Community Health Conundrums

I Satya Sundaram

Atwo-day (March 20th & 21st, 2023) national seminar on the theme, “Community Health and Sustainable Development Goals was held under the auspices of the Department of Sociology and Social Work of Acharya Nagarjuna University, Nagarjuna Nagar-522510, Andhra Pradesh. The Vice-Chancellor is Prof P Raja Sekhar. The Principal is Prof Ch Swaroopa Rani. The Seminar Director is Prof M Trimurthi Rao. The Organising Secretary is Prof V Venkateswarlu.

India is poorly placed in terms of Human Development Index, Happiness Index, Sustainable Development Index and Hunger Index. Community Health is included in Sustainable Development Goals (SDG) 3. There are 17 SDGs. 1. No Poverty. 2. Zero Hunger. 3. Good Health and Wellbeing. 4. Quality Education. 5. Gender Equality. 6. Clean Water and Sanitation. 7. Affordable and Clean Energy. 8. Decent Work and Economic Growth. 9. Industry Innovation and Infrastructure. 10. Reduced Inequalities. 11. Sustainable Cities and Communities. 12. Responsible Consumption and Production. 13. Climate Action. 14. Life below Water. 15. Life on Land. 16. Peace, Justice and Strong Institutions. 17. Partnership for Goals.

The SDGs were adopted in 2020 by 193 countries at the UN General Assembly. Besides 17 SDGs, there are 169 related targets to be achieved by 2030. Experts feel it is not possible to achieve SDGs with current levels of growth (CP Chandrasekhar & Jayati Ghosh: “Why is South Asia performing so badly on the SDGs?” Business Line, March 26, 2019).

India is making progress on SDGs front, but there are differences across the states. Kerala, Himachal Pradesh, Andhra Pradesh, Tamil Nadu and Telangana have made progress in this direction. Experts say a grassroots approach is needed to pursuing SDGs. There is also need to streamline the institutional framework (Parul Jain &Tanveer Ahmed Khan: “A Grassroots Approach to Pursuing SDGs,” Business Line, December 28, 2022).

In India, the poverty ratio has come down to 18 percent. But, the country could not eradicate poverty completely. According to United Nation Development Programme (UNDP), India’s poverty ratio fell from 55.1 percent in 2005-06 to 27.7 percent in 2015-16 and to 16.4 percent in 2019-21. However, there are rural urban disparities–poverty ratio is 21.2 percent in rural areas, 5.5 percent in urban areas. In the Global Hunger Report, India got a rank of 107 out of 121 countries, with a serious malnutrition score.

According to a study published in the journal, The Lancet (February 2023), India is trailing behind in achieving more than 50 percent of indicators under the SDGs, seven years before the 2030 deadline. The study used National Family Health Surveys, 2016 & 2021.

India’s performance on the health front continues to be poor, mainly because of funds shortage. However, some progress has been achieved. Full immunisation drive among children aged 12-23 months has recorded substantial improvement from 62 percent to 76 percent at the all-India level. Institutional births have increased substantially from 79 percent to 89 percent at the all-India level. Institutional delivery is 100 percent in Puducherry and Tamil Nadu and more than 90 percent in 7 States/UTs out of 12 Phase II States/UTs. Child Nutrition indicators show a slight improvement at the all-India level. Stunting has declined from 38 percent to 35 percent, wasting from 21 percent to 19 percent and underweight from 36 percent to 32 percent at the all-India level. In 2021, life expectancy at birth was 69.96 years, fertility rate was 2.18, birth rate 17.38 and infant mortality rate 28.77, All-cause mortality rate was 7.34.

Malnutrition should not be studied in isolation. One should give importance to food and livelihoods. There is a need to combine agriculture, nutrition and health. The National Family Health Survey-5 (NFHS-5) was completed in January, 2020. It revealed, among children aged five years, 35.5 percent were stunted, and 32.1 percent were underweight.

The health sector continues to suffer from funds shortage. Health spending as percent of GDP is 16.9 in the US, 11.2 in Germany, 9.8 in the UK, 4.2 in Turkey and 1.28 in India. This sector is dominated by the private sector. The share of out-of-pocket expenditure in total health expenditure is above 50 percent. The shortfall of specialist doctors is also a serious problem. Of course, spending on social health insurance (at current prices) has almost doubled between 2013-14 and 2018-19.

The Centre has initiated some measures to strengthen the health sector. Of course, food fortification is not enough. The PDS and supplementary nutrition programme should be strengthened. Food habits should change. People have to depend less on rice and wheat, more on coarse cereals, fruits and vegetables. The Year 2023 has been declared International Year of the Millets by the UN, following a suggestion by Indian Prime Minister Narendra Modi. The authorities should encourage organic farming. Public Private Partnership (PPP) has limited scope as health sector is service-oriented.

The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched in 2018. It covers insurance also. However, the Union Budget 2023-24 failed to provide enough funds for this vital sector. Experts say investments need to be prioritised first towards basic services such as nutrition, health, employment, education, educational sanitation and hygiene.

The Centre and the World Bank have signed two complementary loans of $500 million each to support and enhance the country’s health sector development. Through this combined financing of $1 billion, the World Bank will support India’s flagship Programme Pradhan Mantri-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM), launched in October 2021. This mission looks at improving the public healthcare infrastructure across the country. One of the loans will prioritise health service delivery in Andhra Pradesh, Kerala, Meghalaya, Odisha, Punjab, Tamil Nadu and Uttar Pradesh.

The Food Safety and Standards Authority of India (FSSAI) is tightening the labelling norms for breads at a time when a wide number of varieties with health claims are available on retail shelves. From May 2023, bread-makers will need to ensure that a product labelled as whole wheat bread is made of at least 75 percent whole wheat flour and brown bread comprises at least 50 percent whole wheat flour.

The FSSAI is considering releasing a standard operating procedure (SOP) or guidelines on use of health supplements and nutraceuticals. This comes at a time when more and more people are turning to health supplements amid rising awareness on fitness. The producers are usually recommended by coaches or personal trainers at fitness centres. The FSSAI recently directed States to step up the overall surveillance of commonly consumed food products, especially during festival and wedding seasons.

Some voluntary agencies have evolved low-cost health delivery systems.They use the services of retired doctors, charge the cost of medicines only. The very poor get treatment free of charge. The health sector needs innovative strategies.

At the Inaugural session, the Vice-Chancellor said healthy mind is the conduit to happiness. Very often the incidence of mental illness is under- estimated. The power-point presentation by the Keynote speaker, Prof. H. Kalyan Rao, Department of Community Medicine, NRI Academy & Super Speciality Hospital, Mangalagiri, Gunter District, Andhra Pradesh touched on all the dimensions of stress management.

The various papers presented dealt with all aspects of community health. Balanced food alone can reduce the incidence of malnutrition. India’s food security is tenuous because in a climate of inflation and low employment, access to good food becomes difficult. Of course, in a difficult situation, the National Food Security Act is helping the poor. The PDS should function effectively.

Malnutrition should be muzzled. Most children are stunted and wasted. There is also the problem of obesity. Organic farming should be encouraged. Breast feeding should become popular. Mere rise in price support is not enough. A diversified and decentralised procurement system is needed.

The health strategies should be situation specific. In a tribal region, the stress should be on education, sanitation and protected water. Of course, they consume healthy food. Mother’s education is also necessary. Also, violence against women leads to mental ill-health.

The mental health problem has assumed ominous dimensions. It is a serious problem because very often the person affected is abandoned somewhere or thrown out of the house or left in religious places. The rehabilitation services are primarily confined to urban areas. Mental ill-health requires a multi-disciplinary approach. A few papers were presented on CVID-19. Some serious mistakes were committed in tackling the problems. The migrant workers were left in the lurch. Of course, the Government did implement schemes like free ration.

Dr Pravin Yannawar, Assistant. Professor, Department of Psychiatric Social Work, Institute of Human Behaviour & Allied Sciences, Delhi spoke on ‘community mental health in India’. He pointed out India has to fight on various fronts to bring down the incidence of mental illness. Prof P Varaprasada Murthy, Rector and Chief Guest, has observed that good physical and mental health is required to achieve life’s goals. Prof Saraswati Raju Iyer, Dean, Faculty of Social Sciences, has said all developing countries should strive hard to achieve SDGs by 2030.

Major Recommendations
*    India’s food security should aim at balanced food, not merely enhancing food-grain output. India has food-grain security not food security. The stress should be on dietary diversity.
*    The PDS should be used as a conduit to ensure balanced food, and reduce the incidence of malnutrition.
*    The National Food Security Act should be strengthened. There are still some poor families without ration cards.
*    Food wastage needs to be avoided. One can think of more community kitchens.
*    The status of genetically modified (GM) crops should be decided as there are conflicting views.
*    Natural farming should be encouraged not only to reduce cost, but to ensure healthy food and environment protection.
*    Female labour participation should be encouraged as women take care of nutrition needs of children.
*    Budget allocations for social sectors like health and education should be stepped up.
*    India is poorly placed in respect of stunting, wasting and obesity. Hence, India’s rank is not good in the Global Hunger Index.
*    Breast feeding should be encouraged. Food fortification offers cost effective complementary strategy.
*    The government has to bring rural areas too under the coverage of mental healthcare as they are neglected at present.
*    The authorities need not think of “Health for All” To start with, communities and areas which are prone to ill-health frequently should be identified.
*    The health sector needs innovative and cost effective strategies. Some voluntary agencies are following them.

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Vol 55, No. 44, April 30 - May 6, 2023