There is enough scientific evidence on disease prevention. Despite robust evidence and available resources, population disease burden continues to grow, especially in low-middle income countries. Some systemic issues that underlie the dichotomy are – awareness on the part of people, providers, payers, and policymakers, and the behavioral underpinnings of all these actors. Hence, there is a need to undertake a whole systems approach to make a meaningful impact on reducing disease burden.
Policies can make a difference
Policy focus on social determinants of healthis critical in disease prevention and health promotion. We have witnessed many policy announcements in recent years – Swachh Bharat mission (hygiene and sanitation), Ujjwala scheme (clean cooking gas to households), Jal Jeevan Mission (safe drinking water to every household), Fit India program (physical fitness for health), Eat Healthy India thrust etc., thathave an important bearing on health. Their impact will be seen only if these are followed up with effective implementation.
India provides food subsidy to millions of poor people. If the same subsidy is directed towards providing healthier foods (for example, millets or brown rice in place of white rice), it can positively impact the health of these beneficiaries. Governments can also improve people’s health by health-directed urban planning in terms of reduction of air pollution, cycling bays, walking tracks, clean& green spaces for outdoor activities, building norms to encourage stairs in place of lifts among others. India is among the countries that are on track to reducing carbon-emission targets as per the Paris Climate Accord. Various policies directed at this are critical to not only environmental but also to people’s health.
Effective public communication is being increasingly seen asplaying a critical role in health promotion and disease prevention. It played a key role in the success of childhood vaccination programs, family planning, and antenatal care among others. It will play a critical role in controlling and reducing the burden of non-communicable diseases (NCDs). Public role models such as political leadership, actors, sportspersons, and religious heads, among others have to embrace the change they promote and promulgate.
Taxation and subsidies have the power to influence people’s behavior. Higher taxes (known assin taxes) on unhealthy foods such as processed sugars, soft drinks, trans-fatsand on tobacco and alcohol can generate higher public revenues that can be used to subsidize healthy foods such as whole grains, vegetables, fruits, milk, fish and the likes and support health budgets.Sin taxes can also act as deterrents to consumption of unhealthy items. Higher budgetary allocations to health promotion and disease prevention made in the recent budget are in the right direction and will yield higher returns on spending in terms of better health and productivity.
Governments have the legislative powers to enact laws that curb unhealthy habits. Control on the consumption of tobacco and habit-forming, recreational drugscan be achieved only through enactment of various laws, like banning smoking in public spaces and making possession, trade, and consumption of prohibited drugs and substances a criminal act. Many countries are now banning soft drinks and fast foods in schools with childhood obesity becoming a public health issue.
The role of payers in disease prevention
Most health insurance players tend to focus on claims, frauds, and denials to maintain a healthy claims ratio. There is a growing trend of adopting population health management strategies with a focus on health risk assessment and disease prevention to reduce hospitalizations. The Ayushman Bharat program consisting of two components, namely, the Health & Wellness Clinics (HWC) and the Pradhan Mantri Jan Arogya Yojana (PMJAY). This is an example of complementarity of prevention and financial protection. Other government health insurance schemes like CGHS, ECHS, ESI etc., have also adopted the combined approach of clinics focusing on prevention and primary care along with providing financial protection to their beneficiaries. Private health insurance systems are yet to adopt these strategies in a big way. However, a gradual movement is seen in this direction.
Health risk assessment (HRA) is vital in defining insurance premiums and in designing the benefit packages. It also provides an opportunity to design risk reduction strategies to curb the need for hospitalizations and the associated high expense claims. A majority of the insurance programs have periodic renewal systems. This presents an opportunity to undertake basic health risk assessment as a precondition to renewal, making it a powerful lever in practicing preventive care.
The role of providers inprioritizing preventive care
Private health provider behavior is skewed by fee-per-service payment systems in favor of high cost curative and hospital-based services. Public health providers are fraught with chronic understaffing and poor health professionals’ performance management systems.
Higher reimbursement to preventive and primary care services coupled with outcomes-based pay for performance strategies can have a positive influence on private provider behavior. Similarly, strengthening comprehensive primary health care (CPHC) with incentives for higher provision of preventive services in public provider systems will enable a similar change.
There has been a growing realization of the business potential of wellness, leading to intense market competition in health screening services at highly competitive prices. While this trend has raised public awareness and increasedthe access to affordable services, it is fraught with the growth of unscientific and unethical practices along with growing inequity in utilization of these services. Providers are using these screening programs to improve their footfalls and conversions. For example, there are clear guidelines on cardiac stress testing for diagnosis of coronary artery disease. However, current offerings that include routine stress testingare leading to unwarranted angiograms and angioplasties. Information on family history, smoking, hypertension, diabetes, and cholesterol are sufficient to arrive at a 10-year risk of a person developing cardiovascular disease.
Similarly, simple breast palpation is as effective a screening tool for breast cancer, as is expensive mammography.Urine examination for protein excretion is the most cost-effective test to diagnose early kidney involvement in diabetes. Periodic eye fundus examination plays a major role in preventable blindness in diabetics. There is a need to create standard preventive screening and treatment guidelines to curb growing unscientific practices. Majority of the providers focus only on screening. While screening unearths underlying preventable risk factors and future risk of disease, it is not effectively followed up with preventive treatments.
Effective Public Health system is essential in disease prevention
A core function of public health systems is disease control, which encompasses robust disease surveillance system, screening and prevention programs, efficient monitoring systems, and effective public information, education, and communication (IEC) campaigns. Public health systems have to be highly responsive to the changing trends in risk factors and disease burden. India has a high burden of both communicable and non-communicable diseases. Along with the ongoing focus on preventing maternal, neonatal, infantile and under-5 deaths and on preventable infectious diseases, there is a growing emphasis on prevention of various non-communicable diseases. Every rupee invested in preventive care yields much greater returns than that invested in curative care.
People have to own more responsibility for their own health
People are at the center of complex health systems. While the rest of the system is responsible for the health of its people, it is often forgotten that people are equally responsible for their own health. With the wide reach of mobiles, internet and social media, people now have access to useful and unlimited information on health. Unfortunately, they are also being flooded with a lot of misinformation. Reliable and consistent public messaging that people can trust is vital to countering this misinformation. Promotional activities of various private players in the wellness space are also aiding in the increased awareness on healthy living and preventive care. People now have easy access to various screening tests, thanks to the growing tribe of online and at-home services and self-care digital tools and apps. Frontline health workers (ASHA and ANMs) in public health are playing an important role in creating awareness and making screening programs accessible.
Despite the growing awareness around prevention and easy access to screening programs, people continue to neglect positive life style changes and preventive therapies. There is a growing focus on studying people’s underlying behavioral issues to come up with strategies that can improve adherence to preventive programs. Traditional systems that focused on holistichuman developmentsystems (mind, body, and soul) like yoga, vipassana (mindfulness) and other forms of meditation are gaining popularity across the world. These systems focus on a healthy diet, physical fitness, mental concentration, awareness or mindfulness, discipline, perseverance, right conduct, morals and ethics. These have grown out of religious constructs to become universal techniques for wellness and wellbeing.
The power of digital and molecular technologies in preventive care
Advances in digital technologies are revolutionizing every form of healthcare including promotive, preventive, curative, and palliative healthcare. Wearable devices, self-monitoring tools and apps, point-of-care diagnostics, online services, and at-home services have significantly improved access to care. Mobiles, internet, and social media are powerful tools to spread awareness on health promotion and disease prevention. Disease management apps are empowering people to take care of themselves and others. Lay people and healthcare professionals are using simple risk assessment tools in planning preventive strategies. Whole exome and genome sequencing are adding additional tools for individual risk assessment and individual responses to various drugs.
Standards-based and interoperable digital health information systems are becoming critical in building personal health records (PHR) and electronic health records (EHR). Federated health data exchanges will make population level health data available to providers, payers, policy makers, and public health professionals, enabling them to make preventive programs more efficient and effective. In addition, national and sub-national disease surveillance systems will become more dynamic and responsive. Big data analytics, machine learning tools, and artificial intelligence will further add to the power of these technologies.
It is evident that there is a need for systems level thinking to create a positive impact on health promotion and disease prevention. Each component of health system – be it its governance, payers, providers, public health professionals, people, and information systems – has a role to play in bringing about this impact.
Dr Krishna Reddy Nallamalla
Reginal Director (South Asia), ACCESS Health International
Views expressed by the author are personal.