India’s health indicators do not match our recent economic performance. Public expenditure on health as a proportion of GDP continues to be among the world’s lowest. The crib deaths in West Bengal, the misuse of NRHM funds in Uttar Pradesh, the poor state of maternity homes in the country’s capital, rightly raise a public outcry. The state of the public system, subjected to unprecedented neglect for decades, is truly shocking in many parts of the country. Nor does the conduct of some government health workers generate confidence that the public system will ever deliver basic health services of decent quality. The despair is so overwhelming that critics often miss out on some of the emerging positive trends in many hitherto backward states, on account of the attention given to the public system with the advent of the NRHM. Though NRHM is a Centrally-sponsored programme, health is a state subject and it is the leadership at the state level that makes all the difference.
Let us look at hard evidence. The just published Sample Registration System data from the Census office places India’s infant mortality rate (IMR) for 2010 at 47, a three-point decline for the second consecutive year. IMR declined by a bare three points, from 60 to 57 between 2003 and 2006. Between 2007 and 2010, the decline is of 10 points. More interestingly, the rate of decline in rural areas is almost double that in urban areas during this period. The IMR decline in hitherto backward states like Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Orissa, has been 3-5 points per year, a rate never achieved previously in consecutive years. States like Tamil Nadu and Gujarat have also made significant gains during this period.
Unfortunately, these declines have not got the attention they deserve — perhaps because this time, it’s the public system that has made the difference. The Centre also seems reluctant to take credit, as NRHM is designed so that states (rightly) lead the programme. Yet, for someone travelling extensively across the country, the change that NRHM has brought about is clearly a very real one. Dirty, dingy and uncared-for health facilities are receiving facelifts. Nurses and doctors are being recruited on an unprecedented scale. Innovations and partnerships for emergency transport, diagnostics and drug availability are being born. Professional managers, accountants and data professionals are available to the public healthcare system for the first time, and in large numbers. The Janani Suraksha Yojana has increased institutional deliveries massively.
Nothing exemplifies the transformation as dramatically as the case of Bihar. From 39 patients a month at block public health centres in 2005, the state has recorded more than 3,500 patients per month for the last three to four years. Institutional deliveries are up from 1.4 lakh to over 13 lakh a year. Drugs, diagnostics and doctors are available round-the-clock at block PHCs, with outsourced arrangements for generators, ambulance, security and cleanliness. Health sub-centres, too, are being revived. Now, Bihar almost equals the national IMR — and its death rate is better than the national average!
Every state has its own stories of transformation. Tamil Nadu leads the way, with NRHM funds being put to very good use, making PHCs 24x7 and fit for quality institutional deliveries. The turnaround is seen in the cascading decline of MMR and IMR in that state. Very silently, Madhya Pradesh has pushed institutional deliveries to over 80 per cent. Orissa has focused on strengthening its PHCs and district hospitals. Rajasthan is now trying to guarantee full availability of medicines free of cost.
The efforts at crafting credible public systems under the NRHM began with provision of management, accountancy and data professionals at all levels. The thrust on decentralised planning, a need-based provision of human resources and flexible untied funds to cover gaps created confidence that failing public systems would start delivering quality services. The resident community worker programme, called “Asha”, NRHM’s most visible face, helped in connecting households to health facilities. States are learning from each other to adopt innovations that have worked. Today, over six states have set up corporations like the Tamil Nadu Services Corporation to provide quality generic drugs and equipment at reasonable cost.
If reform in nutrition programmes had been speeded up, and the ICDS revamped to focus attention on 0-3 year olds, adolescent girls and pregnant women (the three distinct groups among whom universal intervention is required to reduce malnutrition), the decline in IMR would have been even more significant. Unfortunately, nutrition does not lend itself to narrow departmentalism and needs a wider human development approach.
If the trend of the last two years in the decline of IMR is sustained and marginally improved upon over the next five years, and a significant effort at fighting malnutrition with a human-development approach adopted even now, India will certainly achieve the health-related Millenium Development Goals (an IMR of 30 and an MMR of 100). By a mere increase of public expenditure on health from a little below to a little above 1 per cent of GDP, the gains of NRHM are perceptible.
There’s a long way to go before we cross 3 per cent of GDP, which is what’s needed for universal health coverage. So let us not focus only on PPPs, but also on crafting credible public systems, with public accountability. Health does not lend itself to market principles very easily, and the countervailing presence of the public system of health care is necessary to ensure quality and reasonable cost in the private sector.
The writer is a civil servant