Public health on paper

The condition of health sub-centres is so pathetic that even poor families are forced to turn to private medical care.

India now figures prominently among those major countries where the overwhelming majority of people do not have real access to affordable health care. Nowhere else so many millions of poor people have to depend on out-of-pocket expenses to meet essential health care. This is particularly tragic when the pockets of many of them are anyway empty -- recent studies  indicate that millions of poor people are regularly pushed into poverty because they have to borrow at high interest rates to pay for emergency medical needs.

At one time high hopes were raised that during the 12th Plan the proclaimed objective of ‘health for all’ will make good progress. But these hopes have started receding already at an early stage of this plan. Firstly, the actual increase in health budget is nowhere near the real needs, or even the more limited promise  that had been raised earlier. Last year (2012-13) the original budget estimate in the Union budget for the ministry of health and family welfare was Rs 34,388 crore which was reduced to Rs 29,273 crore in the revised estimate. In this year’s budget there is only a very modest increase compared to the previous year’s original estimate.

Secondly, the lack of adequate regulation of the high-profits medicine and medicare industry is likely to lead to the diversion of a major share of the budget to profit rather than need. Even though some commendable initiatives have been taken in states like Rajasthan and Tamil Nadu to increase availability of essential medicines to needy people, on the whole the record of price-control of essential medicines remain poor. Despite court orders following public interest petitions, the Union government has not yet taken the right steps to make available essential medicines at fair price to people. Even in the high-priority area of vaccines, a drift towards high-profit combinations of dubious utility has been seen.

On paper the government’s health infrastructure covers almost all areas, but in greater part of the country the condition of health centres or sub-centres is so pathetic that even poor families are forced to turn to private medical care. In several small towns the availability of public health care has actually declined in recent times. At the same time, the lack of adequate and proper regulation of the fast proliferating private sector has exposed the majority of people to rampant fleecing and unethical medical practices.
The government has  made only symbolic gestures to make the rapidly spreading private sector responsive to poor people’s needs by insisting on a small proportion of hospital beds being reserved for free care (in lieu of highly concessional land given to private hospitals). But even this priority has been widely violated or else has been implemented in a half-hearted way.

Expensive standards

At the same time there is a danger that insistence on some expensive standards for all hospitals will threaten the very existence of some public spirited health-care efforts in remote rural areas whose dedicated efforts to serve the poorest and vulnerable sections have won widespread acclaim.

The introduction of the National Rural Health Mission and Janani Suraksha Yojna (for reducing maternal and infant mortality) had raised hopes and some good work has certainly been done in a few areas. But we need to ask why all these efforts have not succeeded in reducing maternal and infant mortality to the extent that was expected.
When an ASHA follows her instructions and dutifully takes women to a community health centre for safe child-birth, they find that essential care facilities do not really exist. In case of any complication, the doctor or nurse may merely refer her to a district or city hospital. Also due to overburden, the mother and baby may be discharged quickly even if there are some complications. The payment supposed to be made to the family and ASHA for institutional delivery is unlikely to be made in time, and even if the cheque is ready, commissions or gifts will be demanded.

So despite the existence of schemes which look good on paper to reduce maternal and infant mortality, the actual achievement is for below the need as well as the potential. Already at very early stage, many ASHAs are feeling demoralised and let down, as despite the hard and dedicated work done by many of them, they feel cheated and lack essential support.

Of course the private sector can also make a very important contribution but it should be regulated properly and price-control of essential drugs should be ensured. At the same time, the services of those who have served with dedication and in innovative ways in remote rural areas or among other sections of the poor and vulnerable people should be suitably encouraged and rewarded.

The government's health-budget should not only go up significantly, but in addition (what may be even more important) should be used strictly in accordance with the real needs of the people. International pressures to divert a high share of the budget to isolated objectives favoured by certain vested interests should be resisted firmly. In the past such pressures have led to huge wastage of national funds and misuse of health personnel in dubious work. Only a strong, well-organised and long-term public health campaign can ensure that the government's health priorities remain true to the real needs of people.