In many sectors including health, India is at a cross roads and looking for new directions and avenues. In health we are facing a situation with stagnant and high ...
Indian Journal of Community Medicine Vol. 31, No. 2, April - June, 2006
View Point National Health Promotion Initiative: An idea whose time has come A. Krishnan1, S.K. Kapoor2 In many sectors including health, India is at a cross roads and looking for new directions and avenues. In health we are facing a situation with stagnant and high maternal and childhood mortality rates congruent with its developing country status while simultaneously facing the emerging challenge of non-communicable diseases (NCDs). (1,2) This is occurring at the backdrop of liberalization and globalization with rethink on the government's role in health.
has been well documented by WHO in its recently released WHO Global Report on "Preventing Chronic Diseases: A Vital Investment 9 ". Evidence from UK suggests that 58% of the prevented deaths due to cardiovascular diseases during the period 1981 to 2000 were attributable to the decrease in the population levels of risk factors10. In India, we seem to be moving towards having a healthier public policy and advocacy. The government seems committed to tackle the burden of NCDs11. We also seem to have a sound public health policy as far as tobacco is concerned. However, our public policies are still driven by individual initiatives rather than a collective initiative. We need a public health movement towards building systems and structures that promote "healthy" approaches of decision making. There is also a need for a broader involvement of stakeholders and different ministries like commerce, urban development, education, environment, agriculture, industry etc. We need to create systems for engagement of all these stakeholders in a meaningful dialogue so as to create a supportive environment. However, all initiatives will fail unless we strengthen community action and provide them with skills to adopt healthy behaviour.
Currently, for the Government of India, the focus is on building the infrastructure and improve its utilization by the community. The recently launched National Rural Health Mission, presents a major initiative in this regard with emphasis on ensuring a basic quality of care (public health standards) and increasing its accessibility and utilization3. We need to strengthen our health systems as without a strong backbone, no system can function effectively. While these steps are welcome and necessary, they are not sufficient to cause improvements in health status of the community. These are technological solutions to health problems and have inherent limitations. There are important social and behavioral determinants of health4. Focusing on these is likely to prevent diseases and cause considerable resource savings to the country in the long run. Major childhood illnesses like malnutrition and infections are largely determined by socially conditioned behaviours5. These are related to daily habits like feeding, defecation, water storage etc. Similarly, many chronic adult diseases are cumulative result of longstanding behaviours like tobacco and alcohol consumption, diet and physical inactivity6.
For this, there is a need to launch a National Health Promotion Initiative in India. There are obviously major challenges in such ventures. Within our limited experience of a health promotion campaign in Ballabgarh, we identified leadership and capacity- both technical as well as social as the most important challenges. Other challenges identified were getting involvement of stakeholders, developing a community ownership and ensuring sustainability. Perhaps, the greatest challenge is to generate resource for this initiative. However, as they say - where there is will, there is a way.
These behaviours need to be changed in the right direction, if any serious dent in the high mortality rates of the country has to be made. Following Geoffery Rose's seminal paper on "sick individuals and sick populations", it is clear that we should work towards shifting the population distribution rather than work at the ends of the distribution7. This is the approach used in health promotion. This unified approach enables us to deal with multiple health challenges facing the country be it childhood infections, HIV/AIDS or NCDs.
In order to fund this initiative, we could create a National Health Promotion Fund (NHPF). The funds for this could come from allocation, taxation or donation. Government can start by allocating some seed money into this grant to which private sector can contribute. Government could also go for a cess on "unhealthy practices" (fast foods, tobacco etc.) to partially fund this initiative. Contributions by the private sector to this fund could be rewarded by some special schemes.
The strategy of health promotion involves advocacy, empowerment and mediation to create healthy public policy, supportive environment, strengthen community action, develop personal skills and reorient health services8. The evidence for its effectiveness already exists for chronic diseases and
This NHPF could be managed professionally by a broadbased group of individuals like doctors, communication specialists, behavioral scientists, public health professionals, educationists, industrialists. The fund so raised need to be utilized for communication campaign, capacity building of different stakeholders at different level especially at community level, advocacy aimed at policy makers, and monitoring and
1. 2.
Centre for Community Medicine AIIMS, New Delhi. Comprehensive Rural Health Services Project, Ballabgarh AIIMS , New Delhi. Received : 27.01.2006
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evaluation of the program and strengthening of health systems. Research must be an integral part and would need to be carried out at different phases of the program to address operational issues. The question is even if we have the commitment do we have the technical capacity to execute such a program. We need to strengthen existing institutions like Central Health Education Bureau (CHEB) to address these challenges. We need to invest more in terms of manpower, training in social and behavioural sciences as they are scarce and those available are treated like "second-rung citizen" by public health and medical professionals. It is for us, the public health professionals to advance this agenda to policy makers and program managers and we could well have another success story in public health. Are we ready for it? We do seem to be moving in this direction with efforts to form a sub-committee on Health Promotion within IAPSM. But it is moving too slow. Unless we take the initiative now this would again be the usual story of missed opportunities that abound in our discipline and we would have surrendered yet another success story to clinicians. It is right time for us to get the act together.
National Commission on Macroeconomics and Health. NCMH Background Papers: Burden of Disease in India. Ministry of Health & Family Welfare, Govt. of India, New Delhi, 2005.
3.
Ministry of Health & Family Welfare. National Rural Health Mission (2005-2012): Mission document . Government of India, Delhi, April 2005.
4.
Marmot MG., Wilkinson RG (ed.) Social Determinants of Health, Oxford University Press, 1999.
5.
Claeson M., Waldman RJ. The evolution of child health programmes in developing countries from targeting diseases to targeting people. Bulletin of the World Health Organization 2000; 78:1234-45.
6.
World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, 2002
7.
Rose G. Sick Individuals and sick populations. International Journal of Epidemiology 1985;14: 32-38 WHO. Ottawa Charter for Health Promotion . First International Conference on Health Promotion, Ottawa, 17-21 November, Copenhagen: WHO Regional office for Europe, 1986.
8.
9.
Preventing Chronic Diseases: A Vital Investment: WHO Global Report. World Health Organization, 2005.
10. Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation 2004; 109: 1101-7.
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11. Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet. 2005; 366:1744-9.
Abdul Ghaffar, K. Srinath Reddy, Monica Singhi. Burden of Non - Communicable Diseases in South Asia. Br Med J 2004; 328: 807 - 810.
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