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Looking at the Villages: The Nuances of Public Health Service Delivery in Rural India

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Pooja Paswan
September 27, 2020

“The health of people is the foundation upon which all their happiness and all their powers as a state depend”
– Benjamin Disraeli, British Prime Minister

The practice of public health (in the pre-COVID era) has been dynamic in India, and has witnessed many hurdles in its attempt to affect the lives of the people of this country. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus (HIV) have been addressed through a concerted action of the government. Social development coupled with scientific advances and healthcare has led to a decrease in the mortality rates and birth rates.

The new agenda for public health in India includes the epidemiological transition (rising burden of chronic non-communicable diseases), demographic transition (increasing elderly population) and environmental changes. The unfinished agenda of maternal and child mortality, the HIV/AIDS pandemic and other communicable diseases still exerts immense strain on the overstretched health systems.

The Silent Epidemics

In India, the tobacco-attributable deaths range from 800,000 to 900,000/year, leading to huge social and economic losses. Mental, neurological and substance use disorders also cause a large burden of disease and disability. The rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000 deaths in 2005) makes it next in the list of silent epidemics. Behind these stark figures lies human suffering.

The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender and race or ethnicity. Lack of adequate progress on these underlying social determinants of health has been acknowledged as a glaring failure of public health.

In the era of globalization, numerous political, economic and social events worldwide influence the food and fuel prices of all countries; we are yet to recover from the far-reaching consequences of the global recession of 2008.

Health Information System

The Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector. Health profiles published by the government should be used to help communities prioritize their health problems and to inform local decisionmaking. Public health laboratories have a good capacity to support the government’s diagnostic and research activities on health risks and threats, but are not being utilized efficiently.

Health research system

There is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.

Health promotion

Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity; These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened.

Public health policy

Identification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector, e.g. in the United States, the, “Healthy People 2010,” offers a simple but powerful idea by providing health objectives in a format that enables diverse groups to combine their efforts and work as a team. Similarly, in India, we need a road map to, “Better health for all,” that can be used by states, communities, professional organizations and all sectors. It will also facilitate changes in resource allocation for public health interventions and a platform for concerted intersectoral action, thereby enabling policy coherence.

Community participation

Community participation builds public support for policies and programs, generates compliance with regulations and helps alter personal health behaviors. One of the major strategic interventions under NRHM is the system of ensuring accountability and transparency through people’s participation—the Rogi Kalyan Samitis. Potential areas of community participation could be in lifestyle modification in chronic diseases through physical activity and diet modification, and primary prevention of alcohol dependence through active community-based methods like creating awareness and behavioral interventions.

The road ahead

In this changing world, with unique challenges that threaten the health and well-being of the population, it is imperative that the government and community collectively rise to the occasion and face these challenges simultaneously, inclusively and sustainably. Milestones in the history of public health have had a telling effect on millions of lives , such as launching the Expanded Program of Immunization in 1974, Primary Health Care enunciated at Alma Ata in 1978, eradication of smallpox in 1979, launch of polio eradication in 1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few. It was a glorious past, but the future of a healthy India lies in mainstreaming the public health agenda in the framework of sustainable development. Social determinants of health and economic issues must be dealt with using a consensus on ethical principles—universalism, justice, dignity, security and human rights. The ultimate yardstick for success would be if every Indian, from a remote hamlet in Bihar to the city of Mumbai, experiences the change.


Author: Pooja Paswan is an Assistant Professor in the Department of Political Science at Jamia Millia Islamia University, New Delhi, India. She has Ph. D in Public Administration and specializes in Public Policy. She was recipient of the ASPA 2019 Founders Fellow. She has worked extensively in the area of development administration and policy. She can be reached at https://jmi.academia.edu/PoojaPaswan and [email protected]. Twitter @poojapaswan

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