The Hindu : Health checkup

Online edition of India's National Newspaper
Friday, Mar 12, 2004

Opinion

Opinion - Leader Page Articles

Health checkup

By Jean Drèze

As a ratio of GDP, public expenditure on health in India is among the lowest in the world — about one per cent.

SOMETIMES THE most important things in life are least talked about. For instance, it is hard to think of anything more important than health for human happiness and the quality of life. And yet, health is virtually absent from public debates and democratic politics in India.

To illustrate, consider the coverage of health issues in the mainstream media. In an earlier analysis of 300 opinion articles published in one of India's leading dailies over a period of six months (January to June 2000), it emerged that not one of these articles dealt with health-related matters. Just in case, I repeated the exercise this year for the period January-June 2003. This time, I did find an article dealing with health issues — it was about the SARS crisis in China!

This silence would perhaps be tolerable if the Indian population enjoyed good health and adequate health services, but nothing could be further from the truth. Indeed, India's health indicators are among the worst in the world. For instance, according to the latest National Family Health survey (1998-99), half of all Indian children are undernourished and half of all adult women suffer from anaemia. At the time of the survey, 30 per cent of all children under the age of three had fever, another 20 per cent had diarrhoea, and another 20 per cent had symptoms of acute respiratory infection. Even after allowing for some overlap between these different groups, this suggests that at least half of all Indian children below three suffer from one of these conditions at any given point of time.

The condition of health services is no less dismal. As a ratio of GDP, public expenditure on health in India is among the lowest in the world — about one per cent. In fact, the health system is almost totally privatised. To illustrate, only 15 per cent of total health expenditure in India is public expenditure; the rest is private expenditure, such as over-the-counter drug purchases from chemist shops. By contrast, the ratio of public expenditure to total health expenditure is 40 per cent in east Asia, 50 per cent in Latin America, 75 per cent in Europe, and as high as 85 per cent in Britain. In large parts of India, there are no public health facilities worth the name, except for female sterilisation and polio immunisation.

Recent health facility surveys conducted by the International Institute for Population Sciences (Mumbai) give a chilling picture of the state of health centres around the country. To illustrate, only 69 per cent of Primary Health Centres (PHCs) have at least one bed, 20 per cent have a telephone, and 12 per cent enjoy "regular maintenance". These are national averages, and the corresponding figures for the poorer States are much worse. In Bihar, for instance, a large majority of PHCs make do without luxuries such as electricity, a weighing machine or even a toilet. It is worth remembering that a PHC is supposed to be a facility of major importance, serving a population of 30,000 or so.

Even when health facilities are available, their utilisation leaves much to be desired. According to a forthcoming Harvard study, absence rates among health workers range between 35 and 58 per cent in different Indian States. A similar picture emerges from an ongoing study of health services in Udaipur district (Rajasthan). More than half of the health sub-centres were found to be closed during regular opening hours, and even in the PHCs and Community Health Centres, 36 per cent of the personnel was absent on average. Meanwhile, local residents suffer from horrendous levels of morbidity: one-third of all adults had a cold during the 30 days preceding the survey, 42 per cent had "body ache", 33 per cent had fever, 23 per cent suffered from fatigue, 11 per cent had chest pains, and more than half suffer from anaemia. Close to one-third would find it difficult to draw water from a well and one in five has difficulty standing up from a sitting position.

It is worth noting that even the rich in India often do not have access to decent health services. The technology and the expertise are there, but public facilities are highly inefficient and private services are virtually unregulated, leaving patients at the mercy of unscrupulous practitioners. Fraud, over-medication and unnecessary surgery are the bread and butter of the private health sector. To illustrate, according to a recent study of health services in Mumbai, about 65 per cent of deliveries performed in the private sector end up with a Caesarean, compared with 9 per cent in the public sector (the latter is close to WHO norms).

If anything, the neglect of health services in public policy has intensified in the "liberalisation" period. Public expenditure on health declined steadily in the early Nineties, as a share of GDP. The ratio picked up again towards the end of the decade, but mainly because of salary increases (in the wake of the Fifth Pay Commission), without any improvement in real inputs. As the recent budget indicates, the spotlight today is on expensive, high-tech facilities such as modern hospitals, and also on "vertical" programmes sponsored by foreign agencies, such as the pulse-polio programme. Basic health services, for their part, have been grossly neglected, to the extent that the coverage of routine immunisation has shrunk in recent years, according to the Reproductive and Child Health surveys. The decline of infant mortality has also slowed down, after a spell of rapid decline in the Eighties.

On the positive side, some States (Kerala, Tamil Nadu, Himachal Pradesh, among others) have recognised the importance of good public health facilities, and planned accordingly. In an illuminating study, Leela Visaria has drawn attention to the comparatively good functioning of health services in States such as Tamil Nadu. Last year, I had an opportunity to observe this myself when I visited health centres in three districts of Tamil Nadu. They were clean, lively and well staffed. Plenty of medicines were available for free, and there were regular inspections. The walls were plastered with charts and posters giving details of the daily routine, available facilities, progress of various programmes, and related information. Patients streamed in and out, evidently at ease with the system. It was a joy to see this, in contrast with the bare, deserted, gloomy, hostile premises that pass for health centres in north India. In Tamil Nadu, according to the latest National Family Health Survey, 99 per cent of births are preceded by antenatal checkups and 89 per cent of children are fully vaccinated. The corresponding figures in, say, Uttar Pradesh are 35 and 21 per cent — most women and children there are left to their own devices as far as health is concerned.

One reason for this contrast is that, in Tamil Nadu, health care has been brought within the ambit of democratic politics. Health and related issues, such as mid-day meals, are a subject of lively public debate and play an important role in election campaigns. In north India, however, health does not figure on the political agenda, and nor do other basic needs such as elementary education or child nutrition.

The Supreme Court gave a useful wake-up call to the Government on November 28, 2001, with an order calling for the provision of a functional anganwadi in "every settlement". Active implementation of this order could go a long way in protecting Indian children from hunger and disease. Unfortunately, the Government has taken little notice of it. In fact, according to the Department of Women and Child Development, a recent proposal to expand the Integrated Child Development Services (ICDS) was "categorically rejected" by the Cabinet, on the grounds that there was "no money". Meanwhile, lavish resources are spent to placate the more influential sections of society — private corporations, the military establishment, public employees, and the so-called "middle classes", among others. Who would have expected the practice of child sacrifice to persist into the twenty-first century?

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