Health in India--1

Health in India: 

The story of deep neglect Extreme inequality in access to health care services and the poor living conditions of a majority of the people are responsible for the poor conditions of health in India. While people who can pay are able to receive world class treatment facilities, for most people in India a major illness in the family plunges the family into extreme poverty and destitution. Not only are healthcare facilities out of reach for most people, routine public health measures to protect our people are denied to a majority. India continues to figure among the bottom in global estimates regarding deaths among infants and young children and among pregnant women. India lags behind most countries, including many much poorer than us, even in providing routine immunization to children. India is also currently experiencing a ‘multiple burden of disease’. Several preventable infectious diseases are growing unchecked, nutritionlinked health problems (gross under-nutrition coexisting with a rising trend of obesity) continue to affect millions, while chronic health conditions are rising substantially. Every family in India dreads a medical emergency. When a family member falls ill, we pay from our pocket – often by selling our assets or by borrowing. Thus the poor are either denied care because they cannot bear the expenses or the family gets pushed to further poverty and destitution. As families cope with health shocks the vicious cycle of poverty and ill-health continues. Poor health services in the country  are a tale of deep apathy of successive governments towards the suffering of a majority of the poor and the vulnerable. Those in power have contributed to the systematic neglect of the public health system on one hand and to an aggressive expansion of unaffordable, often unnecessary, unethical and low quality private health services on the other. In this booklet we highlight some of the key issues pertaining to health of millions of Indians and raise some of the key demands for improvement of access to quality health care. Poor Conditions of Health One-fifth of world’s children who die before their fifth birthday are born in India, while the highest number of mothers who die while giving birth are from India. We perform poorly in comparison to most countries in the world, including most developing countries. Even in our region, only two countries lag behind India. See Box 1 to understand how we continue to be one of the worst performing countries in the world as regards healthcare and health outcomes. A survey of 179 countries across the world shows that India is among the least safe countries to be a mother (Save the Children, 2015). High undernourishment prevalent among women in the reproductive age group, coupled with low coverage of care during pregnancy (ante natal care – ANC) make women vulnerable at the time of delivery and lead to complications. Millions of children die every year from preventable diseases because they are not immunized and from hunger and malnutrition. Over one-third of our children do not get enough food, a rate that is comparable or worse than some of the poorest countries in Africa. Children die routinely from common diseases like diarrhea and pneumonia because of lack of access to safe drinking water, lack of sanitary facilities and absence of free public facilities for treatment.

Surveys show that only 68.7 % of women have received three antenatal check-ups, only 26.3% of pregnant women have consumed more than 100 iron and folic tablets and only 61% of children (12 -23 months) have been fully immunized. India ranks 119thof 169 countries in Human Development Index(HDI)

India ranks 140th of 179 countries as the best place to be a mother (State of World’s Mother 2015) India is placed at 67thof 84 countries in Global Hunger Index (GHI) More than a fifth of under five deaths per year, take place in India – the highest anywhere in the world; a majority of these deaths are preventable More than 100 million children under five are undernourished, and 8.5 million suffer from severe acute malnutrition. Only half of children under five receive routine immunisation (National Family Health Survey III) Only about half (52%) of deliveries are safe: (National Rural Health Mission) Only one-third of children having diarrhoea receive ORS (State of the World’s Children, UNICEF, 2011) Pneumonia: 69% taken to hospital and only 13% receive antibiotics (SoWC, 2011) Only half of the pregnant women receive 3 or more check ups before delivery Box 1: Where do we stand in protecting our people’s health? Table 1: A cross country comparison of key health outcomes and outputs

As we can see from Table 1, India fares poorly in comparison to even developing countries, including our immediate neighbours Sri Lanka and Bangladesh. The state of public health is clearly depicted by the fact that we are not able to protect a large number of children from vaccine preventable illnesses. Childhood vaccination is regarded as one of the most cost effective interventions to prevent child deaths. A third of the un-immunized children across the world are in India. Large inequalities in immunization coverage persist in India, across and within states and according to wealth, caste, religion, location etc. Children from the richest wealth group are 2.5 times more likely to be immunized than their poorest counterparts. It is distressing to note that states which had performed well earlier (as per data available in 2005-06) have slipped back over the last ten years, including Tamil Nadu, Haryana, Uttarakhand and Maharashtra (Fig 1). Most significant is the decline in TN. From being among leading states in terms of full immunisation coverage, the state has experienced a dramatic 11.2 percentage point decline. The major reason for stagnation or decline in overall immunisation coverage is decline in coverage in urban areas. Most noteworthy is the decline in Haryana (from 82.2 to 57%), Maharashtra (68 to 55.8), Tamil Nadu (83.7 to 73.3) and Uttarakhand (67.2 to 56.5).

 Health of Women and Girls Discrimination faced women and girls have a lasting and tragic impact on their health status. Data from National Family Health Survey (NFHS) shows that child deaths rates for girls are 61 per cent higher than those for boys after the first month, all the way up through age four. Among 15-19 year olds in the country, complications during pregnancy are the leading cause of death. As many as two out of three adolescent girls living in India’s backward districts have experienced sexual violence. Maternal death rates continue to be very high (at 190/ 100,00 live births, one of the highest rates in the world). Maternal deaths are highest amongst young women, while girls continue to be married off before the legal age of marriage. Too many girls become pregnant before tyhey are old enough and before their bodies are ready for pregnancy. This combined with malnutrition and anemias ensure that young women, many still in their teens, die during pregnancy. Women also continue to die around child birth because health facilities in many parts of the country are not equipped to provide emergency care to them when complications arise, the quality of care during pregnancy available is inadequate, and safe abortion services in the public sector are inaccessible for the majority of women. Quality contraceptive services as are not provided according to what women need. Instead women are targeted for hysterectomies to achieve family planning camps. Horrendous accounts surface periodically of how women are herded into unhygienic and under staffed hysterectomy camps.

The burden of communicable, non-communicable diseases and mental distress is also seen more in women. Sexually transmitted diseases amongst women remain undiagnosed, and when diagnosed can have drastic social consequences for them. Heart attack and stroke are more lethal for women, and depression twice as common. Women over the age of 60 years have greater disability and suffer more from ill health than men of the same age-group, due to delays in or lack of healthseeking, mismatched care provision (as women are under-represented in health care delivery systems and in research, particularly related to chronic diseases).Gender-based violence is extremely high, with as many as 40.3% of women reporting at least one instance of physical abuse. There seems to be an epidemic of sexual violence against women in recent years. Mental and physical consequences of violence against women need to be addressed by the health sector

Neglect of public health system In most countries where people have near universal access to health care, it has been achieved through a well-functioning public health system. Here we may note that while a well functioning system to provide universal access to care is a necessary condition for good health outcomes, it is not sufficient on its own. Good health is a result of better nutrition, safe drinking water and sanitation, universal access to education, gainful employment and equitable and inclusive development, better working and living conditions, control over addictions as well as environmental pollution and an end to various forms of discrimination. Reduction in poverty itself contributes immensely to improved health outcomes. A strong, comprehensive public health system is the most efficient way to provide appropriate health care. It creates a separation between health care needs and people’s ability to pay for healthcare. It also allows much stricter control of health care costs, serves as an effective check on unregulated growth of the private sector and helps prevent unethical practices in the private  sector. However, in India the public health system has experienced continuous neglect, systematic underinvestment, provisioning of a select set of services and a ‘targeted’ approach. The introduction of National Rural Health Mission had introduced some efforts to strengthen public systems for a limited set of services;however recent trends show that there is a reversal already taking place due to cuts in budgets. India’s poor investment in health care translates into a failure to create the necessary health infrastructure, or to build a health workforce, or to ensure availability of necessary equipment, diagnostic facilities and medicines. We are just not adding enough beds in public hospitals or enough doctors and nurses to make public services effective. After the introduction of some public health measures under the NHRM, some improvements did take place. Services of close to 23,000 doctors, 35,000 nurses and 70,000 ANMs and 10,000 management staff were added under the NRHM. However as compared to the government’s own Public Health Standards, this is less than one-third of the total number of public health workforce that is required. Further the terms of engagement of these staff were extremely adverse -- almost all of the additional staff under NHRM is contractual, with remuneration packages often less than half of the regular staff that does the same work, and with no security of tenure. There continue to be substantial shortfalls in the number of SubCentres (SC), Primary Health Centres (PHCs) and Community Health Centres (CHCs) across states. Nationally, there are only 0.16 facilities for every 10,000 persons, and there are approximately 5.5 government beds for every 10,000 persons. Outpatient visits have nearly doubled from 55 per 1,000 persons in 1995-96 to 100.7 per 1,000 in 2014, with more marked increases in urban as compared to rural areas. Inpatient episodes increased nearly three-fold in the same period, from 15 per  1,000 persons in 1995-96 to 44 per 1,000 in 2014. Yet the number of beds in the public sector, per 10,000 population has remained stagnant since the 1980s. For SCs, nearly 21 states had shortfalls ranging from 4.4% in Jammu and Kashmir to 50.6% in Delhi. Uttar Pradesh (33.9%), Jharkhand (34.5%), Meghalaya (46.6%) and Bihar (47.7%) also have high shortfalls in the number of SCs. For PHCs, the states of Uttar Pradesh, Delhi, Bihar, Madhya Pradesh, West Bengal and Jharkhand had shortfalls ranging from 28.6-69.8%. For CHCs, states with shortfalls above 30% included Madhya Pradesh, Maharashtra, West Bengal, Andhra Pradesh, Karnataka, Sikkim, Assam, Tripura, Uttar Pradesh, Bihar and Delhi. Nationally, the shortfall was: SCs, 20.1%; PHCs, 24.1%; and CHCs, 37.9% (GoI, 2011). More than three quarter of Sub-centres (76.4%) do not have any water supply. Piped water is not available in a majority of PHCs (63.3%) and CHCs (54.6%). Almost a third of PHCs (32.5%) do not have a functional labour room for conducting deliveries. Seven out of every ten CHCs (70.9%) do not have regular power supply (Concurrent evaluation, NRHM, 2011). One of the most important reasons for underutilization of primary health care facilities is the lack of the full range of required primary care services. Most sub-centers and PHCs provide little beyond immunization services, some ante-natal care and at best care for normal delivery. Most treatment of chronic illness like hypertension and diabetes is referred away and so is the treatment for most infectious disease except some of those on the national programmes. This would accounts for less than 20% of all health care needs. Along with expansion of infrastructure and filling up vacancies of human resources, quality of care delivered at public health facilities need immediate attention.