HEALTH CARE
IN INDIA - VISION 2020
ISSUES
AND PROSPECTS
R. Srinivisan
INTRODUCTION
Key linkages in health
Health and
health care need to be distinguished from each other for no better reason than
that the former is often incorrectly seen as a direct function of the latter.
Heath is clearly not the mere absence of disease. Good Health confers on a
person or groups freedom from illness -
and the ability to realize one's potential. Health is therefore best understood
as the indispensable basis for defining a person's sense of well being. The
health of populations is a distinct key issue in public policy discourse in
every mature society often determining the deployment of huge society. They
include its cultural understanding of ill health and well-being, extent of
socio-economic disparities, reach of health services and quality and costs of
care. and current bio-mcdical understanding about health and illness.
Health care
covers not merely medical care but also all aspects pro preventive care too.
Nor can it be limited to care rendered by or financed out of public
expenditure- within the government sector alone but must include incentives and
disincentives for self care and care paid for by private citizens to get over
ill health. Where, as in India, private out-of-pocket expenditure dominates the
cost financing health care, the effects are bound t be regressive. Heath care
at its essential core is widely recognized to be a public good. Its demand and
supply cannot therefore, be left to be regulated solely by the invisible had of
the market. Nor can it be established on considerations of utility maximizing
conduct alone.
What makes for
a just health care system even as an ideal? Four criteria could be suggested- First universal access, and access to an
adequate level, and access without excessive burden. Second fair distribution of financial costs for access and fair
distribution of burden in rationing care and capacity and a constant search for
improvement to a more just system. Third
training providers for competence empathy and accountability, pursuit of
quality care ad cost effective use of the results of relevant research. Last
special attention to vulnerable groups such a children, women, disabled and the
aged.
Forecasting in Health Sector
In general
predictions about future health - of
individuals and populations - can be
notoriously uncertain. However all projections of health care in India must in
the end rest on the overall changes in its political economy - on progress made in poverty mitigation
(health care to the poor) in reduction of inequalities (health inequalities affecting access/quality'), in
generation of employment /income streams (to facilitate capacity to pay and to
accept individual responsibility for one's
health ). in public information and development communication (to promote preventive
self care and risk reduction by conducive
life styles ) and in personal
life style changes (often directly resulting from social changes and global influences). Of course it will also
depend on progress in reducing mortality and the likely disease load, efficient
and fair delivery and financing systems in private and public sectors and
attention to vulnerable sections- family planning and nutritional services and
women's empowerment and the confirmed interest of me siat-e 10 ensure just health care to the Largest
extent possible. To list them is to recall that Indian planning had at its best
attempted to capture this synergistic approach within a democratic structure.
It is another matter that it is now remembered only for its mixed success.
Available health forecasts
There is a
forecast on the new health challenges likely to emerge in India over tne next
few decades. Murry and Lopez have provided a possible scenario of the burden of disease
(BOD) for India in the year 2020, based
on a statistical model calculating the change in DALYS are applied to the
population projections for 2020 and
conversely. The key conclusions must be understood keeping in the mind the tact
that the concept of DALYs incorporates not only mortality but disability viewed
in terms of healthy years of life lost. In this forecast, DALYs are expected to
dramatically decrease in respect of diarrhoeal diseases and respiratory
infections and less dramatically for maternal conditions. TB is expected to
plateau by 2000, and HIV infections are
expected to rise significantly up to 2010.
Injuries may increase less significantly, the proportion of people above 65 will increase and as a result the burden of
non-communicable disease will rise. Finally cardiovascular diseases resulting
any from the risk associated with smoking urban stress and improper diet are
expected to increase dramatically.
Under the same
BOD methodology another view is available from a four - state analysis done in 1996
these four states -
AP, Kamataka, W. Bengal and Punjab -
represent different stages in the Indian health transition. The analysis
reveals that the poorer and more populated states. West Bengal, will still face
a large incidence of communicable diseases. More prosperous states, such as
Punjab further along the health transiting will witness sharply increasing
incidence of non-communicable diseases especially, in urban areas. The
projections highlight that we still operating on unreliable or incomplete base data on mortality and causes of death
in the absence of vital registration statistics and know as yet little about
how they differ between social classes and regions or about the dynamic
patterns of change at work. It also highlights the policy dilemma of how to balance between the articulate
middle upper class demand for more access to technologically advanced and
subsidized clinical services and the more pressing needs of the poor for
coverage of basic disease control interventions. This conflict over deployment
of public resources will only get exacerbated in future. What matters most in
such estimates are not societal averages with respect to health but sound data
illumining specifically the health conditions of the disadvantaged in local
areas that long tradition of health sector analysis
looking at unequal access, income poverty
and unjustly distributed resources
as the trigger to meet health needs of the poor. That tradition has been
totally replaced by the currently dominant school of international thought
about health which is concerned primarily
with efficiency of systems measured by cost effectiveness criteria.
Future of State Provided Health Care
Historically the Indian
commitment to health development has been guided by two principles-with three
consequences. The first principle was State
responsibility for health care and the second (after independence)
was free medical care for all (and not merely
to those unable to pay),
The first set of consequences was inadequate priority to
public health, poor investment in safe water and samtati on and to
the neglect of the key role of personal hygiene in good health, culminating in
the persistence of diseases like Cholera.
The second set of consequences pertains to
substantially unrealized goals of NHP 1983
due to funding difficulties from compression
of public expenditures and from organizational inadequacies. The
ambitious and far reaching NPP - 2000
goals and strategies have however
been formulated on that edifice in the hope that the gaps and the inadequate
would be removed by purposeful action. Without being too defensive or critical
about its past failures, the rural health
structure should be strengthened and funded and managed efficiently in all
States by 2005. This can trigger many dramatically changes over the next twenty
years in neglected aspects or rural health and of vulnerable segments.
The third set of consequences appears to be the inability to develop and
integrate plural systems of medicine
and the failure to assign practical roles to the private sector and
to assign public duties for private
professionals.
To set right
these gaps demanded patient redefinition of the state's role keeping the focus
on equity. But during the last decade there has been an abrupt switch to market
based governance styles and much influential advocacy to reduce the state role
in health in order to enforce overall compression of public expenditure an
reduce fiscal deficits. People have therefore been forced to switch between
weak and efficient public services and expensive private provision or at the
limit forego care entirely except in life threatening situations, in such cases
sliding into indebtedness. Health status of any population is not only the
record of mortality and its morbidity profile but also a record of its
resilience based on mutual solidarity and indigenous traditions of self-care - assets normally invisible to he planner and
the professional. Such resilience can be
enriched with the State retaining a strategic directional role for the good
health of all its citizens in accordance with the constitutional mandate.
Within such a framework alone can the private sector be engaged as an
additional instrument or a partner for achieving shared public health outcomes.
Similarly, in indigenous health systems must be promoted to the extent possible
to become another credible delivery mechanism in which people have faith and
away fond for the vat number of less than folly qualified doctore in rural
areas to get skills upgraded. Public programs in rural and poor urban areas
engaging indigenous practitioners and community volunteers can prevent much
seasonal and communicable disease using low cost traditional knowledge and
based on the balance between food, exercise medicine and moderate living. Such
an overall vision of the public role of the heterogenous private sector must
inform the course of future of state led health care in the country.
KEY ACHIEVEMENTS IN HEALTH
Our overall achievement in
regard to longevity and other key health indicators are impressive but in many
respects uneven across States, The two Data Annexure at the end indicate
selected health demographic and economic indicators and highlight the changes
between 1951and 2001. In the past five
decades life expectancy has increased from 50
years to over 64 in 2000. IMR has come down from 1476 to 7. Crude birth rates have dropped to 26.1 and death rates to 8.7.
At this stage, a process
understanding of longevity and child health may be useful for understanding progress
in future. Longevity, always a key national goal, is not merely the reduction
of deaths as a result of better medical and rehabilitative care at old age. In
fact without reasonable quality of life in the extended years marked by
self-confidence and absence of undue dependency longevity may men only a
display of technical skills. So quality of life requires as much external
bio-medical interventions as culture based acceptance of inevitable decline in
faculties without officious start at sixty but run across life lived at alt
ages in reduction of mortality among infants through immunization and nutrition
interventions and reduction of mortality among young and middle aged adults, including adolescents getting
inform about sexuality reproduction and safe motherhood. At the same time, some
segments will remain always more vulnerable -
such as women due to patriarchy and traditions of infra-family denial), aged (whose survival but not always
development will increase with immunization)
and the disabled (constituting a
tenth of the population).
Reduction in child mortality
involves as much attention to protecting children from infection as in ensuring
nutrition and calls for a holistic view of mother and child health services.
The cluster of services consisting of antenatal services, delivery care and
post mortem attention and low birth weight, childhood diarrhoea and ARI
management are linked priorities. Programme of immunization and childhood
nutrition seen in better performing stats indicate sustained attention to
routine and complex investments into growing children as a group to make them
grow into persons capable of living long and well Often interest fades in
pursuing the unglamorous routine of supervised immunization and is substituted
by pulse campaigns etc. Which in the long run turn out counter-productive.
Indeed persistence with improved routines and care for quality in immunization
would also be a path way to reduce the world's highest rate of maternal
mortality.
In this context we may refer
to the large ratio-based rural health infrastructure consisting of over 5 lakh trained doctors working under plural
systems of medicine and a vast frontline force of over 7 lakh ANMs, MPWS and Anganwadi workers besides community
volunteers. The creation of such public work force should be seen as a major
achievement in a country short of resources and struggling with great
disparities in health status. As part of
rural Primary health care network lone, a total of 1.6 lakh subcenters, (with 1.27
lakh.' ANMa in position) and 22975 PHCs
and 2935 CHCs (with over 24000 doctors and over 3500 specialists to serve in them) have been set up. To promote
Indian systems of medicine and homeopathy there are over 22000 dispensaries 2800
hospitals Besides 6 lakh angawadis serve
nutrition needs of nearly 20 million
children and 4 million mothers. The total
effort has cost the bulk of the health development outlay, which stood at over
Rs 62.500/- crores or 3-64 % of total
plan spending during the last fifty years.
On any count these are
extraordinary infrastructural capacities created with resources committed
against odds to strengthen grass roots. There have been facility gaps, supply
gaps and staffing gaps, which can be filled up only by allocating about 20% more funds and determined ill to ensure
good administration and synergy from greater congruence of services, but given
the sheer size of the endeavor thee wilt always be some failure of commitment
and in routine functioning. These get exacerbated by periodic campaign mode and
vertical programme, which have only increased compartmentalized vision and
over-medicalization of health problems.
The initial key mistake arose from the needless bifurcation of health
and family welfare and nutrition functions at all levels instead of promoting
more holism. As a result of all this the
structure has been precluded from reaching its optimal potential. It has got
more firmly established at the periphery/sub-center level and dedicated to RCH
services only. At PHC and CHC levels this has further been compounded by a weak
referral system. There has not been
enough convergence in "escorting" children through immunization
coverage and nutrition education of mothers and ensuring better food to children,
including cooked midday meals and health checks al schools. There has also been
no constructive engagement between allopathic and indigenous systems to build
synergies, which could have improved people's perceptions of benefits from the
infrastructure in ways that made sense to them.
One key task in the coming
decades is therefore to utilize fully that created potential by attending to
well known organizational motivational and financial gaps. The gaps have arisen
partly from the source and scale of funds and partly due to lack of
persistence, both of which can be set right.
PHCs and CHCs are funded by States several of whom are unable to match
Central assistance offered and hence these centers remain inadequate and
operate on minimum efficiency. On the other hand over two thirds cost of three
fourths of sub-centers are fully met by the Center due to their key role m
family welfare services. But in equal part these gaps are due to many other
non-monetary factors such as undue centralization and uniformity, fluctuating
commitment to key routines at ground level, insufficient experimentation with
alternatives such as getting public duties discharged through private
professionals and ensuring greater local accountability to users.
Health Status issues
The difference between rural
and urban indiactors of health status and the wide interstate disparity in
health status are well known. Clearly the urban rural differentials are
substantial and range from childhood and go on increasing the gap as one grows
up to 5 years. Sheer survival apart there
is also the we known under provision in rural areas in practically all social
sector services. For the children growing up in rural areas the disparities
naturally tend to get even worse when compounded by the widely practiced
discrimination against women, starting with foeticide of daughters.
In spite of overall
achievement it is a mixed record of social development specially failing in
involving people in imaginative ways. Even the averaged out good performance
ides wide variations by social class or gender or region or State. The classes
in may States have had to suffer the most due to lack of access or denial of
access or social exclusion or all of them. This is clear from the fact that
compared to the riches quintile, the poorest had
2.5 times more IMR and child mortality, TFR at double the rates and
nearly 75% malnutrition - particularly during the nineties.
Not only are the gaps
between the better performing and other States wide but in same cases have been
increasing during the nineties. Large
differences also exist between districts within the same better performing
State urban areas appear to have better health outcomes than rural areas
although the figures may not fully reflect the situation in urban and
peri-urban slums with large in migration with conditions comparable to rural
pockets. It is estimated that urban slum population wilt grow at double the
rate of urban population growth in the next few decades. India may have by 202 a total urban population of close to 600 million living in urban areas with an
estimated 145 million living in slums in 2001. What should be a fair measure for
assessing success in enhancing health status of population I any forecast on
health care?
Disease
Load in India and China:
We need a basis for comparative scenario building.
Among the nations of the world China alone rank in size and scale and in
complexity comparable to India differences between an open and free society and
a semi-controlled polity do matter. The remarkable success in China in
combating disease is due to sustained attention on the health of the young in
China, and of public policy backed by resources and social mobilization- While
comparing China and India in selected aspects of disease load, demography and
public expenditures on health, the record on India may seem mixed compared to
the more all round progress made by china. But this should also be seen in the
perspective of the larger burden of disease in India compared to china and of
the transactional costs of an open and free democracy,
Though India and China
recorded the same rate of growth till 70s,
China initiated reforms a full decade earlier. This gave it a head stat for a
higher growth rate and has resulted in an economic gap with India which has
become wider over time. This is because domestic savings in China are 36% of GDP whereas in India it hovers at 23%, mostly in house-hold savings. Again.
China attracted $40 billion in foreign
direct investment against $2 billion in
India. Special economic zones and relaxed labour laws have helped. Public expenditure
on health in China has been consistently higher underlining the regressive
nature of financing of health are in India. Nevertheless- it is not too
unrealistic to expect that India should be able to reach by 2010 at least three fourth the current level
of performance of China in all key health indices. India's current population
is not a bit more than 75% that of China
and India will of course be catching up even more with China into the 21 century. This would be offset by the
handicap that Indian progress will be moderated by the fact that it is an open
free and democratic society. A practical rule-of-thumb measure for an
optimistic forecast of future progress in India could be - that between 2000 and 2010 India should do three fourths as well as
China did in 1990-2000 and, after 2010, India should try to catch up with the
rate of performance of China and do just as well thereafter. This will
translate into, for, instance, a growth rate of about 8% for India till 2010 and
as close to 10% as possible thereafter
thus enabling doubling first in ten yeas and doubling first in ten year and
doubling twice over every seven years thereafter prior to 2025.
keeping this perspective in mind, we may now examine the profile of
major disease control effort; the effectiveness of available instruments for
delivery and financing public health action and assess factors relevant to the
remaining event of vulnerability within jout emerging social pyramid over next two or three
decades,
MAJOR DISEASE CONTROL EFFORTS
A careful analysis of the
Global Burden of Disease (GBD) study focusing on age-specific morbidity during
2000in ten most common diseases (excluding injuries) shows that sixty percent
of morbidity is due to infectious diseases and common tropical diseases, a quarter
due to life-style disorders and 13% due
to potentially preventable per-natal conditions. Further domestic R&D has
been so far muted in its efforts against an estimated annual aggregate health
expenditure in India ofRs- 80,000/-crores R&D expenditure in India for
public and private sector combined was Rs 1150
crores only. India must play a larger part in its own efforts at indigenous
R&D as very little world-wide expenditure on R&D is likely to be
devoted to infectious diseases. For instance out of the 1233 new drugs that came into the market between 1975 and 1997
only 11 were indicated specifically for
tropical country diseases,
We have already the
distinction of elimination or control acceptable to public health standards of
small pox and guinea worm diseases. In the draft National Health Policy -21 It has now been proposed to eliminate or
control the following diseases within limits acceptable to public health
practice- A good deal of the effort would be feasible.
• Polio Yaws
and leprosy by 2005 which seems distinctly feasible though the
removal of social stigma and reconstructive surgery and other rehabilitation
arrangements in regard to leprosy would remain inadequate for a decade or more.
• Kalaazar by 20I0 and Filalriasis by 2010
which also seems feasible due to its localized prevalence and the possibility
of greater community based work involving PR institutions in the simple but
time-limited tasks or public health programs-
• Blindness
prevalence to 0.5% by 2010 sees less feasible due to a graying
population. At present the programme is massively supported by foreign aid as
there are many other legitimate demands on domestic health budgets-
• AIDS
reaching zero growth by 2007 appears to be problematic as there are
disputes even about base data on infected population. On most reckonings,
affordable vaccines re not likely to be available soon nor anti-retro viral
drugs appear likely at affordable prices in the near future. Further the
prevalence curve of Aids in India is yet to show its shape. There is also
larger unresolved question of where HIV/ATDS should be fitted in our priorities
of public health, especially in this massively foreign aided programme what
happen if aid does not become available at some point.
Unfinished burden of communicable diseases
Apart from the above, there
remains a vast unfinished burden in preventing controlling or eliminating other
major communicable diseases and in bringing down the risk of deaths in maternal
and peri-natal conditions. Endemic diseases arising from infection or lack of
nutrition continue to account for almost two thirds of morality ad morbidity
India. Indeed eleven out of thirteen diseases recommended by the Bhore
Committee were infectious diseases and at least three of them may well continue
to be with us for the next two decades Baring Leprosy which is almost on the
path to total control by 2005, the other
key communicable diseases will be TB Malaria and Aids- to which diarrhoea in
children and complicated and high risk maternity should be added in view of
their pervasive incidence and avoidable mortality among the poorer and under
served sectors,
Tuberculosis:
Tuberculosis has had a world
wide resurgence including in India. It is estimated lhai about 14 million persons are infected, i.e. 1.55 of total population suffer from radio
logically active Tuberculosis. About 1.5
million cases are identified and more than 300
000 deaths occur every year Between NFHS
1 and NFHS 2 the prevalence has
increased from 4678 per lakh population
to 544. Unfortunately, prevalence among
working age adults (15-59) is even higher
as 675. All these may well be
underestimates in so far as patients are traced only through hospital visit.
Only about half reach the hospital. Often wrong diagnosis by insufficiently
trained doctors or misunderstood protocols is another key problem both public
and private sectors. TB is a wide spread disease of poverty among women living
and working in ill ventilated places and other undernourished persons in urban
slums it is increasingly affecting the younger adults also in the economically
productive segments. No universal screening is possible. Sputum positive test
does not precede diagnosis but drugs are prescribed on the basis of fever and
shadows as a result incomplete cure becomes common and delayed tests only prove
the wrong diagnosis too late. Improved
diagnosis through better training and clear protocols and elimination of drug
resistance through incomplete cure should be priority. Treatment costs in case
of drug resistance can soar close to ten times the normal level of Rs. 3000 to 4000/-per person treated. Similarly
even though the resistant strain may cover only
8% at present, it could suddenly rise and as it approaches 200/o or so, there is a danger that
TB may get out of control. The DOTS programme trying for full compliance after
proper diagnosis is settling down but already has some claims of success. More
tan 3000 laboratories have been set up
for diagnosis and about 1.5 lakh workers
trained and with total population coverage by
2007 cure rates (already claimed to have doubled) may rise
substantially. There is reason to hope that DOTS programs would prove a greater
success over time with increased community awareness aeneration. The key issue
is how soon and how well can it be integrated into the PHC system and made
subject to routines of local accountability, without which no low cost regime
of total compliance is feasible in a country as large as India.
An optimistic assessment
could be that with commitment and full use of infrastructure it will be possible
to arrest further growth in absolute numbers of TB cases keeping it at below 1.5 million till 2010 even though the population will e growing. Once that is done
TB can be brought down to less than a million lie within internationally
accepted limits and disappears as a major communicable disease in India by 2020.
Malaria:
As regards malaria, we have
had a long record of success and failure and each intervention has been
thwarted by new problems and plagued by recrudescence. At present India has a
large manpower fully aware of all aspects of malaria about often low in
motivation. It can be transformed into a large-scale work force for awareness
generation, tests and distribution of medicine. In spite of past successes,
there is evidence of reemergence with focal attacks of malaria with the
virulent falciparum variety especially m tribal areas. Priority tnbal area
malaria stands fully funded by the center. About
2 millioncases of malaria are recorded allover India every year with
seasonal high incidence local failures of control. Drug resistance in humans and insecticide
resistant strains of mosquitoes present a significant problem. But there is a
window of opportunity I respect ofDDT sensitive areas in eastern India where
even now malaria incidence can be brought down by about 50% within a decade and be beneficial for control of kalazaar and
JE. There is growing interest and community awareness of biological methods of
control of mosquito growth. Unfortunately diligent ground level public health
work is in grave disarray n these areas but can be improved by better
supervision greater use of panchayatraj institutions and buildings on modest
demonstrated successes. As regards a vaccine, there seems t be no sufficient
incentive for international R&D to focus on a relatively lower priority or
research. Roll back malaria programmes of the WHO are more likely to
concentrate on Africa whose profile of malaria is not similar to ours. The
search for a vaccine continues but has little likelihood of immediate success.
In spite of various
difficulties, if the restructuring of the malaria work force and the
strengthening of health infrastructure takes place, one can expect that the incidence
can be i educe by a third or even upto half in the next decade or so. For this it is necessary that routine tasks
like timely spraying and logistics for taking blood slides testing and their
analysis and organic methods of reducing mosquito spread etc. Are down staged to community level and
penormed under supervision throLigh panchayais wiih comaiLiniLy participation
public education and local monitoring. Malaria can certainly be reduced by a third even upto
a half in ten years, and there is a prospect of near freedom from malaria for
most of the country by 2020.
The
case of AIDS:
There is finally the case of
HIV AID. The magnitude in the numbers of HIV infected and of AIDS patients by 2025 can be known only as trends emerge over a
decade from now. when better epidemiological estimates are available but at
present these figures are hotly contested. 'We cant start with the number
infected with HIV as per NACO sentinel surveillance in 2000 a cumulative total 3.86
million, a figure disputed in recent public health debate. We can then assume
that about 10% will turn into full-blow cases of severe and intractable stage
of Aids. There is as yet no basis to know how many of those infected will
become AIDS patients, preventive efforts focused on behavior change will show
up firmly only after a decade or so. During this period one can assume an
additional 10% growth to account for new
cases every year. The Draft NHP 2001
seeks to stop further infection by educating and counseling and condom supplies
to level it off around 2007, which seems
somewhat ambitious. We have yet to make a decisive dent into the problem of
awareness with the broader population and so far we have been at work only on
high risk groups. NFHS2 shows only a
third of woman reporting that they even knew about the HIV/AIDS. Further such
awareness efforts must be followed by multi-pronged and culturally compatible
techniques of public education that go beyond segments easier to be convinced
or behaviour changed. There are voices already raised about the appropr
lateness of IEC mass media content and of the under emphasis of face to face
counseling, calling for innovative mobilization strategies rooted in indigenous
belief systems.
What it implies is that we may be carrying by 2015closeto 5 million infected
and upto a tenth of them could turn into full blown cases. We may not be able
to level off infection by 2007 Further these magnitudes may turn out
m actual fact to be wildly off the mark. On any account it is clear that AIDS
can lead to high mortality among the productive groups in society affecting
economic functioning as also public health. Even if 10% of them say 50 to 60000
cases becomes full blown cases the state has the onerous and grim
choice to look at competing equities and decide on a policy for free treatment
of AIDS patients with expensive anti-retro viral drugs. And if it decides not
to, the issue remains as to how to evolve humane balanced and affordable
policies that do not lead to a social breakdown. In about a decade vaccine
development may possibly be successful and drugs
may by more effective but they may not always be affordable nor can be given
free.
There would hopefully be
wider consultation with persons with caring sensibilities including AIDS
patients on how to counsel in different eventualities and to get the balance
right between hospital and home care and how to develop a humane affordable
policy for anti retroviral drugs for AIDS patients. Is there a
case for providing them with drug free of cost merely to extend
their lives for few years? The matter involves a true dilemma, for public health
priorities themselves certainly argue for more
funds should address diseases constituting bigger population based hazards. Investments made m such expensive
interventions can instead be made in supporting hospice efforts in the
voluntary and private sectors.
Whatever position may emerge
in research or spread of infection of case fatalities, a multi pronged attempt
for awareness, must continue and tough choices must get discussed openly
without articulate special, often urban middle class interests denying other
views and especially public health priorities of the poor. The promotion of barrier protection must
increase but has to related to a system of values, which would be acceptable to
the people’s beliefs. We need to
strengthen sentinel surveillance systems and awareness effort. We also
need sensitive feed back on the effects they leave on younger minds for a
balanced culturally acceptable strategy.
All this is feasible and can be accomplished if we are not swept
away by the power of funding and advocacy and fear of being accused to be out
of line with dominant world opinion.
In any case many of the ill
cannot afford the high prices or have access to it from public agencies. The strict patent regimen under TRIPS is
bound to prevail, notwithstanding the ambivalently worded Doha decision of WTO
that public health emergencies provide sufficient cause of countries to use the
flexibility available from various provisions of TRIPS. A recent analysis reveals that the three drug
regimen recommended will cost $10000 per person per year from Western companies
and the treatment will be lifelong.
Three Indian companies are offering to Central Government anti retro;
viral drugs at $600/ Rs. 30,000/per person per year and to an international
charity at an even lower price $ 350/ Rs. 13,000/per year provided it was
distributed for humanitarian relief free in S. Africa. It has been public policy in Brazil that the
drug is supplied free to all AIDS should be no exception. If drugs are supplied acting on a public
health emergency basis and prices can stabilize at Rs. 1000/- or so per year
the public health budget should be able to accommodate the cost weighed against
true public criteria. But the aim of
leveling off infection of 2007 still seems unlikely.
Maternal and Parental Deaths
Maternal and parental deaths
are sizeable but the advantage here is that they can be prevented merely by
more intensive utilization of existing rural health infrastructure. Policy and implementation must keep steady
focus on key items such as improved institutional deliveries better trained
birth attendants and timely antenatal screening to eliminate anaemia and at the
same time isolate cases needing referral or other targeted attention. After all Tamil Nadu has by such methods ensured
closed to 90% institutional deliveries backed by a functional referral. Firm administrative will and concurrent
supervision of specified screening tasks included in MCH services can give us a
window of opportunity to dramatically bring down within a few years alarming
maternal mortality currently one of the highest in the world. From NFHS I data,
it was estimated at 424 per lac births it has risen to 540 per lac births in
NFHS II, but the WHO estimate puts it higher at 570. There can be a systematic campaign over five
years to increase institutional deliveries as near as possible to the Tamil
Nadu level, also taking into account assisted, home deliveries by trained staff
with doctors at call. For the interim TBAs
should be relied on through a mass awareness campaign involving Gram Panchayats
too. Over a period of time there is no
reason why ANMs entitled benefits of children to help in their growth and not
remain as welfare measure. Using the
infrastructures fully and with community participation and extensive social
mobilization many tasks in nutrition are feasible and can be in position to
make impact by 2010.
Child Health and Nutrition
Associated with this is the issue of infant and
child mortality, (70 out of 1000 dying in the first year and 98 before vide years) and low birth weight (22% UW at birth ands 47% EJW at below 3 years)
most mortality occurs from diarrhoea and the stagnation in IMR in the last few
year is bound to have a negative effect on population stabilization goals. A
recent review of the Ninth plan indicated that even with accelerated efforts we
may reach at best IMR/50 by 3002, but
more like IMR/56. since the easier part of the problem is taking child
mortality is over every pomt gain hereafter will deal with districts at greater
risk and needing better organizational efficiencies in immunization. At the
same time, more streamlined RCH services are getting established as part of
public systems and through private partnerships Therefore there is every reason
to hope that the NPP 2000 target of 30 per thousand live births by 2010 will be met barring a few pockets
of inaccessible and resource lean areas with stubborn persistence of poverty
and dominantly composed of weaker sections (e g in part of Orissa as seen from
NFHS II).
As regards childhood
diarrhoea, deaths are totally preventable simple community action and public
education by targeting children of low birth weights and detecting early those
children at risk from malnutrition through proper low cost screening procedure,
the present arrangement has got too burdened with attempting total population
coverage getting all children weighed even once in three months and making ANMs
depots for ORS and for simple drugs for fever and motivating the community to
take pride in healthy children are the lessons of the success of the Tamil Nadu
Nutrition Project, If this is done there is a reasonable chance of two thirds decline in moderate malnutrition and abolition of
serious grades completely by 2015. The success can be built upon till 2025 for
reaching levels comparable to China.
Concentration on preventive
measures of maternal and child health and in particular improved nutrition
services will be particularly useful because it will help that generation to
have a head start in good health who are going to be a part of the demographic
bonus. The bonus is a young adult bulge of about
340 million (with not less than 250
million from rural population and about 100
million born in this century). The bonus will appear in a sequence with South
Indian States completing the transition before North Indian States spread it
over the next three decades- To ensure best results aL this stage the present
nutritional services must be converted into targeted (and entitled) benefits of
children to help in their growth and not remain as welfare measure. Using the
infrastructures fully and with community participation and extensive social
mobilization many tasks in nutrition are feasible and can be in position to make impact by 2010.
Mild and moderate malnutrition
still prevalent in over half of our young populaaon can be halved if food as
the supplemental pathway to better nutrition becomes a priority both for self
reliance and lower costs. There has been a tendency for micro nutrient
supplementation to overwhelm food derived nourishment. This trend is assisted
by foreign aid but over a long run may prove unsustainable- By engaging the
adolescents into proper nutrition education and reproductive health awareness
we can seamlessly weave into the nutritional
security system of our country a corps of informed interconnected
and imaginative ideas can be tried out. Such social
mobilization at low cost can be the best preventive strategy as has
been advocated for long by the Nutrition Foundation of India (< Gopalan
2001) and can be a priority in this decade over the next two plan
periods.
Unfinished
agenda - non communicable diseases and
injuries
Three major such diseases viz,, cancer
cardiovascular diseases and renal conditions -
and neglect in regard to mental health conditions - have of late shown worrisome trends. Cures for cancer are still
elusive in spite of palliatives and expensive and long drawn chemo - or radio -therapy which often inflict
catastrophic costs, In the case ot'CVD and renal conditions known and tried
procedures are available for relief. There is evidence of greater prevalence of
cancer even among young adults due to the stress of modem livmg. In India
cancer is a leading cause of death with about
1.5 to 2 million cases at anytime
to which 7 lac new cases are added every
year with 3 lakh deaths. Over 15
lakh patients require facilities for diagnosis and treatment. Studies by WHO
show that by 2026 with the expected increase
in fife expectancy, cancer burden in India will increase to about 14 lac cases.
CVD cases and Diabetes cases are also increasing with an 8 to 11 % prevalence of the latter due to fast life
styles and lack of exercise. Traumas and accidents leading to injuries- are
offshoots of the same competitive living conditions and urban traffic
conditions Data show one death every minute
due to accidents or more than 1800
deaths every day- in Delhi alone about 150
cases are reported every day from accidents on the road and for every death 8 living patients are added
to hospitals due to injuries. There is finally the emerging aftermath of
insurgencies and militant violence leading to mental illnesses of various types. It is estimated that 10 to 20 persons out of 1000 population suffer from severe mental
illness and 3 to 5 times more have emotional disorder. While there are some
facilities for diagnosis and treatment exist in major cities there is no access
whatever in rural areas. It is acknowledged that the only way of handling
mental health problems is through including
it into the primary health care arrangements implying trained screening and
counseling at primary levels for early detection.
All these are eminently feasible preventive steps and can be put into practice
bv 2005 and we should be doing as well or better than China by 2020 considering the greater load of non
communicable diseases they bear now. The burden of non-communicable diseases
will be met more and more by private sector
specialized hospitals which spring up in urban centers. Facilities
in prestigious public centers will also be under strain and they should be
redesigned to take advantage of community based approach of awareness, early
detection and referral system as in the mode) developed successfully in the
Regional Cancer Center Keraia. Public sector institutions are also needed to
provide a comparator basis for costs and evaluating technology benefits.' For
the less affluent sections prolonged high tech cure will be unaffordable.
Therefore public funds should go to promote a
routine of proper screening health education and self care and timely
investigations to see that interventions are started in stages I and II.
HEALTH INFRASTRUCTURE IN THE PUBLIC SECTOR
Issues in regard to public
and private health infrastructure are different and both of them need attention
but in different ways. Rural public infrastructure must remain in mainstay for
wider access to health care for all without imposing undue burden on them. Side
by side the existing set of public hospitals at district and sub-district
levels must be supported by good management and with adequate funding and user
fees and out contracting services, all as part of a functioning referral net
work. This demands better routines more accountable staff and attention to
promote quality. Many reputed public hospitals have suffered from lack of
autonomy inadequate budgets for non-wage O&M leading to faltering and
poorly motivated care. All these are being tackled in several states are part
health sector reform, and will reduce the waste involved in simpler cases needlessly
reaching tertiary hospitals direct These, attempts must persist without any
wavering or policy changes or periodic denigration of their past working. More
autonomy to large hospitals and district public health authorities will enable
them to plan and implement decentralized and flexible and locally controlled
services and remove the dichotomy between hospital and primary care services.
Further. most preventive services can be delivered by down staging to a public
health nurse much of what a doctor alone does now. Such long term commitment
for demystification of medicme and down staging of professional help has been
lost among the politicians bureaucracy and technocracy after the decline of the
PHC movement. One consequence is the huge regional disparities between states
which are getting stagnated in the transition at different stages and
sometimes, polarized in the transition.
Some feasible steps in revitalizing existing infrastructure are examined
below drawn from successful experiences and therefore feasible elsewhere,
Feasible Steps for better performance:
The adoption of a ratio based approach tor creating facilities and
other mpuls has led lo shortfalls
estimated upto twenty percent. It functions well where ever there is diligent attention to supervised administrative
routines such as orderly drugs procurement adequate O&M budgets
and supplies and credible procedures for redressal of complaints. Current PHC
CHC budgets may have to be increased by 10%
per year for five years to draw level. The proposal in the Draft NHP 2001 is timely that State health expenditures be raised to 7% by 2015 and to 8% of
State budgets thereafter. Indeed the target could be stepped up progressively
to 10% by 2025. it also suggests that Central funding should constitute 25% of
total public expenditure in health against the present 15%. The
peripheral level at the sub center has not been (and may not now ever be)
integrated with the rest of the health system having become dedicated solely to
reproduction goals. The immediate task would be to look deepening the range of
work done at all levels of existing centers and in particular strengthen the referral links and fuller
and flexible utilization ofPHC/CHCs. Tamil Nadu is an instance where a review
showed that out of 1400 PHCs 94% functioned in their own buildings and had
electricity, 98% of ANMs and 95% of pharmacists were in position. On an
average every PHC treated about 100
patients 224 out of the 250 open 24
hour PHCs had ambulances. What this illustrates is that every State must look
for imaginative uses to which existing structures can be put to fuller use such
as making 24 hours services open or
trauma facilities in PHCs on highway locations etc.
The persistent under funding of recurring costs had led to
the collapse of primary care in many states, some spectacular failures
occurring in malaria and kalazar control. This has to do with adequacy of
devolution of resources and with lack of administrative will probity and
competence in ensuring that determined priorities in public health tasks and routines are carried out timely and in full.
Only genuine devolution or simpler tasks and resources to panchayats, where
there will be a third women members- can be the answer as seen in Kerala or
M.P. where panchayats are made into fully competent local governments with
assigned resources and control over institutions in health care. Many innovative cost containment initiatives
are also possible through focused management -
as for instance in the streamlining of drug purchase stocking distribution
arrangements in Tamil Nadu leading to 30%
more value with same budgets.
The PHC approach as
implemented seems to have strayed away from its key thrust in preventive and public health action. No
system exists for purposeful community focused public information or seasonal
alerts or advisories or community health
information to be circulated among doctors in both private practice
and in public sector. PHCs were meant to be
local epidemiological information centers which could develop simple
community.
Tertiary hospitals had been given concessional land,
customs exemption and liberal tax breaks against a commitment to reserve beds
for poor patients for free treatments.
No procedures exist to monitor this and the disclosure systems are far
from transparent, redressal of patient grievances is poor and allegations of
cuts and commissions to promote needless procedure are common.
The bulk of noncorporate
private entities such as nursing homes are run by doctors and doctors-
entrepreneurs and remain unregulated cither
in terms of facility of competence standards or quality and accountability
of practice and sometimes operate without systematic medical records and
audits. Medical education has become more expensive and with rapid
technological advances in medicine, specialization has more attractive rewards. Indeed the reward expectations of
private practice formerly spread out over career long earnings are squeezed
into a few years, which becomes possible only by working in hi tech hospital some times run as businesses.
The responsibilities or private sector in clinical and preventive public health
services were not specified though under the NHP
1983 nor during the last decade of reforms followed up either by
government of profession by any strategy to
engage allocate, monitor and regulate such private provision nor
assess the costs and benefits or subsidization of private hospitals. There has
been talk of public private partnerships, but this has yet to take concrete
shape by imposing pubic duties on private professionals, wherever there is
agreement on explicitly public health outcomes. In fact it has required the
Supreme Court to lay down the professional obligations of private doctors in
accidents and injuries who used to be refused treatment in case of potential
becoming part of a criminal offence.
The respective roles of the
public and private sectors in health care has been a key issue in debate over a
long time. With the overall swing to the Right after the 1980s, it is broadly accepted that private provision of care
should take care of the needs of all but the poor. hi doing so, risk pooling
arrangements should be made to lighten the financial burden on theirs who pay
for health care. As regards the poor with priced services. Taking into account
the size of the burden, the clinical and public health services cannot be
shouldered for all by government alone.
To a large extent this health sector reform m India at the state level
confirms this trend. The distribution of the burden, between the two sectors
would depend on the shape and size of the social pyramid in each society. There
is no objection to introduce user fees, contractual arrangements, risk pooling,
etc. for mobilization of resources for health care. But, the line should be
drawn not so much between public and private roles, but between institutions
and health care run as businesses or run in a wider public interest as a social
enterprise with an economic dimensions. In a market economy, health care is
subject to three links, none of which should become out of balance with the
other - the link between state and
citizens' entitlement for health, the link between the consumer and provider of
health services and the link between the physician and patient.
HEALTH FINANCING ISSUES
Public expenditure levels
Fair financing of the costs
of health care is an issue in equity and it has two aspects how much is spent by Government on publicly funded health care
and on what aspects? And secondly how huge does the burden of treatment fall on the poor seeking health care?
Health spending in India at 6% of GDP is
among the highest levels estimated for developing countries. In per capita
terms it is higher than in China Indonesia and most African countries but lower
than in Thailand. Even on PPP $ terms
India has been a relatively high spender information sheets based on reporting
from a network associating private doctors also as has been done successfully
at CMC Vellore in their rural health projects or by the Khoj projects of the
Voluntary Health Association of India. It is only through such community based
approach that revitalization of indigenous medicines can be done and people
trained in self care and accept responsibility for their own health.
PHC approach was also
intended to test the extent to which non-doctor based healthcare was feasible
through effective down staging of the
delivery of simpler aspects of a care as is done in several
countries through nurse practitioners and physician assistants, ANMs; physician
assistants etc can each get trained and recognized to work in allotted areas
under referral/supervision of doctors.
This may indeed be more acceptable to the medical profession than the
draft NHP proposal to restart licentiates in medicine as in the thirties and
give them shorter periods of training to serve rural areas. Such a licentiate
system cannot now be recalled against the profession's opposition nor would
people accept two level services.
Finally it is important 10 noie some dangers inherem m arrangemenis
itiai promote delivery systems substantially outside government channel either
through NGOs or through registered societies at State and district levels.
Clearly this may by a better approach than leaving it to the market and welcome
as path breaking of innovative efforts as a precursor to launching a public
program. But as a long run delivery mechanism it is neither practical nor
sustainable as such arrangements tend to bypass government under our
constitutional scheme of parliamentary responsibility and would also cut into
the potential of panchayatraj institutions. Each major disease control program
has now got a separate society at state and district levels often as part of
access to foreign aid. What is lost is the principle of parliamentary
accountability over the flow of funds that arise out of voted budgets and
international agreements to which Government is a party and answerable to
parliament. Like campaign modes and vertical interventions, the registered
society approach would weaken the long-term commitment and integrity of public
health care systems.
SHAPE OF THE PRIVATE SECTOR IN MEDICINE
The key features of the
private sector in medical practice and health care are well known. Two
questions are relevant. What role should be assigned to it? How far and how
closely should it be regulated? Over the last several decades, independent
private medical practice has become widespread but has remained stubbornly urban with polyclinics, nursing
homes and hospitals proliferating often through doctor entrepreneurs. At our
level tertiary hospitals in major cities are in may cases run by business
houses and use corporate business strategies and hi-tech specialization to
create demand and attract those with effective demand or the critically
vulnerable at increasing costs. Standards in some of them are truly world class
and some who work there are outstanding leaders in their areas. But given the
commodification of medical care as part of a business plan it has not been
possible to regulate the quality, accountability and fairness in care through
criteria for accreditation, transparency in fees, medical audit, accountable
record keeping, credible grievance procedures etc. such accreditation, standard
setting and licensure systems are best done under self regulation, but self
regulation systems in India medical practice have been deficient in many
respects creating problem in credibility.
Acute care has become the
key priority and continues to attract manpower and investment into related
specialty education and facilities for technological improvement. Common
treatments, inexpensive diagnostic procedures and family medicine are replaced
and priced out of the reach of most citizens in urban areas.
Public health spending accounts for 25% of aggregate expenditure the balance being
out of pocket expenditure incurred by patients to private practitioners of
various hues. Public spending on health in India has itself declined after
liberalization from 1.3% of GDP in 1990 to 0.9%
in 1999. Central budget allocations for
health have stagnated at 1.3% to total
Central budget. In the States it has declined from 7.0% to 5.5.% of
State health budget. Consider the
contrast with the Bhore Committee recommendation of 15% committed to health from the revenue expenditure budget,
Indeed WHO had recommended 55 of GDP for
health. The current annual per capita public health expenditure is no more than
Rs.
160 and a recent World Bank review showed that over all primary health
services account for 58% of public
expenditure mostly but on salaries, and the secondary/tertiary sector for about 38%, perhaps the greater part going to
tertiary sector, including government funded medical education. Out of the
total primary care spending, as much as 85%
was spent on or curative services and only 15%
for preventive service. about 47% of total Central and State budget is spent on curative care
and health facilities. This may seem excessive at first sight but in face the
figure is over 60% in comparable
countries, with the bulk of the expenditure devoted publicly funded care or on
mandated or voluntary risk pooling methods, in India close to 75% of all household expenditure on
health is spend from private funds and the consequent regressive effects on the
poor is not surprising. In this connection. Ehe proposals in the draft NHP 2000 are welcome seeking to restore the key
balance towards primary care, and bring it to internationally accepted
proportions in the course of this decade.
Private expenditure trends
Many surveys confirm that
when services are provided by private sector it is largely for ambulatory care
and less for inpatient carte. There are variations in levels of cost, pricing,
transactional conveniences and quality of services. There is evidence to suggest that disparities
in income as such do not make a difference in meeting health care costs, except
for catastrophic or life threatening situations Finally it has been established
that between 2/3rds to 3/4ths of all medical expenditure is spend on privately
provided care every household on the average spends up to 10% of annual household consumption in meeting
health care needs. This regressive burden shows up vividly in the cycle of
incomplete cure followed by recurrence of illness and drug resistance that the
poor face in diseases like TB or Kalazar or Malaria especially for daily wage
earners who cannot afford to be out of work.
Privatization has to be
distinguished from private medical practice which has always been substantial
within our mixed economy. What is critical however is the rapid commercialization
of private medical practice in particular uneven quality of care. There are
complex reasons for this trend. First is the high scarcity cost of good medical
education, and second the reward differential between public and corporate
tertiary hospitals leading to the reluctance of the young professional to be
lured away from the market to public service in rural areas and finally there
is the compulsion of returns on investment whenever expensive equipment in
installed as part of practice. Increasingly, this has shifted the balance from
individual practice to institutionalizes practice, in hospitals, polyclinics,-
Etc. this conjunction explodes into
unbearable cost escalation when backed by a third party payer system/- This in
turn induces increases in insurance premiums making such cover beyond the
capacity to pay. There is a distinct possibility
of such cycles of cost escalation periodically occurring in the
future, promoted further by global transfer of knowledge and software,
tele-medicine etc. especially after the advent of predictive medicine and gene
manipulation.
Doctors practicing in the private sector are
sometimes accused of prescribing excessive, expensive and nsky medicines and
with using rampant and less than justified use of technology for diagnosis and
treatment. Some method of accreditation of hospitals and facilities and better
licensure systems of doctors is likely within a decade. This will enables some
moderation in levels of charges in using new technology. High cost of care is
sometimes sought to be justified as necessary due to defensive medicine
practiced in order to meet risks under the Consumer Protection Act. There is little evidence from decisions of
Consumer Courts to justify such fears. While the line between mistaken
diagnosis and negligent behaviour will always remain thin, case law has already
begun to settle around the doctor's ability to
apply reasonable skills and not the highest degree of skill. What
has lieen established is the right of the
patient to question the treatment and procedures if there is failure to treat
according to standard medical practice or if less than adequate care was taken.
As health insurance gets established it may impost more stringent criteria and
restrictions on physician performance which may tempt them into defensive
medicine. There may also be attempt to collusive capture and (indirect
ownership) of insurance companies by corporate hospitals as in other countries.
Advances in medical technology are rapid and dominant and easily travel world wide
and often seen as good investment and brand equity in the private sector.
Private independent practices - and to
smaller extent hospitals, dispensaries, nursing homes tele- are seen as markets
for medical services with each segment seeking to maximize gains and build
mutually supporting links with other segments. More than one study on the
quality of care indicates that sometimes more services are performed to
maximize revenue, and services/ medicines are prescribed which ffl-e not always
necessary. Allegations are also widely made of collusive deals between doctors
and hospitals with commissions and cuts exchanged to promote needless referral,
drugs or procedures
Appropriate regulation is likely in the next decade for minimum standards and
accountability and that should consist of a balanced mix of self regulation
external regulation by standard setting and accreditation agencies including
private voluntary health insurance.
How far can health insurance help?
What constitutes a fair
distribution of the costs of care among different social groups will always be
a normative decision emerging out of political debate. It includes risk pooling initiatives for sharing costs among the healthy
and the sick leading to insurance schemes as a substitute for or as
supplementary to State provision for minimum uniform services. It also covers
risk sharing initiatives across wealth and income involving public policy
decisions on progressive taxation, merit subsidy and cross subsidization by dual
pricing. Both will continue to be necessary in our conditions with more
emphasis on risk sharing as growth picks up. Risk
pooling within private voluntary and mandated insurance schemes has
become inevitable in all countries because of the double burden of sickness and
to ensure that financial costs of treatment do not become an excessive burden
relative to incomes. It is difficult but necessary to embed these notions of
fair financing into legislation, regulations and schemes and programs equity is
aimed at in health care.
With the recent opening up
of the general Insurance sector to foreign companies, there is the prospect of
two trends. New insurance product will be putout so expand business more be
deepening than widening risk covered. The second trend would be to concentrate
on urban middle and upper classes and settled iobholders with capacity to pay
and with a perceived interest in good health of the family. Both trends make
sound business sense in a vast growth market and would increase extensive hospital
use and protection against huge hospitalization expenses, and promoted by urban
private hospitals since their clientele will increase.
Insurance is a welcome necessary step and must
doubtless expand to help in facilitating equitable health care to shift to
sections for which government is responsible. Indeed for those not able to
access insurance it is government that will have to continue to provide the
minimum services, and intervene against market failures including denial
through adverse selection or moral hazard. Indeed in the long run the degree of
inequity in health care after insurance systems are set up will depend
ironically on the strength and delivery of the public system as a counterpoise
in holding costs and relevance in technology.
The insurable population in
India has been assessed at 250 million
and at an average of Rs 1000/- per person
the premium amount per year would be Rs 25,000/- crores and is expected to
treble in ten years- While the insurance product will dutifully reflect the demands
of this colossal market and related technological developments in medicine, it
should be required to extend beyond hospitalization and cover domiciliary
treatment too in a big way; for instance, extending cover to ambulatory
maternal and selected chronic conditions like Asthma more prevalent among the
poor. The insurance regulatory authority has announced priority in licensing to
companies set up with health insurance as key business and has emphasized the
need for developing new products on fair terms to those at risk among the poor
and in rural areas. Much will turn on
what progress takes place through sound regulation covering aspects indicated
below. In order to be socially relevant and cominercially viable the scheme
must aim at a proper mix of health hazards and cover many broad social classes
and income groups. This is possible in poor locations or communities only if a
group view is taken and on chat basis a population-
based nsk is assessed and community rated premiums determined
covering families for all common illnesses and based on epidemiological
determined risk. In order that exclusions co-payments deductibles etc. remain
minimum and relevant to our social situation, some well judged government merit subsidy can be
incorporated into anti poverty family welfare or primary education or welfare
pension schemes meant for old age. Innovative community based new products can
be developed by using the scattered experience of such products for instance in
SEWA, so that a minimum core cover can be developed as a model for innovative
insurance by panchayats with reinsurance backup by companies and government
bearing part of promotional costs. The bulk of the formal sector maybe covered
by an expanded mandatory insurance with affordable cover and convenient modes
of premium payment. Outside the formal manufacturing sector innovate schemes
can be designed around specific occupation
groups in the informal sector which are steadily becoming a base for
old age pension entitlements, as in Kerala and Tamil Nadu - and brought under common risk rating.
Finally, as in the West health insurance should develop influence and capacity
as bulk purchaser or medical and hospital services to impact on quality and cost and provide greater
understanding about Indian health and illness behaviours, patterns of
utilization of care and intra family priorities for accessing medical care.
Health insurance should be welcomed as a force for a fairer healthcare system.
But its success should be judged on how well new products are developed with a
cover beyond hospitalization, how fairly and
inclusively the cover is offered and how far community rated
premiums are established. The IRDA has an immense responsibility and with its
leadership one can optimistically expect
about 30% coverage by 2015 relieving the burden on the public systems.
HEALTH PERCEPTIONS AND PLURAL SYSTEMS:
Health perceptions play an important part in
ensuring sound health outcomes. To a large extent they are culturally
determined but also subject to change with economic growth and social
development. People intuitively develop capacity to make choices tor being
treated under the western of indigenous systems of medicines, keep a balance
between good habits traditionally developed for healthy living and modem lifestyles,
decide on where to go for chrome and acute care and how to apportion
intra-family utilization ofhealthcare resources. The professional is generally
bound by his discipline and its inherent logic of causation and effect and
tends to discount even what work as successful practice, I fit does not fall
within the accepted understanding of his profession. Some movement is occurring
among eminent allopathic doctors trying, for instance, to rework Ayurveda
theory in a modem idiom starting from respectful reverse analysis for actual
successful contemporary practice of Ayurveda and provide a theoretical frame
linking it to contemporary needs. There is evidence from public health
campaigns in Tamil Nadu where every seventh person spontaneously expressed a preference
for Sidda Medicine. Homeopathy for chronic ailment is widely accepted. The
herbal base for Ayurvda medicine widely practiced in the Himalayan belt has
down world attention a huge export market remains to be tapped according to the
knowledgeable trade sources but the danger of bio-privacy remains and legal
enablements should be put in place soon that would fully expand on our rights
under the WTO agreements. The draft national policy on ISIvIH has attempted to
place these plural systems in a modem service delivery and research and
education context, it has covered its natural resource base, traditional
knowledge base and development of institutions to carry a national heritage
forward. There is hope for the survival and growth of the sector only if it becomes
an example of convergence between people's and planner's perceptions and ensure
its relevance, accountability and affordability to contemporary illnesses and
conditions. At the same time it is undeniable that there is much cross practice
by ISM practitioners which usually include prescriptions we western medicine as
part of indigenous treatment Appropriate regulation is needed to protect people
from fraud and other dangers but the larger question is how to make the
perceptions of the professionals and planners regarding indigenous system of
medicine less ambivalent. The separate
department for ISM&H should be able to
bring about functional integration of ISM and western medicine in service
delivery at PHC levels by 2005 whereby it will usher in an uniquely Indian system of care.
EMERGING SCENARIO
What then can we conclude
about the prospects of health care in India in 2020? An optimistic scenario
will be premised on an average 8% rate of
economic growth during this decade and 10% per annum thereafter- If so, what
would be the major fall out in terms of results on the health scene? In the
first place, longevity estimates can be considered along the following lines.
China in 2000 had a life- expectancy at
birth of 69 years (M) and 73(F) whereas
India had respectively 60 (M) and 63 (F). More importantly, healthy life
expectancy at birth in China was estimated in the World Health Report 2001 at 61
(M) and 63.3 (F) whereas in Indian
figures were 53 (M) and 51.7 (F). If we look at the percentage of life
expectancy years lost as a result of the disease burden and effectiveness of
health care systems, Chinese men would have lost
11.6 years against Indian men losing 12.7
years. The corresponding figures are 13.2
for Chinese women and 17.5 for Indian
women. Clearly, an integrated approach is necessary to deal with avoidable
mortality and morbidity and preventive steps in public health are needed to
bridge the gaps, especially in regard to the Indian women. Taking all the
factors into consideration, longevity estimates around 20-25 could be around 70
years, perhaps, without any distinction between men and women.
This leads us to the second question of the
remaining disease burden in communicable and non-communicable diseases, the
effective of interventions, such as, immunization and maternal care and the
extent of vulnerability among some groups. These issues have been death with in
detail earlier. Clearly an optimistic forecast would envisage success in polio,
yaws, leprosy, kalazar t'ilaria and blindness. As regards TB it is possible to
arrest further growth in absolute numbers by
2010 and thereafter to bring it to less than an million withm
internationally accepted limits by 2020.
With regard to Malaria, the incidence can be reduced by a third or even upto
half within a decade. In that case, one can expect near freedom from Malaria
from most of the countries by 2020. As
regards AIDS, it looks unlikely that infection can be leveled of by 2007.
The prognosis in regard to the future shape of HIV / AIDS is uncertain. However, it can be a
feasible aim to reduce maternal mortality from the present 400 to 100
per lakh population by 2010 and achieve
world standards by 2020. As regards child
health and nutrition, it is possible to reach IMRV30 per thousand live births
by 2010 in most parts of the country
though in some areas, it may take a few years more. What is important is the
chance of two thirds decline in moderate malnutrition, and abolition of serious
malnutrition completely by 2015 in the
case of Cancer, it is feasible to set up an integrated system for proper
screening, early detection, self care and timely investigation and
referral. In the matter of disease
burden as a whole, it is feasible to attempt to reach standards comparable to
china from 2010 onwards.
Taking the third aspect viz fairness in financing of
health care and reformed structure of health services, an optimistic forecast
would be based on the fact that the full potential of the vast public health
infrastructure would be fully realized by 2010.
its extension to urban areas would be moderated to the extent substantial
private provision of health care is available in urban areas, concentrating on
its sensible and effective regulation. A reasonably wide network of private
voluntary health insurance cover would be available for the bulk of the
employed population and there would be models of replicable community based
health insurance available for the unorganized sector. As regards the private
sector in medicine, it should be possible in the course of this decade to
settle the public role of private medical practice - independent or institutional. For this purpose, more experiments
are to be done for promoting public private partnerships, focusing on the issue
of how to erect on the basis of shared public health outcome as the key basis
for the partnership. A sensible mixture of external regulation and professional
self-regulation can be device in the consultation with the profession to ensure
competence, quality and accountability. The future of plural systems in medical
understanding and evaluation of comparative levels of competence and
reliability in different systems - a task
in which, the separate department for Indian systems of medicine and homeopathy
will play a leading role in inducting quality into the indigenous medical
practices.
The next issue relates to
the desirable level of public expenditure towards health services. China
devotes 4.5% to its G-DP as against India
devoting 5.1%. but this hides the fact
that in China, public expenditure constitutes
38% whereas in India, it is only 1S% of total health expenditure. An
optimistic forecast would be that the level of public expenditure will be
raised progressively such that about 30%
of total health expenditure would be met out of public funds by progressively
increasing the health budget in states and the central and charging user fees
in appropriate cases. The figure mentioned would perhaps correspond to the
proportion of the population which may still need assistance is social
development.
Finally it is proper to
remember that health is at bottom an issue in justice. It is in this context
that we should ask the question as to how far and in what way has politics been
engaged m health care? The record is disappointing. Most health sector issues figuring
in political debate are those that affect interest groups and seldom central to
choices in health care policy. For instance conditions of service and reward
systems for Government doctors have drawn much attention often based on inter
service comparison of no wider interest. Inter-system problems of our plural
medical care have drawn more attention from courts than from politics. Hospital
management and strikes, poor working of the MCI and corruption in recognition
of colleges, dramatic cases of spurious drug supply etc have been debated but
there has been no sustained attention on such issues as why malaria
recrudescence is so common in some parts of India or why complaints about
absence of informed consent or frequent in testing on women, or on the variations
in prices and availability of essential drugs or for combating epidemic attacks
in deprived areas seldom draw attention. The far reaching recommendations made
by the Hathi Committee report and or the Lentin Commission report, have been implemented patchily. The role to
be assigned to private sector in medicine, the need for a good referral system
or the irrationality in drug prescriptions and sue have seldom been the point
of political debate. Indeed the lack luster progress of MNP over the Plans
shows political disinterest and the only way for politics to become more
salient to the health of the poor and the reduction of health inequalities is
for a much greater transfer of public resources for provision and financing - as has happened in the West, not only in UK
or Canada but in the US itself with a sizable outlay on Medicaid and Medicare.
