 |
 |
 |
| |
|
 Sunday, 12 October 2008 |
|
|
India is seriously sick |
|
|
|
Written by Pamela Philipose
|
|
Thursday, 26 January 2006 |
Will Budget 2006 apply a healing touch, Mr Chidambaram?
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.
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.
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 systemof 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.
Tuesday, January 24, 2006, Pamela Philipose, Indian Express
Reprinted from http://www.indianexpress.com/full_story.php?content_id=86481
|
|
|
|
 |
 |
|
 |
|
