A jobs scheme to im­prove pub­lic health

Mint ST - - VIEWS -

Like the US’ De­pres­sion-era pub­lic works pro­gramme, MGNREGA labour

could help elim­i­nate dis­eases

The tragedy of chil­dren with en­cephali­tis dy­ing in a Go­rakh­pur hos­pi­tal has caused much out­rage about hos­pi­tal mis­man­age­ment. Far more out­ra­geous is the fact that en­cephali­tis threat­ens many thou­sands of lives ev­ery year in Go­rakh­pur alone, and this in the 21st cen­tury.

Peo­ple liv­ing in places with a high preva­lence of com­mu­ni­ca­ble dis­eases un­der­stand­ably con­sider it nor­mal to suc­cumb to dis­ease. This was also the case a cen­tury ago in the de­vel­oped world. The state has to im­prove san­i­ta­tion and pub­lic health ser­vices to re­duce the preva­lence of these dis­eases, de­spite lack of pub­lic de­mand for such ser­vices. Most coun­tries around the world have made this a pri­or­ity, view­ing it as es­sen­tial to build­ing de­vel­op­ment in­fra­struc­ture, im­prov­ing hu­man cap­i­tal and labour pro­duc­tiv­ity, and re­duc­ing poverty.

Health ser­vices in In­dia have pri­or­i­tized med­i­cal ser­vices, ne­glect­ing pub­lic health ser­vices that seek to re­duce the pop­u­la­tion’s ex­po­sure to dis­ease. This ne­glect is ev­i­denced in many ways, such as the ex­plo­sive growth of an ar­ray of mos­quito-borne dis­eases. Fae­cally trans­mit­ted dis­eases, which in­clude in­fec­tions from a whole cafe­te­ria of par­a­sites, viruses and bac­te­ria, cause wide­spread de­bil­ity and can be fa­tal. Treat­ment for such dis­eases is sought on a huge scale across the coun­try, while fae­cal waste con­tin­ues to be poorly man­aged. Stud­ies show that ma­jor In­dian rivers now con­tain an­tibi­otic-re­sis­tant mat­ter, sup­ply­ing wa­ter that can threaten im­mu­nity to avail­able drugs.

Re­duc­ing ex­po­sure to com­mu­ni­ca­ble dis­eases is of the high­est pri­or­ity in pub­lic health ser­vices, as their spread causes se­vere neg­a­tive spillovers. This ap­plies also in coun­tries where these dis­eases have long been elim­i­nated, to avoid their resur­gence. For ex­am­ple, there is con­stant mon­i­tor­ing of mos­quito-breed­ing in the US, al­though malaria was elim­i­nated by the 1940s. There is con­stant sur­veil­lance of im­ported cases of com­mu­ni­ca­ble dis­eases, so as to quickly limit their spread. As Lau­rie Gar­rett, se­nior fel­low for global health at the Coun­cil on For­eign Re­la­tions in New York, put it, “Fo­cus­ing on clin­i­cal ser­vices while ne­glect­ing ser­vices that re­duce ex­po­sure to dis­ease is like mop­ping up the floor con­tin­u­ously while leav­ing the tap run­ning.”

These ser­vices save in­cal­cu­la­ble med­i­cal costs. Quan­ti­fy­ing such coun­ter­fac­tu­als is dif­fi­cult, but con­sider the cost to the de­vel­oped world if com­mu­ni­ca­ble dis­eases were still en­demic there. An in­di­rect in­di­ca­tor of the gains from com­mu­ni­ca­ble dis­ease con­trol is the small gap in life ex­pectancy be­tween the rich­est and the poor­est in the US, de­spite their vast dif­fer­ences in liv­ing con­di­tions and ac­cess to health­care. A 2016 study by Raj Chetty and col­leagues, pub­lished in the Jour­nal Of The Amer­i­can Med­i­cal As­so­ci­a­tion, finds that US fe­male life ex­pectancy at age 40 is 79 years in the low­est 1% of the in­come dis­tri­bu­tion, only 10 years lower than those in the top 1%. This sug­gests that In­dian pub­lic funds could im­prove health out­comes far more if spent on pub­lic health in­stead of sub­si­diz­ing health in­sur­ance.

In­dia’s em­ploy­ment guar­an­tee schemes could use lessons from the US’ De­pres­sion-era pub­lic works pro­gramme. In ar­eas badly af­fected by malaria, this labour was used for large-scale drainage and other works to con­trol malaria, with tech­ni­cal in­puts from pub­lic health per­son­nel and san­i­tary en­gi­neers. The Swachh Bharat cam­paign could also use such tech­ni­cal ex­per­tise to max­i­mize its im­pact in re­duc­ing ex­po­sure to dis­eases.

Char­i­ta­ble foun­da­tions can em­u­late the Rock­e­feller Foun­da­tion’s ef­forts to im­prove pub­lic health and san­i­ta­tion. In the early 20th cen­tury, they found that 40% of school-aged chil­dren in the south­ern US had hook­worm, an ag­gres­sive fae­cally trans­mit­ted par­a­site that can cause list­less­ness and stunt­ing. They spon­sored demon­stra­tion projects com­bin­ing de­worm­ing treat­ment, cam­paigns to raise peo­ple’s aware­ness of the prob­lem, and tech­ni­cal as­sis­tance in build­ing la­trines in homes and pub­lic build­ings. The state health au­thor­i­ties learnt from this ap­proach and ap­plied it widely. Hoyt Bleak­ley’s 2006 anal­y­sis in the Quan­ti­ta­tive Jour­nal Of Eco­nom­ics finds that pro­gramme ben­e­fi­cia­ries gained in school at­tain­ment and earn­ings.

The Cen­tral gov­ern­ment can do much to strengthen pub­lic health ser­vice de­liv­ery in In­dia. Tamil Nadu of­fers some ba­sic or­ga­ni­za­tional prin­ci­ples whereby other states can strengthen their pub­lic health sys­tems within their ex­ist­ing ad­min­is­tra­tive and fis­cal re­sources. My col­leagues and I de­scribed this sys­tem in a 2010 ar­ti­cle in the Eco­nomic And Po­lit­i­cal Weekly. The Cen­tral gov­ern­ment could link its fis­cal sup­port to states with phased progress in the es­tab­lish­ment within the state health de­part­ments of sep­a­rate pub­lic health direc­torates with their own bud­gets and staff, man­aged by med­i­cal doc­tors trained in pub­lic health ad­min­is­tra­tion; the en­act­ment of pub­lic health Acts to pro­vide the ba­sic leg­isla­tive un­der­pin­ning for pub­lic health ac­tion; and the re­vi­tal­iza­tion of pub­lic health cadres.

These mea­sures can help use pub­lic funds more ef­fec­tively for pro­tect­ing peo­ple’s health. The gov­ern­ment can do much else with more in­no­va­tive and bet­ter-fo­cused use of other pro­grammes such as the em­ploy­ment guar­an­tee pro­gramme and the Swachh Bharat cam­paign.

Char­i­ties can em­u­late the Rock­e­feller Foun­da­tion’s ef­forts to im­prove pub­lic health

This ar­ti­cle is the fourth and last in a se­ries on pub­lic health in In­dia.

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