|Year : 2021 | Volume
| Issue : 1 | Page : 1-5
Health achieving societies: Past discourses, present predilections, and possible future contradictions
Shaffi Fazaludeen Koya1, Kesavan R Nayar2, Arathi P Rao3, Lekha D Bhat4
1 School of Public Health, Boston University, Boston, MA, USA
2 Global Institute of Public Health, Ananthapuri Hospitals and Research Centre, Thiruvananthapuram, Kerala, India
3 Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
|Date of Submission||17-Dec-2021|
|Date of Decision||20-Jan-2021|
|Date of Acceptance||29-Jan-2021|
|Date of Web Publication||31-Mar-2021|
Shaffi Fazaludeen Koya
School of Public Health, Boston University, Boston, MA
Source of Support: None, Conflict of Interest: None
Economic growth is not an essential prelude to better health as some countries like Sri Lanka and the Indian state of Kerala have shown. Progressive social policies and investments in the social sector have helped some of these countries in the past. This may be unrelated to the present predilections which could certainly lead to future contradictions, especially in giving rise to new scenarios in public health. We have seen that unrealistic setting of goals, ambitious targets given to an ailing health system, together with a lack of clarity regarding activities can result in poor achievements even with incentives. This is more relevant in the future with the complexity of an epidemiological scenario involving both communicable and noncommunicable diseases. Mere techno-centric packages cannot tackle the complex health issues that India face today, as they ignore the larger structural dimensions of the problem. This is especially important with prolonged old age. This necessitates a focused futuristic vision for the population in general and the elderly in particular with a focus on primary care.
Keywords: Elderly health, epidemiological transition, mental health, social determinants of health, sustainable development goals
|How to cite this article:|
Koya SF, Nayar KR, Rao AP, Bhat LD. Health achieving societies: Past discourses, present predilections, and possible future contradictions. J Public Health Prim Care 2021;2:1-5
|How to cite this URL:|
Koya SF, Nayar KR, Rao AP, Bhat LD. Health achieving societies: Past discourses, present predilections, and possible future contradictions. J Public Health Prim Care [serial online] 2021 [cited 2021 Jun 21];2:1-5. Available from: http://www.jphpc.com/text.asp?2021/2/1/1/312696
| Introduction|| |
Achieving society is a well-known theoretical concept developed by David C. McClelland after a rigorous quantitative examination which attributed overall development in the high-income countries to certain psychological factors, especially a character called the achievement motivation. Achievements in health were also linked to such economic growth. This came from empirical observations that societies which had progressed materially also had achieved better health indicators. Such theories and empirical examinations were subjected to much critical scrutiny and especially with respect to health and the general observation was that rigid unilinear explanatory paradigms were unsuitable or insufficient to explain health achievements.
The above observation is the result of some trends evident from hard data. For instance, it was thought that the high-income countries could eradicate much of the infectious diseases and the so-called Neglected Tropical Diseases. But the explanatory paradigms with respect to disease causation got further complicated because the poor among the high-income countries also share the burden of the Neglected Tropical Diseases. It means that the simplistic explanations based on geographical or economic boundaries may not be appropriate for global health discourse.
We want to focus on these complexities and exceptions especially because some countries like Sri Lanka and the Indian state of Kerala achieved better health status without profound economic growth. These exceptional cases of achievement in health without proportional increase in wealth was linked to progressive social policies and investments in the social sector. This is a past discourse and may be unrelated to the present predilections which could certainly lead to future contradictions especially in giving rise to new scenarios in public health.
The “future” from a public health perspective is not just a philosophical question. It is also linked to the empirical context, i.e., the disease scenario in the past and present. The future is especially important given the societal commitment to provide healthy living to the people. For instance, Public health played a significant role in changing the quality of life of people in many countries. In the United States, it made a difference to the quality of life of people by its problem-solving capacity in addressing issues like water quality, immunization, and food safety.
Such problem-solving capacity is enhanced by a number of trends in the present which necessitate an integrated and contextual futuristic vision. These trends are the course of current patterns of diseases and it is important to recognize both the existing and emerging diseases in many parts of the world. Whether a disease-free world is possible is a philosophical as well as a medical/public health question. This is closely linked to the interactions between human beings and the living world as well as the new disease-causing “agent” namely, the lifestyle which is the creation of human beings themselves.
The goal orientation in health
A futuristic orientation in health and wellbeing is discernible in the international context from an official and institutional framework related to the proclamation of goals, firstly the Millennium Development Goals (MDG), followed by the Sustainable Development Goals (SDG). But much before all these goal orientations, a futuristic vision was very much evident in India at different points of time. Even before Independence, Bhore committee recommendations had a range of short-range and long-range goals. The foundations of the health services in the country is still very much in tune with the committee recommendations centered around the establishment of Primary Health Centers, which was proposed for every 40,000 population in the short term and for every 20,000 in the long term. Some of his recommendations are yet to be fully implemented, as once can see from a comparative analysis of the actual set of services that we have even today in Primary Health Centers vis-à-vis his proposed plan to have a range of services ranging from health education to school health to in-patient curative care.
Health for all (HFA) declaration remains a unique chapter in the history of international health. Even though it's still considered a gold standard or benchmark in the policy realm, the declaration failed to achieve its objectives in all practical sense. Even though the Primary Health Care (PHC) strategies that was the key highlight of the declaration influenced the health policies of many countries including India, the strategies were overpowered by the vertical approach of program planning pushed by various international agencies including the IMF. The structural adjustment program pushed the countries to ignore the comprehensive primary care strategies which are considered even today as a “treatise on social sciences in health.” Very simplistic approach of disease control programs with a set of targeted actions operating in silos failed to visualize a comprehensive strategy to achieve HFA, that included community engagement, decentralization, and self-reliance.
Reproductive and Child Health (RCH), National Tuberculosis Control Program, Malaria Eradication Program are all examples of vertical programs with unrealistic goal setting. Years later, all these programs were found to have failed in achieving its stated objectives or targets. In fact, the unifocal actions of these program and the “one-size-fit-all approach” across the whole of India with already existing wide variability in terms of social determinants of health, resulted in wasting time and resources. RCH program for instance, focused more on female sterilization, though the project envisioned reproductive health and gender equality. Comparison of Rural Health Statistics data for Empowered Action Group states for two successive rounds of surveys (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, Uttaranchal) not only indicated no reduction in disparities in RCH status, but in fact showed widening gap in terms of service coverage for delivery and immunizations. This was primarily because the program didn't consider the specific local needs and realities when designing the interventions. The emphasis on family planning without addressing inequalities had negatively impacted the credibility of health services. This also showed that incentive-based programs may not work in such setting with existing inequities. Our own studies in the Malappuram district of Kerala showed that incentives may not work in a situation where social media played an important role in vaccine hesitancy. What is emerging is a Diginet society where new forms of oral traditions, common in tribal societies influence health behavior and health actions.
At the international level, the setting of goals continued to be a trend aiming to accelerate development and eradicate poverty in developing countries. MDG with a design favoring comprehensive improvement in health, education, and empowerment, was by all means, a positive policy development at the beginning of 21st century. However, the lack of reliable baseline data for most of the indicators in developing countries resulted in unrealistic target setting, given the amount of investment and time required for changes to happen in many countries. This was also complicated with the emergence of crises and instability in many countries, as well as the devastating effect of AIDS that singly reversed many of the health achievements till then. The targeted approach with focus on vertical programs continued to erode the PHC approach advocated by the WHO. The SDG were another set of 17 goals adopted by the United Nations member states in 2015 and which replaced the MDGs. This integrated approach is intended to address issues of poverty, hunger, environmental stability, peace, etc., and has set a target of the year 2030.
India also has to be realistic when setting goals. The country has to consider not only the epidemiological parameters or the natural history of any specific problem but also the complex nature of health and health determinants in the country. Targeted interventions which are packaged around techno-centric vertical programs and implemented by cadre staff, will not be able to make changes. The country needs to consider the structural dimensions of the problems and need to preserve and promote comprehensiveness of health services.
Against such a scenario of disorder and disjunctions, there also exists a parallel policy intent both at the international level and in India. Social determinants of health are increasingly recognized to impact disease burden, including noncommunicable diseases. Numerous economic, political, and structural determinants have been identified and widely discussed since the nineties. As of late commercial determinants have been separately identified given the large influence of food, alcohol, and tobacco industry in noncommunicable diseases. The Commission on Social Determinants of Health (CSDH) of the WHO and the High-Level Committee on Universal Health Care of the Planning Commission in India are examples of efforts to mainstream policy and actions around wider health determinants.,, The CSDH gave importance to key issues like health inequities in several developing countries. Both have considerable degree of state and civil society participation and are being discussed in the public domain. However, such intentions need to negotiate with the disordering institutional culture that has resulted from the past policies and actions. In addition, the epidemiological complexity also adds to the disorder.
The epidemiological complexity
Apart from systemic issues and international-national intents in the form of goals, the futuristic vision has now become extremely important given the epidemiological-demographic scenario. The future complexity has to be assessed on the basis of an epidemiological scenario involving both communicable and noncommunicable diseases. Otherwise, the emaciated health services would become increasingly market-driven and could pave the way for a drive for diagnostics and drugs since the noncommunicable diseases entail considerable use of the same. Another important issue that has a futuristic dimension is the demographic situation that could result from aging.
India, the second-most populous country in the world is generally known to be a “young nation.” However, according to projections for India, the elderly in the age group 60 and above is expected to increase from 71 million in 2001 to 301 million in 2051. It is expected that there will be 32.0 million people 80 years and above in 2051. In this scenario, the health and health care need of elderly is of prime importance from a futuristic vision.
The older population face considerable health problems such as Chronic diseases (Diabetes, hypertension, heart disease, stroke, COPD, and cancer), mobility disorders, dementia, and other disabilities. Early studies from India in the nineties and later showed cardiovascular diseases account for one-third of elderly mortality.,, Among the chronic diseases, hypertension, cataract, and osteoarthritis were the three most common illnesses. The higher prevalence of cardiovascular diseases, circulatory diseases, and cancers necessitate a specialized approach. Some of the health problems such as chronic bronchitis, anemia, high blood pressure, kidney problems, digestive disorders, vision problems, diabetes, rheumatism, and depression are also found among the aged. Several risky behaviors such as alcohol use and tobacco use are also found to be high among the aged. Mental health issues among elderly are related to physical ill-health as revealed by many studies globally. However, studies on mental health issues, especially among the elderly, are scarce in India.
Status in Kerala
Kerala state can be taken as an example for analyzing the implications for such a demographic and epidemiological scenario. Kerala, with a population of 33,406,061 has a higher proportion of persons 60 years or older in its population (4,193,393), i.e., 12.6% compared to the national average of 8.6%. This high proportion is likely to be due to the high life expectancy at birth, of 74 years, in Kerala compared to the national average of 63.5 years. Other factors include the low population growth rate with a decadal growth rate of 4.9% compared to the national decadal growth rate of 17.7%. In view of the progressively declining decadal growth rate in Kerala, the proportion of the older population in Kerala is likely to increase in the years to come. The drops in birth rate and near replacement fertility also contribute to this scenario. While high life expectancy and the low decadal growth is a success for the state of Kerala, the increasing proportion of the older population also presents a large number of challenges for the state, their families, and the community at large. The challenges include issues related to partnering in economic growth, economic security in old age, the organization of health care systems and the strength of familial support systems for the elderly. The problem in Kerala is compounded by a high rate of migrations, to other states and other countries (mostly for employment), resulting in declining level of family support to older people. Studies show that the number of older persons living alone in Kerala is higher as a result of migration of the younger age group to other states and the Gulf countries for employment leaving their parents back. It is estimated that 2.1 million persons from Kerala have migrated for employment. The well-known Kerala model of development and the foreign remittances by the nonresident Keralites have brought in prosperity to the state. However, the quality of life of the dependent older persons is hard hit. Studies on the health behavior of such age groups are however scarce.
Health problems of the elderly in Kerala
In this context, available research and reviews based on census and other macro data show that the elderly in Kerala face problems like financial instability as majority of them (84%) do not work mainly due to health problems. Psychiatric problems, loneliness, lack of emotional support, etc., are common. It is found that the elderly suffer from a higher disease burden including disability and debility than other age groups. Census data show that the most common disabilities among the elderly were locomotor disability and visual disability. Persons suffering from Alzheimer's have increased. Diabetes, hypertension, and cardiovascular diseases affect across the adult age groups, but especially affect the elderly lowering their quality of life and reducing their life span. Early studies also reported high burden of hypertension among elderly, with one study reporting a 50% prevalence. In many instances, the elderly usually face multiple morbidities which can hamper their quality of life. Multimorbidity leads to physical dependency and suffering. This in turn can lead to economic and mental dependency, which results in the poor quality of life for the elderly. This scenario in Kerala is likely to be a forerunner to what can be expected in other parts of India in the future.
The social dimensions of health care cannot be concealed in this context. The social ranking or class of the individual, the economic status, and the gender adds different layers of vulnerability for the elderly. For the elderly, their income, dependency on their children or spouse for finance, level of education, occupational status and their social class determine their socio-economic status, which has repercussions on their health status. In Kerala, catastrophic health expenditures were more in households with elderly (51%) when compared to households with no elderly (32%). This was mainly due to the higher prevalence of chronic illnesses among the elderly. Aging has also become a gender issue not only because more women are surviving into old age and more are surviving as widows, but they are also vulnerable and disadvantaged in many ways.
Health care needs of elderly
The health care needs and the health-seeking behavior of the elderly in India, specifically in Kerala have not been studied in detail so far. However, available evidence shows that in Kerala, a significant proportion of the older population often seeks health care with alternative systems of medicine owing to the traditional popularity of these systems. The health-seeking patterns of elderly in Kerala, in a study looking at the status of elderly in select seven states of India, indicates that for acute morbidity 35.8% visit government hospitals, 48.5% visit private hospitals, and 7.6% visit Ayurveda, Yoga, and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) practitioners. The proportion of elderly seeking AYUSH care was highest for Kerala among the seven states studied. This is indeed an important orientation which has implications for future strategies for the elderly.
The neighboring states of Karnataka and Tamil Nadu are also experiencing almost similar trends although not as prominent as in Kerala. According to the Census, Tamil Nadu has one of the highest proportions of the elderly population (10.4% of the total population) just next to Kerala and Goa. The morbidity profile is the same as in Kerala with the majority of the older population suffering from hypertension, diabetes, asthma, and heart diseases. Acute morbidity is high among rural elderly than their urban counterparts. Gastro-intestine related problems are also widely reported. In Karnataka, the Census data show that the proportion of elderly has increased from 7.2% in 2006 to 9.6% in 2011. Studies undertaken in Karnataka show that common morbidities experienced by the elderly include Orthopedic, cataract, respiratory diseases followed gastrointestinal and dental morbidities. Lifestyle diseases like hypertension, diabetes and central nervous system were also found to be prevalent in this population. On the whole, emerging issues regarding the elderly in states like Kerala, Tamil Nadu and Karnataka include high morbidity due to Non-Communicable Diseases, cost of care, access to services, disability.
In the case of elderly care, a disease-oriented view prevails; this is clear from the outpatients departments that focus on spontaneous demand, lack of emphasis on home visits on a regular interval, other appropriate strategy to address loneliness, and safety issues of elders living alone. The main focus is only on diseases or health conditions like diabetes, hypertension with the biomedical model of health taking the lead role. Social determinants of health, quality of life, happiness, safety and security, etc., are neglected in policies and programs.
| Conclusions|| |
As Graham suggests, public health principles are consistent with the principles that can promote conditions that can ensure healthy futures. India has a long history and tradition of a futuristic orientation starting with the well-known Bhore Committee. What we highlighted here is that the public health vision and primary care programs for the future need to be based on the epidemiological reality of the present and the emerging disease and demographic scenario which can present as future maladies. In this context, apart from the example of the elderly that we have highlighted in this paper, possibilities of epidemics and pandemics in future also have to be considered. Public health relies on the existing statistical tools such as probability models for understanding the questions of “what will it be” and “what should it be.” But they have limitations, and an in-depth public health perceptual competence is needed to overcome statistical insufficiencies to enhance and sustain health achievements already heralded as positive. Similarly, primary care should be delivered as a comprehensive strategy rather than isolated activities to achieve stand-alone targets. This requires multi-sectoral coordination, decentralization, and community participation as originally envisioned under “HFA.”
There is a need to address multi-morbidity patterns of elderly problems; and a multi-professional input for the care of older people is essential. This is because issues like loneliness and other psycho-social problems also require equal attention. Safety and security of older people who live alone also need urgent attention through coordinated community efforts which is one of the main pillars of primary care. This is the reason; the status of the elderly and their morbidity profile was examined as an illustration. The care of the elderly is a difficult problem to be tackled. As discussed earlier, most surveys and analyses have highlighted the increasing life expectancy with greater chances of a prolonged old age characterized by poverty, degeneration, dependency, and the typical morbidity profile which have all added to the seriousness of the problem. This necessitates a focused futuristic vision for the population in general and the elderly in particular with a focus on primary care. Elderly people's problem requires a community based PHC approach. Capacity building within communities, care givers, and health care professionals to take care of the elderly is an important area that needs urgent attention. Training of human resources in geriatric care is crucial to ensure the goal of quality life for the elderly. The elderly is increasingly adopting a syncretic orientation depending on multiple systems of medicine and care-seeking pattern. These also include increasing dependence on technology such mobile phones and the Internet for information and even self-care besides the advice of health professionals. This could be perceived negatively by clinicians, but we need to explore such maladies to eliminate the bigger maladies of an epidemiological disaster.
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Conflicts of interest
There are no conflicts of interest.
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