Community participation must be supported to actively engage people in the design, delivery, monitoring and evaluation of health programmes
The basic objective of any healthcare system should ensure that every person who needs healthcare 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 by 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. 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, 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.
Understanding the definition of health
The WHO definition of health is not how health is commonly understood, "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 as elaborated by Crew, "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."
The parameters of mental health as elaborated by Laycock, "It is a complete freedom from internal conflicts. No internal wars, no self-condemnation or self-pity. It indicates well-adjustment 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".
Finally, the parameters of social health take 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 by WHO in 1978 to include the ability to lead a socially and economically productive life.
Health for all
The slogan "Health for All" is possible only if all are mobilised for Health. This meant not just governments and medical establishments, but peoples themselves. The people should not forget that health is not only a commodity that a benevolent government/ institution/ individual bestow 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. 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"
Four priority formula to transform healthcare system
(1) The first priority for transforming of healthcare system should be “a determined effort to strengthen our public health systems.” Primary health care must be improved as mentioned above, 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. Sub- 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.
(2) The second priority should be to improve the size and quality of our health workforce. Without this, the promise of transformation 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. It is indeed a matter of satisfaction thatnew medical colleges at district level are being set up by government. 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.
(3) 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.
(4) 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.
(Author works at Narayana Hospital, Jammu)