By
now it is commonplace to bemoan the poor state of health
services in India. Public provision of health services
is very inadequately funded and its facilities are plagued
by overcrowding, shortage of essential items and of
skilled personnel, and insufficient accountability to
citizens. Private involvement in health provision is
beset by rising costs and problems of exclusion, huge
and growing differentials in the services available
to rich and poor, and inadequate supervision associated
with various manifestations of moral hazard. As a result,
India’s health indicators are among the worst in the
world, explaining to a large extent our appalling low
position in the international Human Development Index.
All this is so well known that it scarcely evokes much
reaction anymore beyond a defeated shrug of the shoulders,
even among normally concerned citizens. What is more
surprising is the apparent paucity of ideas on how to
deal with the current mess, beyond the very obvious
need to increase public spending on health. That is
what makes the recently released Report of the Independent
Commission on Development and Health in India (''Governance
of the Health Sector in India: Has the state abdicated
its role?'', Voluntary Health Association of India,
New Delhi: 2008) such an important contribution.
The Report, authored by former Union Health Secretary
Javid Chowdhury and other Commission members, makes
a number of important points and suggestions. Several
of these are worth reiterating here.
The first point that is generally recognised but still
deserves to be highlighted, is the sheer extent of the
regional imbalances in both process and outcome indicators
for health. The average health status for the country
as a whole is poor and per capita spending on health
is also very low by international standards. Public
health spending is indeed among the lowest in the world,
both as share of GDP and per capita. But this disguises
very sharp differences across states. At one end is
a group of states (Kerala, Maharashtra, Himachal Pradesh
and Tamil Nadu) accounting for 18.8 per cent of the
population, with health indicators similar to those
in more developed middle-income countries like Venezuela,
Argentina and Saudi Arabia. At the other end of the
spectrum are the Bimaru-plus states (Uttar Pradesh,
Orissa, Madhya Pradesh, Assam, Rajasthan, Bihar and
Jharkhand), comprising nearly 42 per cent of the population,
for whom the indicators are close to sub-Saharan and
other low-income countries like Sudan, Nigeria and Myanmar.
The differences across states do not simply relate to
the health outcomes, but also extend to the financing
of health expenditure and the implications for the people.
Thus, the poorer states also had less public provision:
in 2001-02, public health spending as a percentage of
total health expenditure ranged from 7.5 per cent (or
Rs 84 per capita) in Uttar Pradesh to 89.2 per cent
(Rs 836 per capita) in Mizoram. However, not a single
major state achieved the basic threshold level of Rs
500 per capita public health spending.
The regional disparities also extend to the availability
of medical personnel. The availability of graduate allopathic
doctors in the country as a whole is only 0.6 per thousand
population, but they are unevenly spread, much more
concentrated in the South and in more developed states
(so that Punjab has more than five times the availability
of Uttar Pradesh). Also, these doctors tend to converge
on urban and per-urban areas, leaving rural and backward
areas especially deprived.
Even medical colleges are unevenly spread: the four
southern states have 63 per cent of the colleges and
67 per cent of the seats. The states with the biggest
shortfalls in medical personnel are predictably the
Bimaru states (in this case Bihar, Madhya Pradesh, Rajasthan,
Uttar Pradesh, Jharkhand and Chattisgarh) along with
the Northeastern states, Orissa and Haryana. The regulation
and monitoring of personnel also leave much to be desired:
the statutory councils for doctors, nurses, dentists
and others are almost dysfunctional.
So people are forced to turn to private health services,
and in the poorer states more poor people are forced
to pay because government provision is unavailable or
inadequate. Thus, in the poorest states, illnesses involving
hospitalisation are more prone to break poor families’
finances. The Report quotes the NSSO Survey to show
that in Bihar and Uttar Pradesh, more than one third
of those who were hospitalised fell into poverty on
account of medical expenditure.
Not only are private, or out-of-pocket, medical expenses
borne by households far too high in India, but there
is also evidence to indicate that they have gone up
sharply in recent times. According to the NSSO, urban
hospitalisation costs increased by 126 per cent between
1995-96 and 2003-04, while rural hospitalisation costs
increased by 78 per cent. It is alarming to note that
private costs were often borne by households that simply
could not afford them. In general, the Commission notes
that the one-fifth of the population that is just above
the poverty line would automatically slip into poverty
if they faced even one serious health crisis.
One important item of medical expenditure for which
the increase in costs has been particularly rapid is
therapeutic drugs. The average drug expenditure met
out-of-pocket is 75 per cent, but once again those residing
in the poorer states are the worst off even in this
respect. The share of drugs in medical expenditure of
households (both in-patient and out-patient) was as
high as 90 per cent in Orissa and nearly that in Rajasthan,
Bihar, Himachal Pradesh and Uttar Pradesh. In no state
was the ratio less than 61 per cent, indicating clearly
that the health system is ''over-medicalised''.
This growing expenditure on drugs reflects not only
the impact of the new patent regime, but also the lack
of adequate regulation of the Indian drug manufacturing
sector and a lax drug policy that allows the proliferation
of non-essential and even irrational or hazardous drugs.
A crucial area that has recently come into the news
is the absence of public health security, even in terms
of the provision of basic vaccines and drugs. Lack of
investment in public facilities has meant that in general
they cannot meet the WHO’s standards, and the policy
of relying on the private manufacturers to fill the
gap has proved to be futile as they simply did not deliver.
As a result, there is now a shortage of basic vaccines
and other essential drugs, which is holding up crucial
immunisation programmes and threatens a current and
future public health crisis in several states. As for
personal health, government health services are obviously
inadequate, and the private health insurance schemes
that are in existence cover very small pools of people
and do not ensure risk-sharing.
So we have a system that is underfunded, under-regulated,
very expensive for the people given levels of income,
irrational and hugely inefficient. What is to be done
about all this? The Independent Commission on Development
and Health in India makes several very important recommendations,
covering not only more public expenditure but also its
allocation, more and different types of regulation,
new approaches to training and initiatives to change
the current tendencies to over-medicalisation and excessive
dependence upon curative rather than preventive health
care.
The suggestions are eminently sensible. It is foolish
to argue that overall lack of resources in a poor country
is the fundamental constraint. The examples of our neighbours,
Bangladesh and Sri Lanka, show that much can be achieved
in this regard even in the context of a relatively low
income developing country. Indeed, it is sad to think
that we still even need to argue in favour of these
very obvious and urgent requirements.
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