Can it be sustained?


Can it be sustained?
Over the last few years, there has been an impressive improvement in the health status in terms of reduction in infant mortality and birth rate in India. Such changes take India at least closer to, if not fully achieving, the Millennium Development Goal of reaching under five (age group) mortality rate of 38 by the year 2015.

The latest data released for the year 2013 provides an under five mortality of 49 for the country. The reduction in infant mortality rate in recent years has often attracted wide attention from different quarters as it was backed by one of ambitious government programmes, the National Rural Health Mission (NRHM).

This data, released by the Office of the Registrar General of India for the year 2013 shows, improvement in several health indicators in the country. The infant mortality rate has come down to 40 (per every 1000 live births) from over 60 in the early part of the last decade.

The birth rate also has come down rapidly with the number of children per woman coming down to 2.3; very close to achieving the desired goal of 2 children per woman. In the last one decade, infant mortality has declined to the tune of 3 per cent per year while in the last five to eight years, it has registered around 6 per cent decline. Similarly, the birth rate also has been declining at a faster rate of around 2 per cent in the last few years.

Undoubtedly, NHRM has provided renewed focus on reducing infant mortality and improving maternal and child health status in India. It was introduced nationally since 2005. Several components of NRHM directly address to improve child survival. More importantly, the NRHM aims to increase the government allocation to the health sector which was abysmally low at 0.9 per cent to between 2-3 per cent of the GDP.

The continuous decline in the rate of infant mortality rate since the introduction of NRHM is often considered and attributed to the successful implementation of the mission. Beyond enhanced expenditure, NRHM tries to address the institutional bottlenecks by strengthening facilities at various health institutions and by several cash transfer mechanisms to increase the demand for health care.

The recent reports on the possible cut in the health budget of the country to the tune of around 20 per cent for 2014-15 due to fiscal constraints has come as a rude shock. This is particularly so when it was clearly noted through NRHM that even a small increase will help improve health status substantially. The cut is proposed despite the fact that India spends only a pittance as health expenditure compared to many other countries.

Higher spending
The public health spending as percentage of GDP is as high as 8-10 per cent in many western European countries and USA as against a little over one per cent in India. Even many African countries (if you have time, please call him and ask for a couple of names of these African nations) spend much higher than India on health care. Not only that the public health expenditure as part of GDP in is one among the lowest, households spend a substantial amount of their income for health expenditure resulting in many households falling into poverty.

The public health system in the country is marred by several bottlenecks in terms of shortage of medical personnel as well as poor quality of health delivery. These two issues have direct linkages with the continuous flow of money and enhanced allocation. Through the NRHM programme, there has been effort to address both these issues.

The flexibility in appointing health personnel on contract basis was attempted in several places. Moreover, through different types of funds available within the institutions, there are efforts to strengthen the facilities in all types of health institutions from primary health centre to the District hospitals. Therefore, enhanced fund flow during the NRHM period has been quite important in achieving faster changes in the health scenario in the country.

There is evidence available across countries how health status gets affected with decline in funding. One of the major examples of worsening health status with the reduction in heath expenditure comes from the central and eastern European countries that have gone through immense political and socioeconomic restructuring after the collapse of communism around 1990. Not only that there has been significant worsening of the health status in all these countries but despite improvement in recent years, the health status remains far less than western European countries. The poor health outcomes were mainly the result of institutional bottle necks with lack of money to modernise the health care system in these countries.

It clearly indicates that reduction in health care spending can have adverse consequences on the health status of the people. This is particularly since the health situation in India is precariously placed besides having poor allocation. Continued spending is important to sustain the current progress.

With the disease profile of the population also undergoing changes, India would require far more investment in dealing with increasing levels of chronic diseases in the country. Health spending for chronic diseases which are relatively very expensive, lead to families either falling to chronic poverty or getting debt ridden.  Studies now indicate that the prevalence of chronic diseases is as high as 60 per cent among the older people (60 years and above).

With such a huge burden, it is important that the public health system is geared for taking care of the large and emerging health needs by substantially enhancing health expenditure. Therefore, the current attempt to cut down health spending is not only deplorable but might worsen the already achieved health status in the country.
(The writer is with Population Research Centre, Institute for Social and Economic Change, Bengaluru)

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