy makers need to pause and think about how many of us change our opinion merely by reading a newspaper advertisement or a health message on a billboard outside a health facility? Since we do not, then how can we expect the same from citizens? There is a role for billboards and newspaper advertisements but in addition, there is a case for a more science-based and professional approach to engage people in the adoption of healthy behavior. The research findings generated by the studies such as the one published in this issue should be used for programmatic purposes, and then only it will make an impact.
In 2017, India released the third national health policy, which explicitly acknowledges the emerging challenge of NCDs and proposes to tackle the challenge through programmatic interventions. A year after the release of the National Health Policy 2017, the government launched the Ayushman Bharat program with two components of Pradhan Mantri Jan Arogya Yojana (PMJAY) and Health and Wellness Centres (HWCs)., The focus of HWCs is to strengthen primary healthcare services through a range of mechanisms and it intends to improve the provision of NCD services in rural and urban areas. These initiatives should be expedited and approach has to be outcome-based performance measurement and not merely how many people screened or tested for blood sugar levels in the community.
India is known for very well drafted and articulated policies and programs; which remains sub-optimally implemented. The COVID-19 pandemic is another reminder that we need to prepare health systems for any future epidemic or pandemic and that will also be useful in responding to NCDs and other health challenges and keeping citizens healthy. COVID-19 pandemic is also a reminder of the co-existence of infectious diseases and related high risk due to NCDs, as has been the scenario in the ongoing pandemic. There is need for use of this evidence for such decision-making and programmatic modifications.
Effective response to the NCDs requires a real health system, where continuity of care is assured, medicines are supplied and an integrated approach of curative and public health interventions. A high prevalence of NCD risk factors in the community and limited provision of health services for these conditions mandates that India redesigns its health systems to tackle new emerging realities and to ensure universal health coverage, a goal committed through National Health Policy 2017.
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