On The Critical List
During a recent visit to India, Claude Smadja, managing director, World Economic Forum, warned the country that unless there was a social dimension to globalisation, a destructive backlash could hit the liberalisation process. Ranked 135 among 174 nations in the world on the Human Development Index, India could well be on its way to turning this prophecy into reality. Consider this. The last national policy on health was made in 1983 and since then, no major initiative has been undertaken in this area. While reforms are pervading practically every sector, the nations health continues to function in splendid isolation. Caught in a bind in the face of severe budgetary cuts, community health has become the biggest casualty.
The extent of human deprivation is staggering as a report by economist Mahbub ul Haq, Human Development in South Asia, 1997, points out. Nearly 62 million children below the age of five are malnourished, 88 per cent of pregnant women are anaemic, 135 million people have no access to basic health facilities, and 70 per cent of the population lacks sanitation.
The picture is not completely gloomy. There have been some achievements. For instance, the infant mortality rate has fallen from 165 per thousand live births in 1960 to 79 per thousand in 1994. Life expectancy has gone up from 44 years in 1960 to 61 years in 1993. In the same period, the crude birth rate came down from 43 per thousand to 29 while the death rate fell from 21 to 10. Besides, the contraceptive prevalence rate among married women has increased from 12 per cent in 1970 to 43 per cent between 1986 and 1993.
Communicable diseases, however, continue to spread their tentacles. According to the Voluntary Health Association of India (VHAI), last year, tuberculosis (TB) alone killed three million people. Nearly 25 per cent of the worlds TB patients are Indians as 14 million people are afflicted with this disease. Another two to three million people suffer from malaria annually with a large number of them being affected by cerebral malaria. In fact, there has been a resurgence of malaria in the last couple of years. And this year, there was an outbreak of polio in some parts of the country in spite of the massive immunisation campaign that was carried out last year in which 130 million children were immunised on a single day.
Both malaria and TB, however, have not merited the kind of medical and governmental attention that their spread warrants. In comparison, consider the uproar that took place when the dengue epidemic broke out last year killing 453 people with another 10,252 being hospitalised. Health activists believe the reaction was so strong because the disease occurred primarily in Delhi, close to the seat of power. They point to the urban bias of the countrys healthcare apparatus.
Not surprisingly, then, the poor have to fend for themselves. According to the preliminary reports of a study conducted by the National Council for Applied Economic Research (NCAER), the poor spend nearly 24.1 per cent of their annual income on medical care compared to the just around 3.4 per cent spent by higher income groups. A VHAI study in Maharashtra done recently supports this finding and states that the biggest reason for rural indebtedness in illness.
The rising incidence of malaria and TB also underscores the poor performance of the National Tuberculosis Control Programme and the Malaria Control Programme. Now the government has responded by merely drawing up fresh plans based on external funding. The World Bank has promised assistance worth Rs 891 crore for the Enhanced Malaria Control Project, which was launched in September 1997. Another Rs 784 crore will be spent on Phase III of the Revised Strategy of National Tuberculosis Control Programme to minimise the annual rate of infection. The project will cover 102 districts and is expected to benefit three million people, saving 1,40,000 lives a year.
But apart from malaria and TB, the country now has to cope with emerging diseases like AIDS and silent killers like diabetes, heart and blood pressure ailments, which have started claiming more lives than ever before thanks to changing lifestyles. According to World Health Organisation estimates, the country has 2.5 million HIV positive cases -- and the numbers are only growing each year (see page 2).
Yet, the governments overall health spend is a mere two per cent of the gross domestic product. For primary healthcare to reach respectable levels, the current public spending on health will have to be doubled. Already, nearly 90 per cent of the countrys health expenditure is in the private sector.
A major chunk of the governments expenditure is on facilities and on paying salaries rather than providing actual healthcare. Although the government has built a network of 1,32,727 sub-centres, 21,853 primary health centres and 2,424 community health centres, they have not benefitted the poor. The ratio of hospitals to population remained at 13 per 10 lakh people between 1988 and 1991, going up marginally to 16 in 1992. As on January 1993, there were around 4,235 government hospitals, 344 hospitals run by local bodies and 9,113 hospitals run by private and voluntary organisations in the country.
Health activist Amit Sen Gupta believes that the structural adjustment programme of the economy has led to a further squeeze on public health expenditure. Between 1990-91 and 1993-94, there was a fall in real terms in the healthcare expenditure of both the centre and the states. From Rs 659.53 crore in 1990-91, health expenditure allocation came down to Rs 628.99 crore in 1991-92. It then stagnated at around Rs 650 crore till 1995-96, when allocations climbed upto Rs 924 crore. Even so, this is only 1.69 per cent of the total development expenditure.
The government has been evading its responsibility by selling the virtues of a private healthcare system, says Sen Gupta. So the health apparatus is running on a subsistence budget as a result of which the existing machinery is unable to deliver healthcare to the people, he points out.
Another problem is that the primary healthcare system is not accountable to the local authorities. So health centres function without medical personnel. Around 30 to 40 per cent of the posts at the primary health centres are never filled and even if they are, the incumbents dont stick around, points out Sen Gupta.
One senior official in the health ministry points out that the system is unable to cope with growing population pressures since the infrastructure was only created to cater to a certain number of people. The country has one hospital bed for every 1,371 persons and one doctor per 2,439 people. No wonder, the countrys hospitals are overcrowded and ill-equipped and medicinal shortages are common.
Besides, the lack of proper health-related databases makes it difficult to draw adequate strategic plans, the official points out. Unless a problem reaches the scale of an epidemic, it is not taken seriously, the official says.
One of the major reasons for the systems failure, say critics, is that health has been hijacked by the family planning/welfare agenda and the government equates basic health with family planning. Now, both programmes have crashed, says Ashish Bose, demographer and a member of expert group on population policy headed by renowned scientist Dr M S Swaminathan. The programme never looked at improving the quality of life but focused instead on sterilisation, complains Bose.
Minister of state for health, Renuka Chowdhury, who is spearheading the new family welfare campaign, however, defends the programme saying that if it hadnt been undertaken, the country would have faced unimaginable problems (see box below).
Theres no denying, however, that health has been treated like a step-child. Medical professionals have no say on how the sector is run, which is overwhelmed by bureaucrats. But even the attitude of ministers and bureaucrats to the health portfolio reflects how low it is on the priority list. For instance, when there was a cabinet reshuffle in June 1997 and former minister Salim Shervani was moved from the health ministry to the external affairs one, it was regarded as a promotion. And Renuka Chowdhury sulked when she was made minister of state for health and family welfare in place of Shervani.
Alok Mukhopadhyay, executive director, VHAI, warns that if sufficient investments are not made into the sector and the primary healthcare infrastructure not revamped, India will emerge as a nation of sick people requiring extraordinary resources to cure them.
Given the lack of hospital beds, the private sector is awake to the growth potential in the sector. And healthcare groups and companies like Apollo, Escorts, CDR, Wockhardt and Medinova are trying to exploit it (see page 3). Even foreign healthcare companies like Jardine of UK and Parkway of Singapore have evinced an interest in setting up shop in the country. But investments are expected to come in a big way only after the health insurance sector is opened up, which companies claim will make healthcare more affordable and therefore accessible to the population (see page 4).
The health sector is calling for a paradigm shift, believes Mukhopadhyay. Policies have failed all along because of a vertical approach so it is time to decentralise.
Vertical programmes for diseases like TB, malaria and AIDS must be curtailed. Instead, they should be brought under the primary healthcare network to stop the lopsided management of health problems, he suggests. And adds, Health infrastructure in the rural areas should be made accountable to village panchayats and panchayat samitis. Moreover, to avoid duplication, there must be a convergence of all health, population, women and child welfare programmes at the local level to ensure optimum resource utilisation. He has also mooted the idea of having an Indian Health Service so that young professionals are motivated to join the primary healthcare services and healthcare management entrusted to competent people.
At the World Health Assembly held at Geneva in May 1985, India was one of the leading proponents of the concept of health-for-all. But back home, after over 12 years, nothing of the sort has happened. If at all, the situation has worsened. Access to healthcare is likely to remain beyond the reach of a majority of the population unless a paradigm shift takes place and the government is able to inject life into the sector through long-overdue reforms.
Vertical programmes for TB and malaria must be curtailed. Instead, they should be brought under the primary healthcare network. Alok Mukhopadhyay, executive director, Voluntary Health Association of India.