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Rahul Jacob: India's healthcare crisis

The wide disparity between the best healthcare & quackery that much of the population must endure is partly to blame for India's apathy

Rahul Jacob 

Rahul Jacob

Whether Indians in ancient times discovered algebra and the Pythagoras theorem before "selflessly" passing them on to the Arabs and the Greeks as Science and Technology Minister Harsh Vardhan said last week is for agile historians to ponder. Widely accepted is that Indians in ancient times studied the science of logic. Whether our government does in 2015 is debatable.

What is one to make of the plans for the spectrum auction in February that will drive prices through the roof and leave us short of capacity in 3G even as the government tom-toms its plans for Digital India at every opportunity? Even more bizarre is the lack of focus on healthcare, especially for mothers and babies, while holding forth about India's demographic dividend at every investors' forum in the country.

Reuters reported on December 23 that the 2014-15 healthcare Budget was going to be cut by about $950 million, down by about 20 per cent from the Budget allocation of $5 billion. Cuts in the healthcare Budget in the mid to high teens have been true every year for the past few years as the time comes to meet fiscal deficit targets - but this year was supposed to be different.

The Bharatiya Janata Party manifesto promised universal healthcare and a focus on rural health, for starters. Just days after the news that the healthcare Budget was to be cut, the National Health Policy was unveiled. People with incomes of less than Rs 1,640 in rural areas and Rs 2,500 in cities are to qualify for medical assistance. Primary care is to be free for all. The policy also makes a case for more than doubling government spending on healthcare from 1.04 per cent of gross domestic product, among the lowest in the world even among poor countries, to 2.5 per cent.

Anyone with a basic knowledge of arithmetic would notice that the cutting of the health Budget by almost $1 billion and expanding coverage to all does not quite add up. In fact, the Lancet Commission on Investing in Health study of 2013 pegged at $23.6 billion annually what India would have to spend over the next 20 years to achieve a convergence with global levels on infectious disease, child and maternal mortality rates.

Impossible? Perhaps, but we should be trying to move in that direction as if the country was in an emergency. Which, of course, it is, for the parents of babies dying from diarrhoea because of the lack of rehydration salts and zinc that cost all of Rs 15 each. In total, 1.4 million Indian children die before the age of five.

Where would all the money come from? India could redirect at least some of the subsidies lavishly spent on fertilisers (total subsidy for 2013-14 about $11 billion) and petroleum (about $13.5 billion over the same period). Instead of encouraging the excessive use of fertilisers on our farms, and of liquefied petroleum gas cylinders to the extent that some middle-class families hook them up to their water geysers, or of diesel for SUVs as we have done historically, we would do better to invest in healthcare.

Far from aspiring to global averages, India trails poorer countries such as Cambodia, Bangladesh and, heaven help us, Nepal on yardsticks like inoculating babies against diphtheria and tetanus or even the percentage of mothers who breastfeed their babies.

Despite some improvement over the years, what India's poor performance underlines is both too little money being spent on healthcare as well as inefficient primary healthcare systems in many states. As K Srinath Reddy, the president of the Public Health Foundation of India, puts it, the "metric" for success should be the life expectancy of a tribal girl in Madhya Pradesh.

The Gates Foundation in India has targeted turning around high maternal mortality numbers in Bihar and Uttar Pradesh (UP), where many women die in childbirth when wounds turn septic - because midwives and mothers-in-law use cow dung or oil as a salve where the umbilical cord is cut. The foundation's head, Girindre Beeharry, says the Budget next month offers an opportunity to "think big and act big" on healthcare. Likening healthcare spending to a funnel, he says India needs to spend significantly more at the "mouth" and also manage the efficiency of the "stem" that carries that funding to, say, mothers and children needing neonatal care. Working in UP, the foundation has used mobile cards, or mobile kunjis, to help health workers disseminate information to mothers on breastfeeding and the like as well as a recording of a "Dr Anita" that mothers can call into to get tips on looking after their babies. States like Tamil Nadu and Kerala, where I have followed energetic primary healthcare workers making house calls to new mothers on a reporting assignment years ago, show how it can be done.

Rampant absenteeism of doctors and nurses at primary healthcare centres in many of India's 640,000 villages cannot perennially be used as an excuse for withholding funding from healthcare. In Rajasthan last summer, I was impressed to hear the government was considering bussing villagers to primary healthcare centres in towns. It might fail, but the logic was straightforward enough. "Even a saintly doctor needs a small room with a toilet (to rent). We have to accept ground realities," said Rajiv Mehrishi, then chief secretary of Rajasthan and now finance secretary in New Delhi.

The wide disparity between the best healthcare in the country and the quackery and absenteeism that much of the population must endure is partly to blame for India's apathy. With the spread of drug-resistant tuberculosis and antibiotic-resistant infections to the middle class in the cities, we are at a point when the health epidemic is about to hit home, even in New Delhi. As Kaushik Basu observed recently, if poverty were a communicable disease, we would have found more energetic solutions to it.

Twitter: @RahulJJacob

First Published: Wed, January 07 2015. 21:49 IST