Good health stands at the centre of sustainable development. Good health is at the centre of well-being and is vital for everything else we hold dear.
— Jeffrey D Sachs, American economist
Healthcare ought to be easily accessible to all sections of the populace. In life, nothing is more important than health. Poor public health conditions can deter investors and tourists. It has been established that states with lower literacy and poorer health levels have found it difficult to alleviate poverty.
In India, the poor are affected by debility, reduced earnings, increasing expenditure on health and eventual death. The rich suffer from repeated spells of morbidity and this is reflected in the high level of stunting and under-nutrition among children. Studies have revealed that an individual’s access to healthcare services is linked to his/her social or caste background. Discrimination rooted in social, caste, or racial origins severely affects the people’s health. Inequality in health condition is also the major challenge for national and sub-national public health policies. Life expectancy at birth, a basic measurement of health inequality, varied from 77.9 years in rural Kerala to 64.1 years in rural Assam during 2009-13. Similarly, the child mortality rate among mothers without education is more than 10 times the child mortality among mothers with the advantage of schooling.
While healthcare of all rapidly developing nations gets progressively better as GDP increases, it would seem that India is bucking the trend. Global experience shows that more public spending on health and education reinforces growth as well as development. Brazil and Thailand have achieved close to universal health coverage. The government’s share of healthcare in India as percentage of the total health expenditure that is incurred by the people is one of the lowest in the world. We spend just around 1.2 per cent of our GDP, while the total health expenditure is around at 4.2 per cent. Insufficient funding of public facilities, combined with faulty planning and inefficient management, have militated against expansion of the workforce to train and retain them, and this has affected service delivery, regulatory and management functions, as well as research and development. The draft National Health Policy (NHP) 2015 emphasised that unless the country spends 5-6 per cent of its GDP on health, with a major part of it from the government outlay (at least 2.5 per cent of GDP), basic healthcare could hardly be met.
India has followed commercial principles in healthcare by involving the private sector in a big way. Private health services have grown by default, without checks on cost and quality. There is no safety net for the poor in private establishments. The government’s policy on public health is the weakest link in the chain.
The steady deterioration of public health services is attributed to the increase in health insurance coverage, the mushroom growth of private hospitals and misuse of the financial provisions of government health welfare schemes. Data garnered in course of various surveys confirm that instead of providing basic healthcare, the common practice is to engage in unnecessary medical procedures, tests, hospitalisation and surgeries. The vulnerable and gullible are being cheated. The prevailing scenario has been described by the World Bank as ‘medical overuse’. The Jan Swasthya Abhijan has referred to the Rashtriya Swasthya Bima Yojana (RSBY) which offers BPL families a cashless yearly insurance of Rs 30,000 as one of the schemes which is also being misused by unscrupulous doctors.
Child mortality, expressed in terms of Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U5MR), is a sensitive indicator of the country’s socio-economic development. The country continues to lose thousands of children below the age of 5 every day. Globally, India ranks fifth in terms of child mortality; but in terms of numbers the figure is a whopping 14 lakh which is the highest in the world. In a country, that is poised to grow at 7 per cent annually, more than half of the children die within 28 days of their birth, and of causes which are preventable. Bangladesh and Sri Lanka are way ahead in preventing infant and maternity deaths. Even China with almost the same reproductive and child health indices as India has marched ahead. Every 10 minutes, a young woman dies during childbirth somewhere in India and 3 lakh children die the day they are born.
We need to make citizens aware of the fact that public health services, conceptually distinct from clinical services, play a key role in curbing exposure to diseases, for example through food safety and other health regulations, vector control, monitoring waste disposal and water systems, and health education to improve personal health habits. Sanitation is indeed the major cause of diseases and malnutrition. If more people understood these connections, they would be better able to protect themselves and their families.
Governments have long been focusing on tertiary hospital care, deviating from the earlier emphasis on primary health care, which must be improved, starting with sub-centres. The size and quality of the health workforce should also be upgraded. This can be achieved by closely linking healthcare delivery with medical education. According to World Bank data, Cuba produces the largest number of doctors per capita in the world (6.7 per 1000 against 2.5 per 1000 in the US and 0.7 per 1000 in India) and its health indices are better than that of the US, which spends the most on healthcare. It is unfortunate that in 69 years, post-independence India is short of 3 million doctors and 6 million nurses, and its paramedical training programme is virtually non-existent.
It has been estimated that around 25 per cent of the drugs sold are spurious. Quality assurance of discounted drugs must be substantiated with adequate measures for spot checks and appropriate punishment. Otherwise, patients will slowly become skeptical about the quality. Moreover, regulatory systems need to be strengthened — from hospital accreditation to health education and from drug licensing to mandatory adoption of standard management guidelines for diagnosis and treatment of different diseases at each level of health care.
The lack of commitment at the highest levels and the absence of a work ethic have led to a widespread systemic crisis in healthcare. US academic Lant Pritchett had an appropriate explanation for why things go so shockingly awry in India, and why it is incapable in adopting policies and programmes and implement the same. He calls this the flailing state syndrome — “A nation state in which the head, that is elite institutions at the national (and in some states) level remain sound and functional, but that this head is no longer reliably connected via nerves and sinews to its own limbs”. As a result, nothing works here. Pritchett terms flailing as the inability to maintain sufficient control of the administrative apparatus to effectively deliver services through the government “in spite of democracy and strong capability at the state level”.
The writer is a retired IAS officer.