After several decades of vertical disease or age-specific health programmes, there is now general recognition and growing acceptance that the ‘health system’ should be structured and strengthened as an integrated whole to be capable of effectively delivering a variety of health programmes.
Whether it is maternal health or malaria control, even well-intended programmes cannot be force-fitted into a dysfunctional health system. The Sustainable Development Goals of 2015 (SDGs) have brought in health system elements ignored by the Millennium Development Goals of 2000.
Universal Health Coverage (UHC) has been identified as an especially important health system platform for delivering accessible, appropriate and affordable health care to all persons.
Primary healthcare is getting an enthusiastic repositioning as the strong foundation, on which UHC can be built with the promise of delivering integrated and continuous healthcare. However, health extends beyond healthcare. Many determinants of health lie outside the conventional boundaries of the health sector, and many actions that can promote health, prevent disease and aid access to clinical and rehabilitative services have to be undertaken by other sectors.
It is easy to understand how health depends on clean water, sanitation, healthy nutrition, unpolluted environment, safe transport and traffic conditions, control of addictive substances as well as availability of essential drugs, vaccines and health technologies.
Less obvious, but vital, is the impact of assured livelihoods, rural development, education, gender respect and freedom from conflict. Access to healthy nutrition is dependent on production, pricing, processing and marketing of healthy and unhealthy foods. Preventing pollution of air, water and food requires actions across multiple sectors.
While these connections are recognised by policymakers, concerted multi-sectoral action remains a slogan in academic discussions, while the operational reality represents continued compartmentalisation of policies and programmes. The Health Ministry often becomes preoccupied with provision of healthcare services and does not feel empowered to influence policies steered by other ministries—be it agriculture and food processing, or urban design and transport.
The health sector ultimately becomes the mopping brigade of the mess created by inertia or erroneous actions in other sectors. Our attention must shift from strengthening the health system to public health system, wherein all actions—needed to promote, protect and preserve people’s health—are seen as collective responsibilities of all relevant sectors.
With separate budgets and turfs—guarded by implementers with closed mindsets—collaboration and coordination are tough to achieve, unless a unifying public health system regularly connects them to common goals. Ministries may continue to be dedicated to specific domains, but collaborative platforms must be built to enable concerted action to seamlessly serve a prioritised public purpose.
Multi-sectoral action for health will not become real unless all agencies involved do not have a shared ownership of the strategic plan and joint accountability for the health outcomes.
The impetus for such joint action must come from the prime minister, chief ministers and Niti Aayog, while the cabinet secretary and chief secretaries of states must guide and monitor the style, speed and success of collective action towards clearly defined goals.
The SDGs call for an integrated framework of development, with each goal reinforcing the others. Having declared the SDG targets as our guiding lights for India’s developmental journey over next three, seven and 15 years, the next step is to design the architecture of a public health system that will deliver health and well being as promised by the SDGs. ksrinath.reddy@phfi.org