India is seriously sick

Finance minister P. Chidambaram began his budgetary peroration last year with a quote from the Tamil saint poet, Tiruvalluvar: “Health,...

Finance minister P. Chidambaram began his budgetary peroration last year with a quote from the Tamil saint poet, Tiruvalluvar: “Health, wealth, produce, the happiness that is the result, and security. These five the learned say are the ornaments of a polity.” So far so good. Unfortunately, in the course of the budget he then presented, health as a concern got the standard treatment: it was put on a drip. The net result was that the one initiative in that document that held the shadow of a promise on this front — the National Rural Health Mission — was hardly provided for.

Today, the consequences of successive finance ministers failing to spend adequately on health have resulted in some disturbing trends. For one, public health expenditure has steadily headed south. In 1990, it was 1.3 per cent of GDP, a decade later the figure stood at 0.9 per cent. The huge gap created by the poor public provisioning of healthcare has been filled by an often indifferent and rapacious private sector. In 2002, for instance, the private sector accounted for 78.7 per cent of total health expenditure, while public expenditure made up just 21.3 per cent. To see this in perspective, consider this: it’s the other way around in prosperous Britain! Worse, even the little public money made available to healthcare has not reached the people who need it the most. Three times the sum that goes to the poorest quintile of the population (living below the poverty line), reaches the richest quintile, and an estimated four-fifths of the money goes in paying salaries.

This lack of adequate and effective public provisioning has seen a decline by 30 per cent in the proportion of patients seeking public healthcare between 1986-96. Ultimately, those who can afford it the least, end up spending the most on health — and it is one of the most important factors for the sale of personal assets and rural indebtedness. Also, while India has been able to bring down its mortality level, its morbidity (ill health) levels have been consistently rising. This means that less Indians die, but — equally — less Indians live. That is to say, less Indians live fully enabled lives, without having to cope with serious and periodic bouts of ill health. This, obviously, is a huge drain on national resources.

Story continues below this ad

Apart from endemic morbidity, India also has the largest number of maternal deaths in the world — over 1,25,000 every year, with nearly one in seven women developing life-threatening complications during pregnancy. But one stark fact more than any other speaks of India’s inadequate attention to health: the country’s decline in the Infant Mortality Rate (IMR) is threatening to plateau. It had fallen by 27.27 per cent in the ’80s; by the ’90s, the decline was only 15 per cent. At the present rate, India will fail to meet its national/international commitments on infant mortality. As Dr Vinod Paul of the All India Institute of Medical Sciences pointed out at a recent symposium on children and the 11th Plan, the Millennium Development Goals commitment requires us to achieve an IMR level of 27 by 2015, our Tenth Plan target was to reach a target of less than 30 by 2010. But unless things change drastically, India’s IMR will be around 45 by 2015.

Placing public health on the frontburner has never been more urgent. And the finance minister, when he puts on the hat of the Congress activist as he did at the AICC session in Hyderabad, even acknowledges this. The question is whether Budget 2006-2007 will reflect that concern. Health is a state subject. At present, states contribute 85 per cent and the Centre 15 per cent of total expenditure. But the Centre has nevertheless the important responsibility in giving a normative direction to the revival of the health system. A significant instrument it has for this purpose, as health experts like Ravi Duggal have pointed out, is the budget document.

There can be no two ways about it. The decision to increase public spending on health — the National Common Minimum Programme commits to raising it from the present 0.9 per cent to 2-3 per cent of GDP — cannot be postponed any longer. But this project requires more than an infusion of capital. In fact, some initiatives that can immediately help do not even require huge spending. Dr Abhay Bhang and his team has proved in Gadchiroli, Maharashtra, that a low-technology intervention of providing home-based healthcare delivered through trained female community health workers could bring the IMR rate of 76 in 1993-95 to 30 in 2001-03.

So how can the country make up for lost time? The National Rural Health Mission (NRHM) that the finance minister touched upon in his budget last year could be the catalyst for such a revival and deserves careful provisioning to achieve optimal efficiency. At the heart of NRHM is the strategy to train at the household level some three lakh Accredited Social Health Activists (or ASHAs); getting panchayati raj institutions to assume ownership of the health delivery system; and strengthening the existing triad of sub-centres, primary health centres, and community health centres. Getting these mostly defunct health centres to function would require not just the presence of suitably incentivised and trained medical professionals, it demands close supervision by local communities, an expansion of existing infrastructure, a system of regulation and a credible health information system.

Story continues below this ad

The first step then is to revive the basic health delivery system. Everything else depends on this. Even the silver bullet solutions that are sometimes offered — like the expansion of public-private partnerships in health, and a public health insurance — will require the secure foundation of a functioning system. China, incidentally, dismantled its earlier system of free clinics and came up with an insurance plan in which rural residents contribute a sum of a little over a dollar to access health services. It has not worked precisely because the earlier system of healthcare delivery was dismantled. Only an estimated 21 per cent of China’s population is medically insured today in a country that once had universal coverage, leaving large numbers extremely vulnerable — as the SARS epidemic demonstrated.

India has stopped thinking about public health and has paid a very heavy price for that. It now needs to seriously re-imagine strategies. The health-wealth equation cannot just remain an idea in a Tiruvalluvar verse, Mr Chidambaram. It demands not just linguistic but budgetary translation.