While so many differences have emerged in the context of the recent response to COVID-19 in various countries, one point on which it should be possible to establish wider agreement is that this response would have been much better if a robust, strong, rooted among people, trust-creating, community-based, well-resourced health system was in place in all rural as well as urban settlements. Another point on which it should be possible to have wide agreement is that any health system would work much better if it functioned on the basis of need and not on the basis of narrow profit and control gain considerations and if its policy decisions were not influenced by narrow profit and control considerations.
This is an important time to consider need for comprehensive reforms in health sector. While these will be useful for all countries, in the case of the global south (developing and poorer countries) this need is even more compelling as here essential, life-saving interventions still have to reach many people and the problems arising from hunger and malnutrition as well as low resource base also exist in a big way. Hence developing and poorer countries also have to find ways and means of reducing all misuse, profiteering and wastage of resources while meeting essential needs. They cannot afford to spend their scarce budget on inputs or options which are not useful, wasteful or even hazardous. Hence the availability of more resources has to be accompanied by more caution and firmness in avoiding waste and improper use of resources.
While social, economic and technological progress has made possible significant improvements in health to a certain extent and within certain limits, at the same time it cannot and should not be ignored that several regressive factors have also been at work and in some contexts these have been becoming more dangerous in recent times. An even greater threat is posed by wider changes in environment (such as those relating to climate change, deforestation and animal-human inter-actions) and human society (such as those relating to increasing inequalities, high levels of substance abuse and high level of violence of various kinds) which can bring extremely difficult challenges for the health sector to cope with some of which it may be quite helpless despite all the technological advances. For example if and when weapons of mass destruction are used, a very advanced and dedicated health system can also find itself quite helpless in providing much relief to victims despite the best intentions and high levels of commitment. Hence health systems reform cannot be looked at in isolation and it should be clearly understood and stated that wider reforms in peace, justice and environment protection have to provide a firm base within which the health system can try to contribute its best.
Keeping in view these and other important factors a comprehensive program of health reform is presented here–
* Creating Health Systems Which Meet Essential Needs of All People—It is extremely important to create a health system which is able to meet the needs of all people, including the poorest. This means having primary health centers which meet all basic health needs, including immunization, maternity, preventive aspects, essential health-hygiene-nutrition messages for people and care of diseases and injuries which do not involve too many complications and do not require very specialized equipments and expertise. This should be entirely the responsibility of the government with the involvement of decentralized units of governance and people, with special emphasis on women. This should be entirely free for economically weakest sections, and low cost for all others, while those who can afford to pay can be encouraged to make some contributions as well as donations, the principle being that no one is denied the needed care for lack of money. These primary health centers should have adequate staff and funds to carry out all their duties. There can be one primary health centre for a population of around 10000, supported by sub-centers where needed, in rural as well as urban areas. There can be regional variations depending on special needs and features. Health workers, more of them females, should be based in all hamlets. Ambulances should be available in all such centers. Cooperation of people to meet health needs should be encouraged at all levels. All primary hospitals should be linked to bigger and specialized hospitals of the government, with adequate staff and funds, operating on the same principles, with compulsory acceptance of all complicated cases referred to by primary health centers. In addition private doctors, hospitals and health institutions are to be allowed, but will be regulated as per ethical norms. Young doctors and health personnel keen to work in more remote areas with a spirit of serving poorer people should get special encouragement. Philanthropic institutions functioning with a spirit of service are to be welcomed and encouraged but still subject to regulations, and requested to fill gaps rather than duplicate. All government doctors and health staff should be assured good salaries and satisfactory housing near workplace.
* Curbing/ousting forces of profiteering and control—It is important to keep away those forces which seek to turn health sector into a source of high profiteering, domination and control. Health sector will not be able to serve people and meet their needs in a satisfactory way as long as these forces are not checked. At present these forces are extremely powerful. In India the most rapid emergence of billionaires has been in the health sector, a trend that further intensified in recent pandemic times.
*Responding Well to Climate Change, Environmental Threats, Deforestation and Changing Human-Animal Interactions –It is by now widely agreed that climate change is likely to bring extremely difficult health challenges for which humanity is not at all well prepared in many parts of world. What is more climate change cannot be seen in isolation. A number of other critical environmental problems are linked to very serious harm to health. These include air pollution, water crisis, natural forest depletion and other related changes whose combined impact will pose extremely difficult challenges. Inequalities in health are likely to be accentuated as the poor are affected more by climate change and at the same time have less access to health care. It is important to understand health problems related to deforestation, loss of species and their habitats, cruelty to animals and unhygienic, unhealthy congested conditions of keeping, feeding and slaughtering animals. Health sector should help to increase awareness of essential reforms and push for this. The health sector should give much more importance to climate change related emerging challenges in region specific situations. This should include timely warnings about new emerging problems and situations in various regions. *Reducing Exposure to Hazardous Substances–Due to a complex of factors the chances of excessive and prolonged exposure to a range of hazardous and toxic substances, chemicals and radiation are increasing, particularly for children, leading to increase in a host of physical and mental disabilities and serious diseases, including occupational diseases and various cancers. As scientific research in several such contexts has not been adequate or is biased, the chances of remedial action in time are reduced. Health sector personnel and researchers should watch out more carefully for these linkages so that people have timely warning and public regulation and policy are better informed.
*Improving Access to Adequate, Safe and Nutritious Food –While inequalities and poverty remain a major reason for denial of nutritious food to millions of people, other factors are fast emerging which may deny safe and nutritious food to an even larger number of people. Powerful multinational companies strive to control the world food and farming system in unprecedented ways, spreading genetically modified (GM) crops which have a range of adverse health impacts. The same trends make way for food to be contaminated by more and more dangerous agro-chemicals and food additives and preservatives. Availability of fresh safe food from nearby areas seems likely to diminish, according to recent trends and forecasts. Health researchers and personnel should re-emphasize the important role of safe food from a health perspective, as also how access to safe food is likely to become more and more difficult given the recent trends in world food system, so that people and public policy are better informed on this issue of critical importance.
* Curbing Proliferation of Highly Destructive Weapons and Reducing Possibilities of War-In recent times countries like Iraq and Syria have witnessed the horror of how reasonably well-developed health systems can be destroyed by a few days of bombing, also leaving behind a legacy of longer-term health impacts, such as persistent adverse impacts and disease outbreaks caused by the destruction of sanitation systems. Yet this is nothing compared to what may be unleashed by an exchange of nuclear weapons. Medical science, with all its technological advances, will appear quite helpless in coping with the impacts of any significant exchange (or one-sided use) of nuclear weapons. Yet the possibilities of actual use of nuclear weapons are increasing in some significant contexts, and this year 2022 has been particularly dangerous in this context. Also new very dangerous weapons, such as robot (or AI or autonomous weapons) are fast emerging. The possibilities of very destructive wars are also increasing, with escalating tensions among the most powerful countries and the breaking down (or non-renewal) of existing nuclear arms control agreements. The health sector should more clearly extend its support to the world peace movement and to the various peace efforts, while also giving adequate and timely warning about the much increased and unacceptably high price of conflict and war in present-day world.
*Helping to Reduce Disaster-Related Threats– Both as a result of and independent of climate change, disasters are increasing and have adverse impacts on the health of people in a number of direct and indirect ways, for example resulting in denial of safe water and food while at the same time increasing threats of disease and injury. High intensity cyclones/hurricanes and floods have in recent times caused great destruction and created huge challenges for the health sector but this is only the more visible aspect of disasters as the harm done by less visible but prolonged , more frequent droughts is also enormous in terms of increasing hunger, under-nutrition and malnutrition as well as other health implications. Prolonged drought in the Horn of Africa and several other regions/ countries of the world has put at risk the life of several hundred thousand people. High intensity earthquake risks are known to exist in some densely populated regions some of which are very inadequately prepared to face the threat. The health sector must be better prepared to respond to higher frequency and intensity of disasters.
*Reducing Risks from Accidents- Despite the better availability of technology, due to a number of factors the risks of a wide range of accidents (not just road accidents) is increasing in many parts of the world. Occupational accidents of some kinds can be very high without attracting much public attention. Higher possibility of accidents is troubling anywhere but is likely to have more dangerous consequences in more densely occupied areas. The health sector must not only make better preparation for timely, early treatment of accident victims, but on the basis of its experience and research should contribute more to understanding and reducing causes of high incidence of various kinds of accidents, accident injuries and deaths. Most accidents and accident deaths can be prevented, and the harm done by accidents can be reduced greatly by the availability of prompt medical care.
* Reducing Risks of Violence, Violent Behavior and Self-Harm– Due to a complex of factors everyday life is become more violent in many parts of world and the risk of injury and deaths from violence, including self-harm, is increasing. On the basis of its careful observations and research, the health sector should contribute not just to better care and cure but also to better understanding and reduction of violence, including various kinds of self-harm and suicides.
* Reducing Mental Health related Problems– Several prevailing and accentuating trends can be seen in increased individualism, loneliness, a culture of instant gratification and much reduced stability / commitment in social relationships at various levels. There are also higher levels of aggressiveness in pursuit of increasingly narrow and self-centered goals. Above all it is increasingly clear that social injustice and inequality, and the poverty and indignities these cause, result in acute anguish and suppressed anger over long periods, resulting in widespread, serious mental health problems. The recent pandemic as well its various uncertainties and confusions further increased the risks of mental health problems. Wider social links of mental health are likely to get much more attention if warnings come from health personnel, doctors and researchers. Hence beyond better treatment the health sector can contribute much more to proper understanding and prevention of mental health problems with their wider social dimensions.
* Reducing Substance Abuse—While more and better efforts to check the consumption of and addiction to tobacco, alcohol and all intoxicants are needed, there is also need to avoid militarization of social and health problems as seen in the so-called ‘war on drugs’. The social causes of various addictions, and not just intoxicants, should be better understood. There are indications of overall higher substance abuse, including in new forms, in several societies. This has implications for increase of a wide range of health problems. The health sector should play a more active role in spreading awareness of health impacts of substance abuse as well as its social dimensions, helping society to reduce substance abuse very significantly.
*Improving Access to Safe Drinking Water—Due to a number of reasons, despite more pipelines and hand pumps being installed, the number of people not having easy access to clean and safe water for drinking, cooking and hygiene is likely to increase in several areas, related to depletion of water sources, pollution of water sources, increased dependence on contaminated groundwater pumped from increased depths and saltwater intrusion, to mention only the more obvious factors. By drawing attention to emerging trends in problem areas and by giving timely warnings about health impacts of this, the health sector can contribute to increased attention being given to this important aspect of health.
* Increasing Concern for Poor and Vulnerable People–While the number of people living in poverty has been reported to be decreasing, there are reasons to suspect that some of these achievements may be over-reported and/or the problem may be defined in such a way as to under-report or hide some disturbing trends. To give an example, people reporting more assets than before may yet may be facing more problems in terms of sustainability of their livelihoods or access to basic needs like safe drinking water and safe food, or also may face the wrath of worse disasters in future. Overall the number of vulnerable people may be increasing, particularly in terms of risks to their health and wellness. The health sector can help by providing a more balanced and nuanced understanding of poverty and health.
* Contribution to Reducing Inequalities– At world level inequalities are increasing sharply. This has an adverse impact on health in various ways, for example in terms of access to nutrition, medicines and health care. By drawing attention to adverse impact of inequalities on disease and health problems, the health sector can strengthen the case for policy reform for reducing inequalities. If inequalities continue to increase, this can lead to much worse implications in a situation of climate change, and this is another aspect that demands attention.
* Reducing Social Discrimination– Social discriminations existing at high levels in various societies on the basis of gender, sexual orientation, caste, ethnicity, race, color, religion, faith etc. also get reflected often in access to health care and education, and also have adverse health impacts on people who suffer discrimination. The health sector should be better prepared for this challenge and must contribute to reducing this discrimination, more particularly the prevalence of any such discrimination in accessing health care.
* Ensuring Access to Medicines–Low cost, rational and good quality medicines should be available to all those who need them. No person, no matter how poor, should be denied medicines essential for him or her. This responsibility should be accepted by the public sector to provide all essential good quality medicines at low cost and very low profit margins. International and national philanthropic organizations should help in this, without any bias or narrow interest. Essential and rational medicines should be identified clearly, including essential medicines needed by relatively smaller number of people, and made available at low and affordable cost. The existing patent laws need to be challenged to the extent that these conflict with this objective. The existing serious distortions in the medicines sector should also be challenged in this context and strong efforts made to restructure the medicines industry in keeping with the real needs of people.
* Ensuring real need-based, rational vaccines–Profit-driven distortions have increased even more in the vaccine industry. Control over vaccines is likely to be increasingly used by powerful organizations and forces to not only push for distorted, high-profit orientation of the vaccine sector but to also use vaccine sector as an entry point for growing dominance and control of health systems. In the process irrational decisions may be taken ignoring real need as well as serious side-effects, all this posing serious problems for health sector and its limited budget. Gates of developing countries may be opened for bills of billions of dollars, that too for products of dubious merit. Decisions regarding vaccines should be taken very carefully on rational, ethical and unbiased basis. All irrational vaccines or those of dubious safety and suspect need should be avoided. As far as possible, manufacture of all vaccines should be with the public sector.
* Preventive Aspects Should Get More Attention–Preventive aspects of health care at the grassroots level should get much more attention. Preventive health covering all aspects – from sanitation to checking substance abuse, from non-violence to accident prevention – should be a very important aspect of primary health care and should be well supported. Sanitation and public hygiene should get high priority.
* Adequate Funds and Their Careful Use Should Be Ensured–Adequate budget should be made available for public health and medicine, but at the same time equal care should be taken to ensure that it is used carefully for real needs. If increase of health budgets is misused by strong entrenched interests for earning super profits then the purpose of increasing budgets will not be achieved. Misuse of public funds for enriching private insurance companies should be checked.
* Areas of Special Needs Should Get Adequate Attention–International organizations helped by professional bodies of health personnel everywhere should draw up special plans to meet the special requirements of most needy areas of world for medicines and medical personnel. These include areas of extreme poverty or those affected by disasters and epidemics, or conflict zones. Within various nations rural and remote areas with a shortage of medical personnel should get special attention.
* Medical Education Should Be Reformed–Medical education should be linked from the outset with real needs and priority concerns, linking high standards of education and expertise with most important concerns of people and medical ethics. Along with treatment, prevention of disease and injury should get higher attention.
* Holistic Approach Is Needed– An approach which integrates modern medicine very well with preventive aspects, social concerns and alternative therapies (which have given good results in particular contexts), an approach that integrates physical, mental and spiritual health, an approach that links professional high attainments with medical ethics, which can integrate present day needs with a futuristic vision, will be most useful.
* Improvements in International Cooperation and Regulation Needed–This is needed badly to ensure better observance of medical ethics all over the world and ensure availability of low-cost, good quality rational medicines, medical devices and vaccines all over the world. This is necessary also for developing wider acceptance of a holistic vision. Genuinely philanthropic organizations can contribute much to this effort.
* Pandemic Response—Rational, evidence-based pandemic response must be emphasized. Special care should be taken to ensure that pandemic is not used as an excuse for increasing super profits of corporate interests (resulting in further diversion of medical budgets from real needs) or authoritarian trends at national and international levels(resulting in irrational, excessive curbing of basic democratic freedoms and choices).
* Much Higher Emphasis on Medical Ethics is Required– Various aspects of medical ethics need much more discussion, attention and commitment. A basic principle– cause no harm–may be getting violated on quite a few occasions and in several important contexts, much more so than is generally realized by most people. Such violations should be checked.
Bharat Dogra is Honorary Convener of Save the Earth Now Campaign. His recent books include Planet in Peril, Man over Machine, A Day in 2071 and Protecting Earth for Children.
