Ills of a nation

It is not lack of resources but absence of commitment that plagues healthcare in India. The nation still spends less than one per cent of the GDP on this sector. A.J. Philip looks at the public healthcare system in the country where the rich have access to state-of-the-art hospitals, while the poor have nowhere to go

VISITORS to the Chinese capital, Beijing, are unlikely to forget the experience of riding on the eight-lane, ultra-modern expressway from the airport to the city centre. Kolkata, too, built an equivalent to provide the visitor hassle-free access to the city.

Alas, the Kolkata road could not survive even one monsoon. The first showers washed away the asphalt top and the road sank at many places. It reminded the Kolkatans about the book titled Virgin Soil Upturned. The road that promised to provide a memorable motoring experience became unmotorable.

"The contractor forgot to build a good foundation. Now the government has given the work of rebuilding the road to another agency. They will take one more year to finish the work. I am sorry for the inconvenience", needlessly apologised the driver who had come to pick me up.

Elsewhere in the world, the road would have been a scam and heads would have rolled but in Left Front-governed West Bengal, these are minor aberrations that the people have to put up with to usher in socialism, discarded even by the Chinese.

The purpose of my visit was to attend the sixth workshop of the Kolkata Group. Every year in February, we, a motley group of ministers, economists, policy makers, political analysts and journalists, meet in the eastern metropolis to discuss one subject.

Nobel-laureate and Lamont Professor at Harvard Amartya Sen is the pivot of the annual conclave. Chatham House rule—nobody should be quoted to the detriment of the person concerned—prevails at the deliberations. Organised by Global Equity Initiative, Harvard, Pratichi Trust, India, and Unicef, India, this year’s subject was universal health entitlement.

The 30^th anniversary of the Alma Ata declaration setting "health for all" as a target provided the backdrop. It was at Alma Ata in the erstwhile Soviet Union that the attendees of the WHO-Unicef conference realised that primary healthcare was "the key to achieving an acceptable level of health throughout the world in the foreseeable future as a part of social development and in the spirit of social justice".

The focus was naturally on India. Statistics rolled out were depressing, to say the least. Of the 9.7 million under five deaths, 25 per cent occurs in India. Nearly one million children die within one month of their birth. Of the 26.3 million un-immunised children, 11.45 million (43 per cent) reside in India. Sixty per cent of the global measles deaths occur in India.

According to the 2007 data, 60 per cent of all polio cases (756 of 1181 cases) occurred in India. Out of 536,000 maternal deaths, 117,000 (22 per cent) were in India. It also accounts for almost 40 per cent of all underweight children under five in the world (54 of 143 million children).

The prevalence rate of under-5 underweight children in India is 43 per cent, compared to a prevalence rate of 28 per cent in sub-Saharan Africa. Forty per cent of all children with low birth weight are born in India. If anything, these figures prove that India has a long way to go before it can achieve "health for all".

The question that naturally arises is, what has the government done to improve the situation? The UPA government at the Centre claims to have increased the allocations for the health sector by introducing such programmes as the national rural health mission.

The National Common Minimum Programme adopted by the Congress and other parties supporting its government has two paragraphs on health. It is instructive to quote them:

"The UPA government will raise public spending on health to at least 2-3 per cent of the GDP over the next five years with focus on primary healthcare. A national scheme for health insurance for poor families will be introduced. The UPA will step up public investment in programmes to control all communicable diseases and also provide leadership to the national AIDS control effort.

"The UPA government will take all steps to ensure availability of life-saving drugs at reasonable prices. Special attention will be paid to the poorer sections in the matter of healthcare. The feasibility of reviving public sector units set up for the manufacture of critical bulk drugs will be re-examined so as to bring down and keep a check on prices of drugs".

With the government’s term nearing an end, these lofty aims remain mostly on paper. The nation still spends less than one per cent of the GDP on healthcare. While state-of-the-art hospitals exist in cities and the nation increasingly talks of encouraging "medical tourism", the poor have nowhere to go. A visit to a few villages in the neighbourhood of Chandigarh – the pampered city with the highest per capita income — was an eye-opener.

There are primary health centres that are never opened and there are doctors and paramedical staff who are invisible forcing the poor patients to fall prey to quackery. It is not lack of resources that prevents a state like Punjab from providing healthcare to its poor people. If Cuba can achieve better health standards for its people than even the US, it shows that more than money it is commitment that is required.

It is nearly a century since cure for malaria, a preventable disease spread by mosquitoes, which can breed only in stagnant water, was found. But even today it is a major health problem, including in New Delhi. Gastroenteritis is a major killer, though it can be fought with simple drugs. Maternal deaths can be prevented if timely gynaecological service is made available. In other words, most of the diseases that kill people are preventable.

What is disconcerting is that many seem to assume that with the economic growth reaching 9 per cent, money would "trickle down" to all, solving the problems of poverty. The government’s latest survey of living standards reports that the number of extremely poor Indians, those chronically unable to consume even the minimum of calories needed for full functioning, is an astonishing 301 million.

"A recent report by the prominent economist Arjun Sengupta emphasised that over 500 million people live on less than Rs 20 a day, which puts them above the official poverty line but still leaves them in abject poverty and excluded from all the glory of a shining India". These poor people cannot be asked to fend for themselves when they fall sick. Tragically, the government has been withdrawing from primary healthcare even in a state like Kerala, where health standards are comparable to those in West European countries.

Primary education, like primary healthcare, cannot be left entirely to the private sector guided as it is by profit motive. Forget the poor, even a middle class family can be ruined if one of its members contracts, for instance, a serious ailment. However grim the situation may be, there are success stories in states like Tamil Nadu, Andhra Pradesh and West Bengal.

The ‘Hyderabad model’ is a term now commonly used among health planners. It is an example of how the private and public sectors can cooperate to make emergency healthcare available to the common man.

Satyam Computers has tied up with the state health department whereby on one toll-free number, advertised all over Andhra Pradesh, a mobile health clinic with all necessary equipment and staff reaches the patient within a few minutes. Needless to say, if the patient needs hospital care, he will be shifted to a nearby hospital.

Far more stimulating was the power point presentation by P Padmanaban, director of public health and preventive medicine, Tamil Nadu. The state has transformed its healthcare system to the point that today 62 per cent of all deliveries are in government hospitals, maternal death is a headline-grabber in the local media and no polio case has been reported during the last four years. Infant mortality and birthrates are far below the national averages.

Padmanaban had to clarify that the photographs he showed were not of idyllic tourist resorts but PHCs in rural areas. Only 2 per cent of the PHCs are now in private buildings. Provision of colour television in PHCs has made them more attractive to women who are addicted to Tamil TV serials. They can look forward to a maternity picnic.

Health planners bemoan the non-availability of qualified doctors in rural areas. Tamil Nadu has solved this problem admirably. Three years of service in a rural PHC is compulsory for an MBBS doctor who aspires to join the state health service.

Such service is also compulsory for admission to a postgraduate course in any of the state’s medical colleges. Those who are ready to serve in the two hilly districts in the state need to put in only two years to qualify for the service. Karnataka also has a similar scheme for compulsory rural service. If Tamil Nadu can restore people’s faith in the primary health centres, there is no reason why other states cannot do it.

Even in West Bengal where 90 per cent of inpatients in rural areas are in government hospitals, doctor shortage is a chronic problem. It employs doctors at Rs 900 per day in sub-centres on contract basis. Small wonder that in rich Gujarat, there are only eight government gyanaecologists serving in the rural areas.

The discussions threw up many ideas, though not consensual, to tackle the problem. Allow ayurvedic practitioners to prescribe selected allopathic drugs. Every state should introduce a short-term medical course that takes care of common diseases. Those who pass the course should be allowed to practise only in the state concerned. Allow setting up of more medical colleges. Encourage use of generic, rather than brand, names of drugs.

Introduce a universal health insurance scheme. Introduce a comprehensive health law as in South Africa, Canada and the UK to make it binding – consequences for non-implementation – accountability, justiciability and liability. Strengthen non-physician healthcare providers (nurses). There is need to make democracy responsive to the impoverished majority.

After all, as Amartya Sen argues in his Argumentative Indian, "The removal of poverty, particularly extreme poverty, calls for more participatory growth on a wide basis, which is not easy to achieve across the barriers of illiteracy, ill health, uncompleted land reforms and other sources of severe societal inequality".

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