Good health and individuals' wellbeing is the third goal of the UN Resolution called the 2030 Agenda. It consists of 17 interlinked global goals called the Sustainable Development Goals (SDGs) that replaced the Millennium Development Goals (MDGs). The goal is fully stating as “to ensure healthy lives and promote wellbeing for all at all ages” . This covers all aspects that impact one's ability to lead a healthy life and lifestyle. Most countries have sought to achieve this goal by focusing on the WHO goal of universal healthcare coverage, which ensures people access and affordability quality healthcare. India is a country that has enacted several policies to achieve this goal. The problems that face India’s health system can be solved through various social policies and collaboration with social workers. This paper will discuss these problems and the social policies that have been enacted to solve them.
Section I: Country Background
Source: National Health Profile. (2017). Statewide doctor to population ratio of government allopathic doctors [Photograph]. Central Bureau of Health Intelligence (CBHI).
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The map above shows that the Indian healthcare system is over-burdened. The country consists of 28 states which are all responsible for their healthcare system. Some states are so overwhelmed that the national government has set health programs to be intensified in those states.
India is the second-most populous country in the world, with a population of over 1.2 billion people. The country is among the group of rapidly developing countries called BRICS, including Brazil, Russia, India, China, and South Africa. This means that it is not a first-world country but rather faces most problems affecting third-world countries. As a result, the Indian government cannot extensively fund its agencies due to a low GDP. This has contributed to the rise of new problems or the continuation of perennial challenges that affect the country. Access to health is one such problem that the Indian government has been trying to tackle for a long period. India is ranked number 154 out of 195 countries in regards to healthcare access. This number is below its neighbors, such as China, Bhutan, and Sri Lanka (Jain, 2018). The country is divided into 28 states which are all responsible for healthcare within their territories. The disparity in size, economic growth, and government regulations in these regions causes chaos and imbalance in healthcare provision throughout the country. Studies reveal that healthcare quality in sub-centers and anganwadis, also called mother and child-care centers, is very low, with most of them being far away from rural citizens and those available lacks adequate resources (Kasrudhi, 2018). This has resulted in a majority of the population preferring private medical centers, which are often expensive and lead to households' impoverishment.
Poverty among Indian citizens has been a contributing factor to their lack of access to healthcare. It causes uneven population distribution, which makes access to healthcare particularly challenging. Rural to urban migration caused by extreme poverty and lack of employment opportunities in rural places has led to overcrowding in urban places such as Mumbai and New Delhi. This leads to an overstretching of available medical resources. These dense populations also lead to the rise of informal settlements, which are perfect environments for disease outbreaks and make it harder to stop the spread of common infectious diseases. The sanitation systems, access to freshwater, and food all combine to make dwellers of these informal settlements more likely to get sick and harder to treat since diseases evolve easily.
Another demographic factor has been the wide gap between the rich and the poor. Indians generally prefer to use private health services due to their convenience and quality, which has seen 70% of the population rely on private healthcare providers (Barik & Thorat, 2015). The increasing gap between the economic capacity of different classes of citizens has led to private health insurance is unaffordable for a large portion of the population. Low-income families who seek care from private medical centers incur high out-of-pocket (OOP) costs which impoverish families and lead to a reduction in general wellbeing (Kasrudhi, 2018). This trend is also seen in the fact that the poor in rural places struggle to get adequate care in public health centers while those in urban areas, including medical tourists, can benefit from the high-end and well advanced private medical centers which have characterized India across the world. In urban areas, only 3% of diseases remain untreated, while in rural places where families are unable to access private care for more serious permanent diseases, 12% of cases are not treated due to a lack of diagnostic equipment in public healthcare centers (Barik & Thorat, 2015). Until recently, people in secluded geographical areas such as those in the Himalayas received medical supplies by air force helicopters (Kasrudhi, 2018). These factors point to a country that receives thousands of medical tourists each year unable to offer its population the same services.
A combination of literacy levels and cultural practices has also presented a challenge in providing health services to all citizens. In some places, especially rural areas, people tend to suffer from easily preventable diseases due to low knowledge of common preventative solutions. A majority of these people are illiterate and are generally unaware of important information regarding their health. This makes the nationwide distribution of medical campaigns such as child vaccinations and preventive education challenging. Negative gender stereotypes have also made it harder for some groups, such as women, to access medical care. Women whose gender roles are traditionally anchored in domestic chores cannot receive specialized care and some services, which would challenge existing traditional moral values. An observational study revealed that women, especially those in the non-reproductive stage of their life, receive almost half less access to healthcare than men (Kapoor et al., 2019). This factor is linked with healthcare facilities' distance from people since more women in New Delhi received care than those in far-flung areas such as Uttar Pradesh or states like Bihar. This study found that family members are reluctant to use any funds to take women to seek specialized health services to hospitals that are far away. Increasing the number of healthcare facilities or quality of services offered in rural health facilities would reduce such access gaps. The caste system, which designated some duties as impure, is a significant cause of unhygienic practices in India, ultimately leading to the spread of diseases. These include open defecation and bad sewage disposal systems since touching any form of human excretion was designated as a role of the lower caste (untouchables), leading to most people avoiding any occupation or duty that brings them in contact with such waste.
Section II: Policy History
After receiving independence from Britain in 1947, the Indian government sought to make health a priority by establishing the Ministry of Health. A national survey called the Bhore Committee was commissioned in 1943 to evaluate India's health condition. This was especially important due to its growing population and upcoming independence. The report recommended for the creation of primary health centers in two stages, which were the short-term measures which included the establishment of various small primary health centers (PHC) to serve the immediate health needs of the people with support from secondary health centers that were also to supervise them (NHPI, n.d.). The next step was the long-term measures which included larger primary health units consisting of 75-bed capacity hospitals to deal with more significant issues, with even larger secondary units consisting of district hospitals of 2500 bed capacity to be built later. Medical training was to include three months in preventive and social medicine to prepare "social physicians.” These recommendations were not fully implemented but formed the bedrock for future reforms.
In 1983 the Parliament legislated the National Health Policy, which would investigate and focus on health issues in need of attention. One of the ways was through the establishment of five-year plans that would determine priority areas. The government also sought to achieve universal healthcare by 2000, and when this proved to be elusive, the program was updated in 2002. In 1975 the government started the Anganwadi (courtyard shelter) program under the Integrated Child Development Services (ICDS) to tackle hunger and malnutrition among children (WCDD, n.d). Today they fall under the Women and Child Development Department and focus on health-related and early learning initiatives of ICDS.
In the five-year plans, healthcare inequality, lack of access to public healthcare services, and lower quality of public health services compared to the private industry were consistently noted as perennial challenges. This led to creating the National Rural Health Mission (NRHM) in 2005, which was to increase health service provision, access, and coverage in rural areas. However, the same historical problems persisted, which were made worse by tougher economic conditions and the ballooning population. Another problem the 12 th plan sought to solve was resource allocation since the NRHM in the 11 th plan had noted that 90% of resources went to family welfare while only 10% was spent on disease prevention (Barik & Thorat, 2015). OOP continued to impoverish families who sought private healthcare services at the expense of their other needs. The 12 th plan noted all these health issues and sought to expand the efforts undertaken during the 11 th plan (2007-2012) and focus on marginalized groups and communities such as the nomadic tribes.
Among other legislation, the government introduced in 2005 alongside NRHM was several national insurance covers. These included the Publicly Funded Health Insurance schemes (PFHI), which allowed low-income families to pay some registration and annual extension fees for schemes to cover hospitalizations and thus reduce catastrophic health expenditures (CHE) (Ranjan et al., 2018). This National Health Insurance Scheme is called the Rashtriya Swasthya Bima Yojana -RSBY. It is not a social insurance scheme since once families voluntarily pay annual token fees, private insurers enroll them while the government pays a premium for each enrolment or renewal. These schemes cover hospitalizations and not ambulatory or outpatient services covered under some mandatory, more expensive, earlier social insurance schemes operating from the 1950s.
The NRHM led to several improvements which were noted across the country. However, a 2012 government analysis in six states revealed a lot was yet to be resolved. The report revealed major infrastructural challenges in most rural primary healthcare centers (PHC), such as lack of beds, wards, toilets, regular electricity, clean drinking water, and clean delivery rooms (Kasrudhi, 2018). Other government and non-government reports had revealed a lack of workforce across the national health industry with 10, 000 people being served by 20 health workers. The distribution of these workers was also uneven since most preferred to work in areas with better infrastructure and improved living standards for their families. In 2012, the government sought to overhaul the NRHM. It created the National Health Mission (NHM), which consisted of NRHM and the newly created National Urban Health Mission (NUHM) of 2013. The program of the NRHM was expanded to include non-communicable diseases and coverage of poor urban communities.
The international community has also led to India focusing on healthcare delivery. The support of UNICEF and the focus of the UN Millennium Goals (the ones that preceded the SDGs) of improving maternity care and reducing infant mortality led the Indian government to focus on Anganwadis. The WHO has made the attainment of Universal Healthcare Coverage (UHC) a core principle and aim of effective health systems in its member countries. The adoption of UHC as WHO's theme of 2018, which called for “Universal Health Coverage-Everyone, everywhere," led to India focusing on increasing health provision and coverage towards marginalized and lower economic status groups. This saw the government of India extend the NHM in March 2018.
Source: Scott et al. (2020, November 30). India’s Auxiliary Nurse-Midwife, Anganwadi Worker, and Accredited Social Health Activist Programs [Photograph]. CHW Central.
The picture above shows an anganwadi worker who could also play an auxiliary midwife-nurse or community health activist. Anganwadi centers are responsible for basic health in most rural places across India.
Section III: Implementation
The NIM (NHRM) adoption, Anganwadi, and PFHI schemes have significantly increased India's healthcare access. This section will discuss a few programs offered under NIM, discuss social workers' roles in the three initiatives, and the success accomplished by these programs.
NHIM
There are several initiatives launched under this policy. The major ones include:
Accredited Social Health Activists (ASHAs). These involve community health volunteers who establish links between the health system and particular communities. Marginalized groups use this platform to demand various health-related services (Nandan, 2011). It has successfully improved the public health system's brand image and thus increased the uptake of services.
Janani Suraksha Yojana. This is a cash benefit scheme aimed at improving institutional delivery in states with low delivery rates. It reduces neonatal and maternal mortality rates by giving cash assistance to entitled women for delivery and post-delivery care (Nandan, 2011). It divides states into Low Performing States (LPS) and High Performing States (HPS). In the former, all women who choose to deliver in public health facilities are eligible for cash benefits, while those who choose accredited private health centers only classified as living below the poverty line or belonging to scheduled caste or tribes are eligible. In the latter, only those classified as living below the poverty line or belonging to scheduled caste or tribes are eligible irrespective of the health facilities they choose.
Janani Shishu Suraksha Karyakram (JSSK) ; This initiative boosts UHC measures by providing free transport, diagnostic services, drugs, diet, and blood services to pregnant women who deliver in public health centers and to sick infants of up to one year.
National Mobile Medical Units (NMMU) ; These offer mobile health services in many unserved or under-served areas.
National Ambulance Services ; These provide free services across the country using a network connected by a toll-free number.
Rashtriya Bal Swasthya Karyakram (RBSK) ; Launched in 2013, this program screens diseases specific to children such as developmental delays, childhood diseases, disabilities, birth deficiencies, and defects. It also provides free treatment, including surgeries for diseases diagnosed under the program.
Untied Grants to sub-centers ; This initiative is used to fund health care services at the grass-roots level. Village Health Sanitation and Nutrition Committees have received funds to increase local communities' involvement and address children and poor households' needs. Auxiliary Nurse Midwives (ANMs) have also been funded to increase antenatal care and other related services.
Role of Social Workers
Social workers play a pivotal role in advancing these initiatives. They provide voluntary, communal-based, non for profit affiliated or even state-affiliated services. They play many functions, such as supporting medical workers in advocacy, driving, committee operations, and data collection. All these services ultimately lead to the success of such governmental interventions. Most care in rural places is offered by untrained informal workers (Mohanan et al., 2016). Thus, social workers augment medically trained professionals in critical need areas and may even seek further training to gain competency for roles such as nurses and midwives. Some serve more than one of the three roles as auxiliary nurses, health advocates, and Anganwadi workers (Scott et al., 2020). They are also critical in recording and providing data on healthcare in rural places, which is essential when making the annual and long-term surveys that help the government structure insurance schemes such as the PFHIs (Ronjan et al., 2018). These insurance schemes have covered hundreds of millions of people and reducing impoverishment caused by OOP costs for hospitalization.
Social workers contribute to better healthcare in India by working in other incidental sectors that contribute to better national health. These include sanitation services, provision of communal education, provision of clean water and food. One such initiative is the Clean India Movement (Swachh Bharat Abhiyan), launched in 2014 to clean the environment and overturn open defecation culture. The government had constructed millions of toilets, but it was the work of social workers who helped push the message and helped in the cleaning services. Today open defecation has reduced from 65% in 2014 to 20% in 2018 (Jain, 2018). This led to eradicating several diseases such as polio and tetanus while continued efforts are being made to eradicate tuberculosis, lymphatic filariasis, and malaria. This new focus on non-communicable diseases is a core function of the NHM. This requires communal awareness, support, and prevention services which social workers from various bodies spearhead. Anganwadi is a key step towards reducing mortality among children, pregnant women and fighting malnutrition in societies. They also focus on providing health education to community members in villages and basic health provision, including contraceptive counseling and supply among adolescents and young women (WCDD, n.d.). Anganwadi workers are trained on the job and must have very good skills and intimate knowledge of the communities they serve. They are largely made up of social workers and play the important role of augmenting an overburdened formal public service.
Despite all these programs, the Indian health system still has a lot to catch up on. Marginalized communities such as the scheduled caste and scheduled tribes do not enjoy the same care that other citizens enjoy. Generally, the system is still overburdened with the national government underfunding it. The system is improving but at a slow pace and still lags in key global metrics.
Source: The Indian Express. (2017, April 7). Five actions to turbocharge India’s public healthcare [Photograph]. https://indianexpress.com/article/opinion/world-health-day-five-actions-to-turbocharge-indias-public-healthcare-5661950/
Section IV: Comparison
The health system in the US is much better than the one in India. However, there are similar challenges that both countries face in achieving UHC. These challenges are expensive healthcare and a shortage of physicians. In the US, the government has created insurance schemes that aim to cover the poor and marginalized groups. Minority groups such as African American and Latin American citizens face racial structural barriers that have prevented them from accessing health services. Most of these challenges are centered on poverty and lack of awareness. The government thus expanded its national insurance covers by passing the Affordable Care Act of 2010. The Act expanded the number of people who receive medical insurance through Medicare and Medicaid (Barnes, 2014). The healthcare standards available to all categories of people have been improved, and a shift is taken towards managing chronic conditions. Another governmental intervention in the US that seeks to improve all Americans' health and wellbeing is creating the US Department of Health and Human Services. Unlike in India, where sanitation matters and health matters may be handled by one body or where the Anganwadi workers may perform so many roles, the HHS has decentralized its programs to more than 100 divisions (HHS, n.d.). This ensures that extensive policies are created for all social problems and enough funds set aside to solve the problems. Such a coherent and well-organized operation ensures that no area affecting health is left unaddressed.
One of the ways local communities can afford healthcare is through advanced nursing practitioners (APN). These professionals' role has been growing more critical in America due to the increasing healthcare costs and lack of medical professionals to serve all American citizens (ANA, n.d.). These professionals perform many roles that Anganadwi workers and informal healthcare social workers do in rural India. They raise medical awareness through communal initiatives such as teaching, counseling, and coaching patients. These efforts are important in disease management, prevention, and research. APNs receive a combination of nursing and medical training, which gives them the competency to act in primary healthcare providers' capacity (Woo et al., 2017). They diagnose, treat, offer laboratory services, and prescribing pharmacological and psychotherapy interventions for their patients. These professionals bridge the gap between access to general practice teams and professionals for millions of people across the country. Most APNs work with rural communities where they are the first contact with medical practitioners for most vulnerable classes of people, with 89% of nurse practitioners (NPs) prepared for primary care provision and 75% providing it (AANP, n.d.). This approach towards training professionals to increase accessible and affordable care to millions is similar in both countries, albeit in the US, the professionals are medically trained and evaluated by competent bodies which certify their specialization in specific health fields.
Conclusion
India has enacted several policies that are supposed to lead to the attainment of UHC. These policies have been successful to a certain degree. The health system still lags due to the country's large population and the low portion of the GDP invested in it. India's problems are comparable to the US, but the US system has created better policies to solve its issues. India should continue investing in its healthcare program and enact more creative policies such as the Anganwadi system to reach its most vulnerable groups. These systems should be provided with more resources and refined to improve access and better healthcare quality.
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