Health policy rethink

The challenge is to contrast the cost with the advantages of introducing strategies that could transform lakhs of lives.

Whatever may be the complexion of the next government, three areas of health policy require urgent rethinking. All three depend upon changing human behaviour which is often a bigger challenge than finding resources. But given the dramatic extent to which a few initiatives can better lives and reduce investments on health, the implication of continuing to function incrementally needs examination.

First there is the issue of fertility and here one refers to quality, not numbers. Fortunately by now, nearly half the country has achieved replacement levels of fertility. But Uttar Pradesh and Bihar, which together account for a third of the country’s annual 27 million births, would need another 15 years to reach there. And while the picture is somewhat better in Madhya Pradesh, Rajasthan, Jharkhand and Chattisgarh, these states too will need another decade to contain fertility.Pushing up the first birth to after the mother is 20 can bring a 50 per cent reduction in maternal mortality. It will allow the mother-to-be to overcome malnutrition and anaemia which predispose her to birth underweight, malnourished and sickly children. The expectation that trickle-down from economic growth will percolate and boost their health is unlikely, given fresh health findings. 

A recently published Lancet survey which covered 36 low and middle income countries has shown that economic growth (GDP) makes little difference to child under-nutrition. That is precisely why demographers and economists need to demonstrate the implications of allowing generations of children to be born too early, only to become victims of malnutrition, infirmity and even stunting, wasting and poor mental development.

But this is far from easy. Rural mindsets favour early marriage and childbearing soon thereafter. To some extent mandatory registration of marriages will oblige more and more families to wait until a girl is 18 years of age. Although a welcome development, it will not address the issue of malnutrition and anaemia which afflict adolescent girls, leaving them in poor shape to bear healthy children. 

Apart from the need to encourage postponement of the first childbirth to after 20, there is also a need to focus on spacing between children. WHO studies show that in rural areas, mortality is highest among infants born within a year, and the risks are progressively lower when followed by a gap of two, three and four years. Every encouragement needs to be given to spacing between children by persuading women at risk and their well-wishers to understand the need for longer birth intervals. Condoms and pills are known to have too many imponderables and when overall contraceptive use is less than 19 per cent among 15 to 24-year-olds, alternatives must be accessible.   

Space births

In China, 40 per cent of the contraception is managed through IUDs (intrauterine device.) In Bangladesh, Indonesia, Iran and Sri Lanka the use of IUDs and injectables - both for spacing and limiting births - helped lower fertility years ago. In India, female sterilisation still accounts for 72 per cent of all contraceptive methods although it is an outmoded strategy. No other country promotes it so widely. The economic gains from widening newer contraceptive use among adolescent and young women needs to be calculated and tools that are reliable and trouble-free offered to them. The second policy area which needs urgent attention is the high incidence of oral cancer. The Union health ministry statistics show that 50 per cent of cancers among men and 25 per cent of cancers among women are related to tobacco use.

According to ICMR, the direct and indirect costs of three major tobacco related diseases – cardiovascular disease, cancer and chronic lung disease total 25 per cent of all public spending. Deaths caused by tobacco use are responsible for more fatalities than those caused by HIV/AIDS, TB and malaria combined. Although excise duties on smoked tobacco have increased, they do not affect the unbridled consumption of non-smoking tobacco - a huge contributor to oral cancer. The ultimate solution lies in phasing out tobacco cultivation. But unless the costs of cancer treatment are juxtaposed in economic terms with the “gains” from tobacco cultivation, including the employment it generates, the agriculture and labour ministries and tobacco growing states will evade conversion to alternative crops.

The third policy area relates to the growing incidence of hypertension, heart disease and diabetes which are ballooning in urban areas. Much of this has to do with high salt, fat and sugar intake, besides sedentary lifestyles. Occasional awareness campaigns and admonitions from doctors are not capable of commanding the lifestyle changes needed on a massive scale. Disincentives, higher duties and health warnings on product labels have succeeded substantially elsewhere in the world. We have to calculate the dangers of soft handling because society will pay the price. 

Who should do it? Discouraging early wedlock and pregnancy will only be pushed by health bureaucracies, if chief ministers champion the need to lower fertility and thereby promote women’s and children’s health. Phasing out tobacco cultivation will need sustained leadership from a prime minister who alone can drive three powerful but reluctant ministries- finance, agriculture and labour to understand the urgency to depart from tobacco cultivation. 

Finally, meddling with the consumer’s right to satiate his palate will be considered political hara-kiri. Yet finance and health ministries in progressive countries are helping citizens to alter life-styles. The challenge is even greater among Indians who value extra-fattening foodstuffs as a mark of big-heartedness. Surely, a combination of public health researchers and micro economists can contrast the cost of doing business as usual with the advantages of introducing strategies that could transform lakhs of lives. And at nominal cost. 

(The writer is former secretary in the Union ministry of health & family welfare, and former Delhi chief secretary)