Democratise health system through public engagement
Whenever a horrific incident involving a grievous failure of health services erupts in public controversy, or when international comparisons are published placing India embarrassingly low in health and other social development indicators, media commentators question why health is not a policy priority in the country.
K Srinath Reddy President, Public Health Foundation of India
Whenever a horrific incident involving a grievous failure of health services erupts in public controversy, or when international comparisons are published placing India embarrassingly low in health and other social development indicators, media commentators question why health is not a policy priority in the country. Public health officials and advocates offer many apologetic explanations for the low profile of health in the policy debates around India’s development. Politicians are more straight forward in their reply: “Health is not a loudly-voiced priority in people’s demands that we feel compelled to respond to.” They are right. In the many priorities of daily living, issues such as water, electricity, food prices, livelihoods, roads, transport and crime take precedence. Health is not an emotive electoral issue.
There are several reasons why health does not feature high on public demands. First, the obvious relationship between the social determinants such as water, sanitation, nutrition, air pollution and health, or the more abstract links of health to poverty, education, gender and social status, are not widely appreciated by public. Second, breakdown of health is perceived as an individual’s personal issue. Third, dissatisfaction with the quality/cost of healthcare is usually articulated as a grievance against the individual provider or healthcare facility rather than as a protest against an ill-resourced, inefficient and inequitable system. Fourth, when system-level faults are recognised, an aggrieved individual feels helpless in waging a lonely war.
It is true that electoral success has occasionally greeted initiatives such as the introduction of Aarogyasri healthcare financing scheme and the 108 emergency ambulances in Andhra Pradesh, as acknowledged by a re-elected chief minister. These have been replicated in several states since. However, in-depth engagement of legislators and parliamentarians in health policy debates does not occur at the level or frequency needed, nor are they held accountable for poor health indicators in their constituencies. The public is greatly distanced from policy making and has no visibility of programme performance.
How can we change this? The answer lies in democratisation of our health system through regular public engagement with priority setting in health policy, implementation of health programmes and monitoring of outcomes. Well-informed and actively-engaged communities can articulate their demands with greater clarity, call for higher investment in health and demand better returns from that investment as gauged by their lived experience. They will also hold their elected representatives accountable for the availability, cost and quality of health services in their region.
Global experience provides excellent examples of such community engagement. Following the enactment of right to health in Brazilian Constitution of 1988, health councils were set up at municipal, regional and federal levels. Over 5,200 municipal health councils have community representatives reviewing health plans monthly. In Thailand, a National Health Assembly is convened annually with representatives from government, professional groups and civil society. The assembly debates on health issues and sets an action agenda through consensus.
In India, too, evidence of impactful community monitoring health programmes is available in Maharashtra, where civil society organisations have energised and assisted some community groups. However, what is needed is a systematic government-initiated programme engaging a wide cross-section of people and organisations. The best features of the Brazilian and Thai models can be combined as contextually appropriate. This can start at the state-level, initiated by some progressive state governments opening doors to participatory health governance. Political parties, too, should consider making progress in constituency-level, or at least district-level health indicators a part of the performance appraisal of their parliamentarians and legislators. Any takers?