From UPSC perspective, the following things are important :
Prelims level : NA
Mains level : Issues in public health management
- A failure to examine and interpret public health problems from a population perspective is leading to ineffective and unsustainable solutions as far as complex public health problems are concerned. There is a strong tendency in public health to prioritise individual-oriented interventions over societal oriented population-based approaches, also known as individualism in public health.
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What are the problems in public health approach?
- Micronutrient supplementation at Individualistic level instead sustainable approach at public level: Problems such as undernutrition, for which individualist solutions such as micronutrient supplementation and food fortification have been proposed as solutions in lieu of sustainable approaches such as a strengthening of the Public Distribution System, supplementary nutrition programmes, and the health services.
- Diagnosis and treatment than the solutions that modify health behaviours: Similar is the case with chronic disease control, wherein early diagnosis and treatment is the most popular solution, with little scope for solutions that can modify health behaviours (through organised community action).
Recent evidences that show individualism is preferred over population-based approach
- Pradhan Mantri Jan Arogya Yojana (PMJAY): A nationwide publicly-funded insurance scheme, the Pradhan Mantri Jan Arogya Yojana (PMJAY) falls under Ayushman Bharat. It is the largest health insurance scheme in the country covering hospitalisation expenses for a family for ₹5 lakh a year. The goal is to ensure ‘free’ curative care services for all kinds of hospitalisation services so that there is no financial burden to the beneficiary.
- Approach needed: What is not talked about in the entire scheme is the need for hospitalisation services per year for any population.
- Approach preferred: Instead, every individual is given an assurance that if there is a need for hospitalisation expenses, the scheme will cover the expenses, highlighting the risk/probability of every individual facing hospitalisation in a year.
- Individualistic response: This is an individualistic response to the problem of hospitalisation expenditure faced by populations. This becomes obvious when one examines the data on annual hospitalisation across populations.
- vaccination for COVID-19 unlike other vaccinations: It was evident that a COVID-19 vaccine cannot prevent people from getting the disease but only reduce hospitalisation and deaths in the event of contracting COVID-19.
- Approach needed: To effectively manage COVID-19, what was needed was to have primary, secondary, and tertiary health-care facilities to manage the above proportion of cases. This is what a population-based approach to epidemic would be focusing on.
- Approach preferred: Instead, by focusing on a vaccination programme for the entire population, it is again an assurance and a promise to every individual that even if you get COVID-19, you will not need hospitalisation and not die. Even after the entire crisis, not much is talked about in terms of the grossly inadequate health-care infrastructure to ensure the necessary primary, secondary and tertiary care services for COVID-19 patients, in turn leading to many casualties.
- Individualistic response: The entire focus has been on the success story that every individual is protected from hospitalisation and death achieved through vaccine coverage. Most of the deaths due to COVID-19 are a reflection of the failure to offer ventilator and ICU support services to the 1%-2% in desperate need of it. Curative care provisioning is never planned at an individual level as epidemiologically, every individual will not necessarily need curative care every time. The morbidity profile of a population across age groups is an important criterion used to plan the curative care needs of a population.
What the data on population hospitalization suggests?
- Episode of hospitalization a year: Data from the National Sample Survey Organisation (75th round) show that on an average, only 3% of the total population in India had an episode of hospitalisation in a year (from 1% for Assam to 4% for Goa and 10% for Kerala the need also a function of availability). The proportion hovers around 3%-5% across most Indian States.
- Population based healthcare planning is necessary: This is population-based health-care planning. Instead, giving an assurance to every individual without ensuring the necessary health-care services to the population is not really helping in a crisis.
Determinants of individualistic approach
- Misconception in philosophy of public health: The dominance of biomedical knowledge and philosophy in the field of public health with a misconception that what is done at an individual level, when done at a population level, becomes public health. This is despite the contrasting philosophy and approaches of clinical medicine and public health and the evidence that support the latter and must be based on population characteristics and economic resources.
- Visibility impact and mistake of judging a population’s characteristics: Health effects are more visible and appear convincing at the individual level, wherein improvements at the population level will be clear only after population-level analysis; this needs a certain level of expertise and orientation about society an important skill required for public health practitioners.
- Market’s role and the effect of consumerism in public health practice: The beneficiaries for a programme become the maximum when 100% of the population is targeted. Instead of making efforts to supply evidence of the actual prevalence of public health problems, market forces would prefer to cast a wide net and cover 100% of beneficiaries. Propagating individualism has always been a characteristic feature of a consumerist society as every individual can then be a potential ‘customer’ in the face of risk and susceptibility.
- The need of the hour is population-level planning, which means, population as a single unit needs to be considered. All forms of individualistic approaches in public health need to be resisted to safeguard its original principles of practice, viz. population, prevention, and social justice.