With over 77 children dead in Gorakhpur due to a lack of public health services, the government does not seem to see public health as a political priority unless there are large-scale deaths.
Although moves have been made in the public health domain, their contradictory nature suggests a lack of a coherent policy, or a vision for public health; on one hand, the government wishes to micro-manage the prices of drugs and surgical implants, on another, it seeks to develop a public-private partnership model for district hospitals. NITI Aayog officials have been calling for a market-dependant healthcare system for a while now, but the health ministry seems unwilling to modify its approach towards healthcare policies and let go of even a bit of control, while providing insufficient facilities. There seems to be a fundamental lack in clarity about the role of the state in public healthcare, and a lack of knowledge about health economics.
Certain aspects to public health have benefits for the entire community and not just an individual. Vaccination programs, and well-functioning drainage and waste management systems contribute to overall welfare and reduces health expenses. Contributions of preventive measures like these impact more than any other aspect of healthcare. A paper by American demographer Samuel Preston showed that only 16% of the gains in global life expectancy between 1938 and 1963 could be attributed to gains in income; investments in public health, which rose rapidly, contributed more to the reduced mortality. Markets, however, have little incentive to provide such public goods, and India, market-driven and recovering from the legacy of the British Raj, is a classic examples of under-provisioning.
Under-provisioning of public funds towards healthcare in India began during British rule, when the government only developed areas with British populations, and focused on curative care. We still have the same focus on curative care (such as making new hospitals, or tackling specific diseases such as malaria) that preventive cure goes widely unnoticed. This distracts from the larger goal of creating an over-arching public health system. Hence, although our disease control programs continue to be successful, the gains are unsustainable because of the weakness of the public health infrastructure. That neglect is seen today when India has become a veritable hotspot for infections, with a high disease burden, which has contributed further to India's nutritional crisis, raising expenditures and lowering productivity.
The Swachh Bharat Program is a step in the correct direction, with the centre taking up charge of sanitation with a vengence; however, its impact is far lesser than it was meant to be. One reason for this is a lack of development of an entire 'sanitation value chain', involving water supply, containment, waste management and sewerage, as pointed out by Bhaskar Pant in a 2016 piece titled Ideas for India. We need a comprehensive framework, with an effective combination of investments. With 2% of our GDP going to public health, India's spending is much lower than its peers.
India could perhaps take a lead out of the Copenhagen Consensus Project, carried out by the Economist magazine and Denmark's Environmental Assessment Institute, which identified a list of welfare projects that would also be economically effective. We need to assess our interventions on the basis of their need and cost-effectiveness, correcting our approach towards preventive healthcare at the same time.