A minimalist approach to tackling population health

Population health is more than just the health of all individuals. The suicide rate is an example of a difference between population and individual health, as Johann McKenbach discusses, While each individual case of suicide has its own specific pathology, the population rate of suicide exhibits remarkable stability over time, ceteris paribus. While individual and population health are inextricably linked, the causes, and thus the interventions needed to address them, vary. Trying to improve population health only with individualistic strategies is predisposed to failure and inefficiency.

individualistic policy measures

In the last decade, the government recognized that the focus of Indian public health was almost exclusively on maternal and child health and infectious diseases for too long. PEG was proposed to be transferred to non-communicable diseases (NCDs) and chronic diseases, whose increasing prevalence reflects enormous economic and productivity losses. This was followed by a set of essentially individualistic policy measures in the form of NCD screening and management infrastructure, wellness and lifestyle interventions, patient referral mechanisms, etc. The question is, what happens to a range of population-level determinants of NCDs that are deeply intertwined with social, economic and political dimensions? Population-level representative surveys seem to adopt an expanded set of indicators, including blood pressure and blood glucose, to reflect the increased policy focus on NCDs in contemporary times. But where are the actual population-level interventions?

A case from the Netherlands may help to make an apt analogy. In 2007, the Minister of Health of the Netherlands outlined his views on improving population health by exploring the inter-relationships between health and other related sectors such as the economy, housing, social cohesion and the environment. Soon, however, the minimalist tendencies of organized medicine came into play, turning it into a paradigm of personalized preventive medical care, supported by health insurance and dominated by health professionals. A natural extension of this also characterizes the Indian approach to NCDs. With health and wellness centres, publicly funded health insurance schemes and vertical NCD control programmes, the entire initiative to address NCDs has been subsumed into a largely biomedical paradigm with scarce remnants of social science. The private sector has come to complement it with a plethora of self-tested, over-the-counter products and lifestyle-change tricks. This is while broadening public interventions that can help raise much-needed revenue for health, such as the sin tax, attracts hesitation.

This minimalist approach rides the pinnacle of an unreasonable reliance on medical and health care professionals for all public health solutions, and a policy myopia that fails to appreciate how many areas other than health have to deal with NCDs. action is required. The great danger is that this approach is rooted in the political and public health tradition. It also reflects the way our research priorities for NCDs are impacted, which remain focused on lifestyle and individual-level NCD determinants and solutions.

a flawed assumption

Particularly in low-resource systems, what is easily actionable gets implemented and what is not, slowly goes down the rug. The elusive nature of social determinants has traditionally attracted funders and policy makers to better defined, easily actionable, albeit short-lived and inefficient technological solutions to large-scale health issues. These technological approaches have resulted in the erroneous assumption that social action for health is a high-level initiative reserved for affluent countries. Only the opposite is true. Developing settings like India can achieve far more health for every rupee spent, by investing in social determinants. The same also makes a strong ethical case by ensuring equitable distribution of such benefits.

For India, NCDs will be a protracted challenge. With estimated losses due to NCDs in the order of several trillion by 2030, the case for investing in an inter-sectoral, population-based, socially embedded approach is ripe. For this there is a need for thorough linking of various departments and sectors for the importance of population health. The emphasis should be on digitization to generate sufficient evidence for concrete action on social health determinants. Government policy announcements will need to include actionable points and clear mandates to address social health determinants. And political circles will need to advance a primarily biomedical paradigm of health.

Soham D. Bhaduri is a physician, health policy expert and editor-in-chief of ‘The Indian Practitioner’.