Over the years, healthcare gravitated towards hospital-based curative care. A gradual shift has started to reverse this trend, as the developed world too is struggling to sustain rising healthcare expenses. It is estimated that only twenty-five percent of the impressive increase in longevity of life is attributed to curative care. Despite this, health budgets are mostly talked in terms of financing healthcare provision.
Access to safe drinking water and improved sanitation of habitats have the potential to prevent millions of deaths caused due to water-borne diseases. Access to clean air( indoor or outdoor) and reduction/ elimination of smoking can reduce the burden of chronic lung diseases, which rank next only to cardiovascular diseases asleading non communicable diseases causing death and disability. Focus on road safety can reduce vehicular accidents, which is the leading cause of deaths in young people. Access to healthy food, especially for pregnant women and children, can prevent heightened future risk of NCDs. Inculcating healthy habits in school going children can have a significant impact on the future risk of lifestyle related diseases like diabetes, hypertension, and obesity that lead to various life-long diseases.
Unfortunately, most policymaking related to health promotion happens outside the purview of the Ministry of Health. These include ministries of water, energy, environment, roads and buildings, labor, education, and finance among others. Health promotion, therefore, has to be stewarded by the Prime Minister himself/ herself. The Ministry of Health shall provide the evidence-based policy brief to all concerned on the issue of health promotion. Convincing research exists on the economic impact of investing in health promotion activities. Unknown to many, various initiatives announced in the recent times contribute significantly to health promotion. These include the Swatch Bharat Abhiyan (hygiene and sanitation), Pradhan Mantri Ujjwala Yojana (reducing indoor pollution), Jal Shakti Abhiyan (safe drinking water to every household), Fit India Movement (inculcating physical fitness in students), Eat Healthy India (creating awareness about health eating) and policies around alternate clean energies that reduce air pollution and therefore both lung and heart diseases. Studies have demonstrated the impact of Swatch Bharat in reducing diarrheal illnesses.
Vaccines illustrate the power of prevention in saving millions of lives across the world. Tobacco control programs have clearly demonstrated an impact on reducing its consumption. Programs on reproductive health not only prevent maternal and neonatal deaths but also reduce the future risk of NCDs as fetal health is linked to it. While seat belts and helmets prevent deaths from road accidents, condoms prevent infections from HIV, and face masks prevent lung infections caused from high polluting air. The Framingham study introduced the concept of risk of cardiovascular diseases, based on simple risk factors such as age, gender, smoking and tobacco use, blood pressure, blood sugar, and cholesterol levels. Similar risk assessment methods have emerged for cancer, chronic kidney, lung, and liver diseases. Large primary and secondary prevention trials have demonstrated the benefitoflife style changes, control of blood pressure and blood sugar, and use of statins and aspirin in preventing future CVDs. Similarly, drugs like ACE inhibitors and angiotensin receptor blockers (ARBs) have similar impact on the progression of chronic kidney disease (CKD). Vaccines against hepatitis and papilloma viruses have reduced the incidence of cervical and liver cancer. Advances in molecular diagnostics are offering additional screening tools including genomic analysis and risk stratification among populations.
Even with enough evidence on the role of preventive interventions, their adoption in improving population health has been surprisingly low. Weak primary healthcare (PHC) systems and strong focus on hospital-based care (HBC) underlie the current state of preventive medicine. Most payer systems focus exclusively on hospital based curative care, and not on outpatient based preventive care. Of late, private players have started focusing more on wellness as their business models. However, many of these programs arestrong on business promotion and weak in scientific design. Ideal preventive screening tests should be of low cost, and easy to administer across wide populations. We do not need master health checkup packages consisting of a plethora of tests, to estimate future risk of a disease or early detection of a disease in high risk populations.
For example, CVD risk for a period of ten years can be estimated by a frontline worker using simple risk assessment tools. We just need to know the age, gender, history of smoking and tobacco use, family history of CVD, blood pressure, and blood sugar to arrive at the risk. A stress test is sufficient for early detection of coronary artery disease in people who are at high risk for CVD. A simple test like urine protein estimation in a diabetic can identify the future risk of CKD, while spirometry can estimate the extent of lung damage in smokers. Similar guidelines exist for cancer risk assessment and screening for early cancers in those at high risk for cancers.
It is not enough to just assess the future risk or make an early diagnosis of a treatable condition. These need to be followed up with effective preventive care. Despite availability of compelling evidence, uptake of preventive drugs is abysmally low in populations. Adequate control of easily preventable comorbidities like diabetes and hypertension is achieved in a very small percentage of population. Hence, there is an urgent need to not only put population-wide screening programs but to also follow-up with effective preventive care programs to realize the impact of preventive care.
Given the above reasoning, the recently presented Union Budget makes sense in allocating more resources for programs aimed at health promotion and disease prevention. There is also a need for good stewardship by the governance systems to curb business-directed wellness programs being offered to gullible people. Organizations can take strategic decisions on investing in health promotion and disease prevention programs for their employees to increase productivity and reduce healthcare expenses.
Dr Krishna Reddy Nallamalla
Country Director, ACCESS Health International
Views expressed by the author are personal.