Govt should emulate proven, successful health structure models

In May this year a high level expert group (HLEG) on health submitted its report suggesting the doubling of health sector allocation from the current 1.2 per cent to 2.5 per cent of the GDP over the 12th Plan period.

 But barely was there time to celebrate the glad tidings when a draft report of the Planning Commission indicated funds for health might be limited to 1.58 per cent of GDP. A debate has since raged among health professionals on the shape, size and form that a national health policy should take.

 Should the commission not stick to the HLEG recommendation of higher allocation, which itself is only half of what China has been spending – roughly 5 per cent of its GDP? These were the cues, as it were, for a full display of the argumentative Indian, as professor Amartya Sen might have said. It has not taken long for a ‘feast of viewpoints’ (to borrow his phrase) to emerge. A point-counter point debate is on threatening to lead to a dead-end of inaction.

Should nutrition, clean drinking water and sanitation, handmaidens of health, be integrated into an overarching plan or dealt with separately as at present? Why not strengthen the existing public health infrastructure instead of putting an untested brand new system in place? Should the government opt for ‘packaged’ medical facility through insurance or will this mean transfer of large sums of public money to private hospitals and the insurance sector, including private sector insurance?

 A presentation on the ‘Rajiv arogyasree insurance scheme’ in Andhra Pradesh at a seminar recently was a pointer to the danger of massive government funds being cornered by private hospitals: Rs 274 crore were dished out to the private sector for 59,000 surgeries while government hospitals received Rs 12 crore for 2,56,000 surgeries under the scheme. Pain-free distribution of insurance without developing infrastructure could bring in the votes, but will not necessarily improve health.

 Government cannot be faulted for dreaming about a health-for-all project. But sceptics cannot be blamed either for dismissing such grand plans as hype considering that the much talked about food bill has been debated in the National Advisory Council for almost three years and is yet to see the light of day. Civil society activist members of the NAC will also have to share blame for adopting an inflexible rather than a consensual approach to the food issue. Any policy needs to be fine-tuned in the light of experience and a decision now should not preclude changes later.

Endless discussions

Food and medicine are matters of life and death. The poor are dying daily from malnutrition and want of critical medical care they cannot afford. They do not have the luxury of time for endless discussions.  

For 65 years India has spent too little on health. But even with the very meagre resources in hand, a public health infrastructure was put in place.  However faulty – with its corruption, maladministration, lack of resources, apathy and paucity of health professionals – modest credit cannot be denied to the creaky system, which is clearly overburdened and needs to be vastly expanded and strengthened. 

In the more developed regions of the world – North America and Europe – the crude death rate (per year per 1000 people) in the ’50s hovered around 10 (UN population division statistics). It continues to remain at 8 to 10, given the demographics of a comparatively aging population. China dramatically lowered its CDR to as low as 7 in the five years from 2005-10.

In India the overall CDR was 16.9 (18.9 rural; 10.3 urban) in 1972. It took us 20 years to bring it down to a more respectable, but far from satisfactory, level of 10.1 (10.9 rural; 7 urban). Currently, after two more decades, it is around 7.2 (rural 7.7; urban 5.8).  Each time it took the countryside 20 years to catch up with urban India. Clearly, rural areas demand urgent attention.

Life expectancy is another reliable indicator of the state of a nation’s health. The average Indian life span was just 47 years at the time of Independence. Today it is 67 years. Kerala records the highest at 73.9 comparing not too unfavourably with China at 74.8. If the current infant mortality (47), under-five mortality (64) and maternal mortality rate (over 200 per 100,000 live births) were to be reduced substantially, life expectancy would further improve. Here again the rural-urban divide is significant.

 The government could emulate proven and successful health infrastructure models in states like Kerala and Tamil Nadu where key indicators are far better than national averages. The quality of medical care in the best public hospitals like the All India Institute of Medical Sciences, PGI in Chandigarh and Tamil Nadu’s Government Vellore Medical College match the best in the private sector.

 What is needed is a strengthening and expansion of the existing public health system: more public hospitals with better and functioning diagnostic aids, more doctors and nurses, adequate stock of free medicines at primary health centres and an efficient referral system for those who require specialised care.

 Ministry of Health statistics show a 50 to 80 per cent shortfall in medical human resources: doctors, specialists, laboratory technicians and nurses. It will take 5 to 6 years to narrow this gap if planning starts right away. 

The clues to a good health policy are staring us in the face. Can the argumentative Indian step aside, please?