Dr Zakir Husain

PUBLIC health, by definition, is more than health services as commonly understood. No population can reach good health and high productivity without good public health investments. Certain public health functions that bring high health outcomes rank higher priority above others.

These are classified as 'essential public health functions'. Performing essential public health functions brings greatest health benefits to most people. Essential public health functions include a range of health actions of which notable ones could be named as follows:

Public health sanitation to reduce or eliminate health hazards in the environment. Primarily, this includes safe dinking water and basic sanitation with safe waste and excreta disposal. This also includes reduction of air, soil and water pollution to recommended permissible levels.

Public health nutrition to ensure adequate and nutritious food and food products; food safety and hygiene; reduction of harmful additives but addition of fortification with micronutrients where needed.

Public health immunisation especially of pregnant women, children, and vulnerable sections of population during epidemic outbreaks.

Public health services to combat health emergencies arising from natural or accidental disasters, epidemic outbreaks and cross border disease contamination.

Provision of drugs, medicines and vaccines essential to prevent and treat diseases of high public health priority.

Public health information and education to improve health literacy and enable changes in behaviour that are healthy.

Research essential to improve public health functions including field epidemiology and evaluation of impact and cost of services delivered.

Public health actions directed at specific population groups such as adolescents and young adults, women and pre-schoolchildren, ethnic minorities and people living in isolated and inaccessible areas.

Within its components, essential public health can be prioritised based on prevailing health and human conditions of a given population, the degree of health returns, and of course the relative costs. The central measure is the greatest good for the largest number.

However, it is not easy or popular to make a strong case for pubic health as key to a healthy population. Medical care is often urgent and cure of acute illness when that occurs overrides other considerations. Indeed, there are significant barriers to access and use of curative medical care when illness strikes. Treatment for illness is sought at any cost- even if the costs are unaffordable. Families have gone bankrupt paying for treatment of severe illness or injuries. Ability to pay the rising costs of drugs, medicines, and treatment technologies, geographic distance and travel cost determine effective access even when the supply is abundant. These and other social or class barriers singly or in combination effectively deny even minimum essential health care to many of who need it most.

On the other hand, inadequate public health services account for much of the high burden of common diseases: malaria, typhoid, diarrhoeal diseases, and parasite infections. The total economic loss due to days lost is staggering. The misery index is high too. The cost of treatment of millions of illness episodes is huge. Deaths occur among the vulnerable children who have lower immunity.

Public sector expenditure failed to keep pace with rising demand and cost. Private sector investments increased but the increased market availability did not trickle down to the poor and needy. For the subsistence households, a major illness in the family could lead to catastrophic financial consequence. The dominant free market regime governments have embraced obliged the public health sector to contract and retreat. The familiar rhetoric of 'safety net' for the poor became a myth. The supply side of health market flourished yet the gap between the health 'haves' and 'have-nots' has widened.

Admittedly, the health condition of population as a whole is the outcome of universal public health services available to all. Good public health services comprise health promotion and disease prevention, health information and education, and a package of minimum essential care. These translate into elements such as safe drinking water and sanitation, adequate food and nutrition, safe motherhood and childbirth, immunisation against common communicable diseases, and essential drugs and medicines at affordable cost.

The state could not extend medical care to all people. In the hierarchy of needs, the state's first duty is to meet the public health needs before providing personal care. Yet, the state invests more in hospitals it could not run efficiently, more in donor-funded specific programmes it could not sustain through a weak health system. Public health is by no means cheap to provide. But the return on investment in human (and in economic) terms is huge; also more cost effective than building more hospitals and running them poorly with limited funds.

By definition, a state of good health is more than mere absence of specific illness that require cure. When the environment is clean and safe, when childbirth is safe, when children are well nourished, the whole nation scores high on human development index. High maternal, infant and child death rates are huge waste and high drain on national well-being. So is high burden of preventable diseases, injuries, and accidents that reduce the productivity in farms, factories and schools. Much of these wastes could be prevented at relatively low cost by good public health services to the entire population.

A healthy Bangladesh deserves the investment it needs. It is the state (meaning the government) that has the duty to take major actions to bring public health security to the entire population. Safe drinking water, an environment free of health damaging conditions, food safety and hygiene, safe effective drugs supply, and medical care of acceptable quality and safety cannot be secured by individuals or groups of people including even the medical professionals. It is for the state to put in place the enabling instruments: programmatic, financial and regulatory.

Only then, individuals, families, communities, and professionals could meet their respective obligation. The state could and should provide policy, technical, and other incentives to enable people to play their part.

There are examples to note. The writer had been to the Kerala state of Indian Union. The state has one of the higher literacy rates (nearing 90 per cent) with high female literacy as well. Kerala is not the richest or even a richer state of India. However, its people enjoy high health status way beyond and above what its economy or per capital income of its population would have suggested. Be it in infant mortality, safe pregnancy and childbirth or child heath and nutrition the state ranks high. That goes to prove that a state need not be rich in per capita income for its people to enjoy good health. Incomes do matter in health. However, what matters equally if not perhaps more is the level of education of the people and a policy of public welfare and social justice that distributes the health and other public resources more equitably. The outcome of such conditions is reflected in health and human development – the end objective of economic growth and development.

The converse is true. The United States currently spends the highest on health. Its per capita expenditure on health could easily be twenty times more than in Kerala sate. Yet, Kerala is not twenty times below its rich comparator. Also, one cannot help note nearly 40 million people in the US are currently without minimum coverage for health and thus remain precariously vulnerable and threatened of catastrophe should major illness or accident visit tem. How does high expenditure or high technology unmatched by any in the world translate into good public health or into social advancement?

The message is clear and unequivocal. Bangladesh need not wait to become a rich country with high GDP to make its people enjoy good health and relatively easy access to good care. A healthy Bangladesh is more the function of good public health policy, adequate public investment in public education, health promotion and disease prevention. In addition, it is the function of regulatory and reforms regime to enforce public safety, quality and ethics in medical care. Above all else, it is the function of a public policy choice of equity and social justice not just in health but also more crucially in economic and social policy. Socialism might have become a bad idea whose time is gone. However, social justice and solidarity remain valid and valued one hopes.