Why invest in Preventive Care?
Healthcare is concerned with individual patients’ disease diagnoses and treatment. Public health is concerned with the prevention of diseases and the promotion of good health for an entire population. While the former is a medical concern, the latter is a policy concern. Preventive care, as the name suggests, is important for preventing both individual and public health emergencies.
What is preventive care?
Preventive care deals with disease prevention. By doing so, it reduces human suffering and the monetary burden caused due to illness or injury. Commonly consumed preventive care measures include immunisation for highly likely infections like prevention of Covid-19 through vaccination or prevention of polio through vaccination. Less commonly consumed preventive care includes cancer screenings or vaccines for less likely illnesses. The uptake of preventive care for illnesses like cancer or infections like Shingles is less likely than that for Covid-19 or polio because the perceived risk (by individuals or public health professionals) is lower.
Is Preventive Care Under-consumed?
People are more risk-averse when the health costs are immediate. If in the midst of a global pandemic you chose not to get vaccinated, you are highly likely to get infected and face immediate health costs. Health costs here can include;
- loss of physical health,
- loss of productivity due to illness,
- the monetary cost of treatment.
But let us look at illnesses for which the perceived risk is lower. Shingles (or herpes zoster), for instance, is a preventable but less common illness. The virus (varicella-zoster) that causes chickenpox, a more common communicable illness, lays dormant in the human body even after the infection has cleared out. This dormant virus may get reactivated at a later stage in one’s life to cause Shingles. The most common symptom of Shingles is a painful rash. This rash can be in the form of fluid-filled blisters, often accompanied by a burning sensation, oversensitivity, redness, and itchiness in the infected area. The pain can persist for weeks after the rash has cleared out. Such an infection affects one’s productivity and quality of life. In low-income groups, such an infection comes at a high monetary cost of treatment. Shingles is also contagious (for a limited duration) and can cause chickenpox among those who have never had chickenpox. This means daily wage workers are likely to lose out on working days (and on wages). While the infection takes 4 weeks or less (depending on treatment), scars may take longer to fade. Depending on the area of infection, Shingles can also affect appearance. Therefore, the actual cost of Shingles can be much higher for some individuals than that of Covid-19. The likelihood of getting infected by Covid-19, however, is much higher than Shingles, resulting in a higher perceived risk.
People also have an optimism bias when it comes to their own health. Optimism bias is a tendency to believe that negative events are less likely than positive ones. This also explains health-risk behaviours – behaviours that increase vulnerability to illnesses, infection or injury. Smokers may be well aware of the risk attached to smoking. If not, the warning sign on the packaging clearly (in India, maybe too clearly) indicates that smoking can cause cancer. But it rarely deters one from smoking. This is because one is more likely to believe she will not get cancer than to believe she will get cancer.
Is the Cost of Preventive Care too High?
While health-risk behaviours and lower perceived risk of less likely illnesses have undesirable health implications, it is rational for humans to think this way. Individuals are not likely to be concerned about all illnesses and therefore not likely to demand and consume all preventive care services. Individual or household income levels often define the consumption of healthcare services. If preventive care is not covered under insurance, for lower income groups, prioritising other expenditures (on food, and education) over consuming preventive care services for illnesses that may or may not occur becomes a rational choice.
Who is Least Likely to Consume Preventive Care?
Social identities affect the consumption of preventive care services. Let’s look at the consumption of preventive care by Indian women. Menstrual Hygiene Management (MHM) is a recurring preventive care measure that menstruators require. Poor MHM makes menstruators more susceptible to UTIs, Hepatitis B, and cervical cancer (weak positive correlation). This can lead to increased out-of-pocket expenditure on primary, secondary and tertiary healthcare. Reproductive Tract Infections (RTIs) are often transmitted to offspring, which poses an additional cost (both in terms of welfare and monetary loss) to mothers, households, and society. While challenges related to WASH infrastructure (or the lack thereof) would require greater intervention, MHM also suffers from a lack of prioritisation. MHM lags far behind on low-income households’ expenditure lists. Lack of prioritisation can also be a result of little to no intra-household bargaining power, stigma attached to menstruation and lack of awareness/information.
India records a high number of cervical cancer cases. Most cases are detected at advanced stages — nearly one-third of all cervical cancer deaths happen in India.
Similar is the case of breast cancer, now the leading cause of cancer-caused death among Indian women. Over 25% per 100,000 women and over 12% per 100,000 women are likely to get and die of breast cancer, respectively.
Why is this immensely troubling? Both cervical and breast cancer are among the most preventable forms of cancer. Regular screenings can help detect breast cancer at its early stages. Breast cancer is even self-diagnosable. In addition to regular screenings, cervical cancer can be prevented through HPV vaccines. There are over 100 types of HPV (Human papillomavirus) – some of these cause cervical cancer. The HPV vaccine is administered in two to three doses. The price of HPV vaccines, however, ranged between INR 3500 and INR 2500 – depending on the cost of administering the vaccine and brand (usually, Cervarix or Gardasil are used in India).
As discussed in the previous section, the perceived cost of preventive care is much higher than its perceived benefit. Further, in India, high-end private voluntary health insurance plans provide preventive care coverage.
When understanding social factors, we must also keep in mind intersectionality. Women belonging to middle-high income groups are better off than low-income group women, upper caste women are better off than Dalit women, and middle-high income Dalit women are better off than lower-income Dalit women.
Why do governments not prioritise preventive care?
In India, the largest health insurance scheme for the poor, PM-JAY (Jan Arogya Yojana), only covers secondary and tertiary care. Over 40 crore Indians have no health insurance at all. Central government estimates suggest high out-of-pocket expenditure and catastrophic health emergencies push nearly 6 crore Indians into poverty every year. In such a scenario, preventive care has an immense role to play in reducing health emergencies and reducing expenditure on secondary and tertiary care. However, the need for treatment is exactly what shifts focus from preventive care.
Preventive care ensures long-term health benefits for society. These are easier to prioritise when they do not come at the cost of short-term care requirements of a population. While immunisation is crucial for a population’s health, not all immunisation can be prioritised. More importantly, public health is unlike other areas of policy. It is similar to food security or the availability of clean drinking water. Short-term needs cannot be neglected for long-term betterment because people’s lives are at stake. Therefore, it is unfair to blame governments for prioritising short-term needs.
What governments can and should be held accountable for is low health prioritisation. Cumulative public health expenditure in India stands at a little over 1%. Standards of publicly provided primary, secondary and tertiary care also remain inadequate due to resource and personnel shortages. Jan Aushadhi Kendras provide some relief with respect to reducing heavy out-of-pocket expenditure on drugs, but shortages are common. The pandemic witnessed a near collapse of India’s healthcare infrastructure, both public and private. The National Centre for Disease Control (NCDC), a crucial public health institution that should have been a key player during the pandemic, lacked capacity. Consequently, the Indian Council of Medical Research (ICMR) — a medical research institution — was assigned the role of a public health institution.
A demand for increased prioritisation of preventive care is valid and crucial but also lost amid the need for several repairs to India’s health infrastructure. What governments can and must do in such a scenario is inform and educate. A crucial function of government-enabled public health is to inform and educate individuals to increase the demand for healthcare services. Healthcare is a merit good — it is consumed less than the desired amount. This is especially true about preventive care. Increasing awareness about cancer screenings, regular eye tests, contraception, good menstrual hygiene practices and different vaccinations can increase consumption of preventive care services. Civil society organisations that are subject-matter experts in the prevention of different illnesses must be viewed as valuable knowledge partners.
About the Author:
Paavi is an Associate at the Centre for Civil Society, New Delhi. She is a public policy graduate, currently working on a digital health research study.
Disclaimer: Nothing in this article can be constituted as medical advice from either the author or the platform.