The Hindu Business Line : India's health needs a dose of funds, reforms

The India Health Report, prepared as a backgrounder for the WHO, provides a comprehensive exposition on the health system in India. The biggest problems with the system, the report says, are the lack of government spending and the inefficiencies and misuse of the meagre resources that are available.

The foremost objective of the Indian health system should be financial risk protection for the poorer and weaker sections of the population. — V. V. Krishnan

THE India Health Report (IHR) was undertaken as a background study for the World Health Organisation's Commission on Macroeconomics and Health (CMH). The CMH was established in January 2000 by the then WHO Director-General, Dr Gro Harlem Brundtland, to assess the place of health in global economic development.

The most important point that the CMH highlighted was the importance of investing in health to promote economic development and reduce poverty. The CMH found that extending the coverage of crucial health services, including a relatively small number of specific interventions, to the world's poor could save millions of lives each year, reduce poverty, spur economic development, and promote global security.

The IHR (prepared by Rajiv Misra, Rachel Chatterjee and Sujatha Rao) fully justifies the endorsements it has received from the members of the CMH (18 internationally recognised commissioners that included development economists, macroeconomists, health economists, and health and economic policymakers from around the world) and especially from Prof Jeffrey Sachs, Chair of the CMH.

As a result, the findings of the IHR have been a critical input in the formulation of the recommendations of the CMH report. Apart from providing one of the most comprehensive expositions to date on the health system in India, its strength is the clarity with which the authors present complex technical material and analyse the issues of healthcare finance and reform in India. I will confine, however, to issues relating to health finance, public healthcare, especially the state of primary health centres, and communicable diseases such as TB and malaria.

Most important, the IHR points out that the biggest problems with the Indian health system are the lack of government spending in the health sector (0.9 per cent of GDP against an average of 2.2 per cent by lower-middle-income countries) and the inefficiencies and misuse of the meagre resources that are available. Since 84 per cent of healthcare is out-of-pocket expense, the system is set up to favour those who can pay. The ambitious goal of providing universal healthcare for all (in 1978, India was a signatory to the Alma Alta declaration, undertaking to provide "Health for All" by 2000) was far from being achieved. As the IHR suggests, the current system needs to be overhauled, both in terms of financial and human resource.

The IHR says, "... If the state has universal healthcare and poverty alleviation as its basic objectives; if there have been gains, however patchy and inadequate; if there are systems in existence though not actually thriving, why is the current health scenario so bleak?"

The IHR rightly points out that this is due to the mismatch between these objectives and resources being spent to achieve them. Policymakers need to define realistic goals and allocate much higher levels of resources for the health sector. The IHR correctly indicates that the foremost objective of the Indian health system should be financial risk protection for the poorer and weaker sections of the population.

While the IHR describes the potential use of Central and State levies, tobacco tax, property taxes and user fees to finance health sector expenditure, one additional mechanism to raise the much needed resources for enhancing health sector expenditures could be through a comprehensive programme of disinvestment.

This author suggests the following scheme for this: After careful analysis and background work, the government works out a major programme of disinvestment and calls a meeting of all the sitting members of the Lok Sabha and informs them of this scheme wherein each MP will be given an equal share of the disinvestment proceeds, but with the specific purpose of its usage only for spending in their respective constituencies for primary health and education depending on the specific needs of each constituency.

Of course, this will require strict monitoring, preferably by the Prime Minister's Office so as to ensure that funds are being utilised for the purpose they were meant for. Such a scheme is likely to help bring together MPs from across party lines as they will all see a gain for themselves (irrespective of their party affiliations) as well as their respective constituencies and possibly unite them to support the disinvestment plans on the floor of the House.

Securing political acceptability to such an idea at the MP level is likely to help a great deal in dealing with the opposition to disinvestment plans from trade unions and others traditionally opposed to it. Although it may seem to be a long shot, but should such a scheme work, it will not only help the government withdraw relatively easily from the loss-making public sector — from running textile mills to steel plants, from managing hotels to operating airlines and a variety of other sectors where it is currently involved in — but also help divert the much needed resources to the areas of primary health and education.

Communicable diseases

The IHR points out that India accounts for a third of global tuberculosis incidence and the largest number of active TB patients. The IHR discusses the Directly Observed Treatment Short Course (DOTS) strategy and Revised Nations TB Control Programme (RNTCP) in detail.

With regard to malaria, according to the IHR, the number of cases decreased to about two million, but owing to local outbreaks, there were high mortality. The IHR suggests that the plasmodium falciparum parasite is the most dangerous strain and this strain of outbreaks has been rising, accounting for almost half of malaria cases in 2001. The IHR suggests various reasons for failure to reduce malarial prevalence (that is, parasite resistance) and suggests practical ways to deal with the problem.

The resurgence of communicable diseases such as malaria and tuberculosis has also partly been due to low levels of public expenditure in India. Another factor in this resurgence is extreme poverty. In 1994, over 1,000 people died in Rajasthan of a malaria epidemic, and during the same time in Delhi, over 300 deaths were attributed to a haemorrhagic dengue fever.

Malariogenic and tuberculous conditions continue to flourish owing to distorted development patterns and commercialisation of medical care as public health and community health services are being replaced by profit-oriented curative care, 80 per cent of which is in private hands.

This has resulted in spiralling medical care costs and rural indebtedness. A resurgence of malaria in India prompted the formation of a Malaria Expert Group, which met in 1996 to formulate malaria control strategy. An estimated 20-30 million episodes of malaria occur in India each year. Since malaria is an exclusively local phenomenon, strategies should be responsive to the epidemiologic characteristics of the different ecotypes. Also needed are flexible, individualised strategies for development project areas and Triple Insecticide Resistance Areas. Most malaria deaths are attributable to delayed diagnosis and treatment. Furthermore, integration of malaria control into India's primary healthcare system will require community participation, appropriate technology, inter-sectoral co-ordination and social equity.

An assessment of utilisation patterns of public and private healthcare providers shows that despite the provision of free or low-cost services at government health facilities, demand for public sector outpatient services are low even amongst that part of the population which falls below the poverty line. The poor are increasingly turning to private providers, even for treatment of infectious disease such as TB and Malaria, which are designated as primary responsibilities of the public health system.

The high percentage of outpatient curative services sought from the private sector, even by the lowest income quintiles of the population suggests that the public health system is not adequately fulfilling the health needs of the poor. Further, studies of the distribution of government health subsidies finds that public health subsidies disproportionately benefit higher quintiles. While this imbalance is less pronounced in southern States such as Tamil Nadu, it is a clear indication of the need for healthcare reform, as the IHR emphatically suggests. In terms of the emerging challenges, the IHR is of the view that HIV/AIDS has not received the attention it deserves (long gestation period and non-diagnosis because of deaths from opportunistic infections such as TB).

As per the IHR, in 2000, there were an estimated 3.86 million Indians infected with HIV. Also, the IHR points out that there is widespread discrimination of HIV/AIDS infected persons. The low income levels of the infected, along with lack of resources in government-funded programmes (despite manufacture and availability of drugs in India), precludes widespread use of highly active anti-retroviral therapy (HAART). Awareness levels were low despite the National AIDS Control Programme and the work of the State AIDS Control Societies. The IHR rightly points out that information, education and communication (IEC) are crucial elements in this regard. Tamil Nadu is a model State where increase in the level of infection was arrested by concentrating on the high-risk segments of the population, raising general awareness levels and devising innovative mechanisms for programme implementation.

While health is primarily a State subject in India, there is a normative framework for public health infrastructure that has been developed at the Central level based on population norms.

For rural care it is expected that there will be a community health centre (CHC) for every 100,000 population. Under each CHC, the norm requires four primary health centres (PHCs) serving approximately 25,000 people each and 24 sub-centres (SCs) serving 4,000-5,000 people each. States are also expected to set up hospitals and dispensaries to provide care in both urban and rural areas. While the responsibilities are essentially at the State level, health sector spending at the State level is far from what is needed.

Primary healthcare

One of the areas where the IHR could have perhaps dwelt more in detail is PHCs. Primary healthcare in India is provided through government-operated PHCs, at village and town levels.

A medical officer (a qualified MBBS doctor) is appointed at each of these PHCs and is supposed to diagnose and manage all medical and surgical illnesses at the primary level, and refer selected patients for higher investigations and treatment or expert opinion to centres based at the district level — the CHCs, where at least one post-graduate surgeon, one physician and one obstetrician-gynaecologist are posted.

PHCs should be functioning as the first level in a hierarchical system of healthcare facilities. PHCs should play two equally important roles: First, diagnosis of diseases based on symptoms and simple laboratory tests, and their treatment either at the centres or through referral.

Second, health education leading to family planning, better hygiene and sanitation, and prevention of communicable diseases, especially sexually transmitted diseases.

At present, the major problems at the primary level in healthcare can chiefly be attributed to: i) shortage of qualified doctors to be posted at PHCs; ii) non-availability of proper infrastructure, including equipment and consumables at the PHCs; iii) poor motivation of the public to seek timely help from the PHCs owing to misbeliefs, superstitions and lack of health education.

The result of non-functioning PHCs has been that in many cases, diseases are neither diagnosed in their early stages nor treated. The rural population has to often travel to urban areas when they can no longer bear the suffering caused by the disease, thus increasing the load on hospitals in the urban areas and ending up with serious complications that, in many cases, could have easily been treated at their early stages.

This ignorance, coupled with the increased mobility between rural and urban areas, has led to an explosive spread of diseases such as HIV/AIDS and Hepatitis B and C.

The IHR, in conclusion, is a very comprehensive document that has dealt with a large number of issues relating to India's health system, both at the federal and the State levels, and in the public and private sectors.

The authors have studied and analysed a wide spectrum of issues and recommended very useful policy options for the Government. There is no doubt that the IHR will go a long way in contributing towards greater public awareness and informed debate on health issues and help generate political and public support for higher investments in health along with wide-ranging reforms that are urgently needed.

From the global point of view, the IHR has been instrumental in helping focus on the key issues of health sector reform and financing in developing countries for the United Nations system, in general, and the WHO, in particular.

(The author is Senior Development Advisor and Director, South Asia Program Center on Globalization and Sustainable Development, Columbia University.)