WHAT NEEDS TO BE DONE IN HEALTH SECTOR?

AS India advances into 2011, optimism about accelerated economic growth must be tempered by the realisation that our health indicators are lagging far behind. A country in which 45 per cent of the children under five are undernourished and account for a third of the global deaths due to measles cannot claim to be a rapidly developing nation. Our infant mortality rate of 53 per 1000 live births is higher than Nepal’s 43 and far exceeds Sri Lanka’s 17. With per capita public expenditure on health at 25 per cent of the level in Sri Lanka and 10 per cent of that in China, we cannot bear comparison with our neighbours on the resources devoted to health.

With urbanisation and globalisation propelling rapid transitions in living patterns, we will have to simultaneously deal with the disorders of maladapted modernity alongside the diseases of under-development. Mid-life heart attacks, diabetes, cancers, obesity, mental illness and injuries are already major threats, co-existing with malaria, tuberculosis and AIDS.

Across the country, health inequity is starkly evident. A baby girl born in Madhya Pradesh is six times more likely to die before her first birthday than if born in Kerala. A pregnant woman in Jharkhand or Chhattisgarh is three times more likely to die in childbirth than in Tamil Nadu. In Kerala 75 per cent of all children are fully immunised, compared to 33 per cent in Bihar. It is pertinent to note that Kerala has higher levels of education and spent Rs 287 per capita on health, in 2004-05, compared to Bihar’s Rs 93, and that Tamil Nadu has a well-defined public health cadre.

When we hope to benefit from the demographic dividend that India will have over the next four decades, of having the world’s largest working age population in the 15-59 year range, we cannot ignore the imperative of protecting and promoting the health of these human resources. The public financing of health is at 1 per cent of the GDP and, as a result, the out-of-pocket expenditure of 78 per cent is among the highest in the world. With the neglect of public services, an unregulated private sector emerged as a default option and has escalated healthcare costs without significantly increasing outreach to rural areas. Severe shortage in the health workforce has resulted in inadequate availability and mal-distribution of doctors, nurses and paramedical personnel. Poor governance and widespread corruption further enfeeble the system and dilute the quality of services.

To overcome these challenges and improve the health of our people over the next decade, we must initiate concerted action to:

Develop and implement a framework for Universal Health Coverage (UHC): Political commitment is required to ensure equitable access for all citizens to appropriate, affordable and accountable health services (promotional, preventive, curative and rehabilitative). The government must become the guarantor of such services, even if it is not the sole provider. Public financing for health should increase, to a minimum of 3 per cent of the GDP by 2020. Health expenditure will have to be mainly tax financed, with additional contributions from employers and private insurance. A universal health insurance scheme must integrate all health-financing programmes into a single payer system and ensure cashless delivery of health services.

Strengthen primary health care: Both rural and urban primary health care need to be reconfigured to promote greater outreach and better quality of services. The National Rural Health Mission must be supplemented by a National Urban Health Mission, to ensure that all basic health services are available within easy reach. At least 70 per cent of all public financing must be directed towards primary health care, since efficient primary health services will substantially reduce the demand for costly secondary and tertiary care.

Expand and reconfigure the health workforce: A planned expansion of the health workforce must be undertaken by developing more training institutions, preferably in states and districts where they are few or absent. Even as more health professionals are trained, competencies must be redefined and responsibilities reassigned to enable effective ‘task shifting’ (from specialist physicians to non-specialist physicians, from physicians to nurses and from nurses to community health workers). Incentives for recruitment and retention in primary care and public services must be increased.

Create a Public Health Cadre: Traditional medical or nursing education prepares students for facility- based care of individual patients. Dealing with the population dimensions of health, whether it is immunisation or tobacco control or managing a nutrition programme or mobilising communities for health action, are not part of the skill set of such professionals. Epidemiology, health economics, social and behavioural sciences and management are critical areas of knowledge deficiency that undermine health planning and programme implementation. There is a need to train a large number of public health professionals, from among physicians as well as non-physicians, and create public health cadres in central and state health services.

Create a strong regulatory framework for quality and cost control: If the private sector has to be responsibly integrated into a system of universal health coverage and the public sector, too, must become a benchmark of quality and cost, a robust regulatory framework is needed. Technical guidelines and pricelists, for common disorders, must be produced periodically by experts, prescribed by governments and independently audited.

Ensure availability of medicines at affordable prices: Policies must be developed for protection of the domestic generic drug industry, price fixation and compulsory licensing, when required. The public procurement of drugs at low cost, with free supply in primary health care, has been shown to be very effective in Tamil Nadu and needs replication in other states.

Align policies and programmes in other sectors to health needs: Policies in sectors which impact on health (such as water, sanitation, agriculture, food processing, environment, urban design and transport) must be made more sensitive and responsive to health concerns.

LAST year was about India’s growth story and how its economy was shining despite the odds. But even in the sheen, something was amiss. That something became clear in November 2010 when the Global Human Development Report showed India that income growths did not guarantee human development, and if nations invested sluggishly in health, they would lose the hard-earned economic gains.

This is what is happening in India. In 2010, we were among the top 10 global gainers on the Human Development Index measured for income growth, but on the life expectancy-measured index, we fell behind even Nepal, Bangladesh and Pakistan.

After five years of promised health service delivery under the National Rural Health Mission, which has spent over Rs 30,000 crore since 2005, our life expectancy at birth remains a dismal 64.4 years as against China’s 73.5, Bangladesh’s 66.9, Pakistan’s 67.2 and Nepal’s 67.5; maternal mortality rate (MMR) remains 254 per one lakh live births as against 43 in Sri Lanka and 12 in Thailand, and under-five mortality rate remains 72 per 1000 births as against Sri Lanka’s 21.

So, why is India losing 31 per cent of the human development value when tested for health indicators? The answer lies in poor and untargeted public spending in health, which needs immediate improvements; acutely skewed health indices across states and the government’s failure to rein in population.

India’s health sector is among the most privatised in the world; drug expenditure met from out-of-pocket being 75 per cent. Public funding of health expenditure remains a poor 1.2 per cent of the GDP, abnormally low for a developing country like India, which houses 16.5 per cent of the world population but contributes hugely to its disease burden – a third of diarrhoeal diseases, TB, respiratory and parasitic infections; a quarter of maternal conditions and the second highest HIV prevalence after South Africa.

Health Minister Ghulam Nabi Azad says voluntary family planning will remain the norm. Statistics show that southern states have reached replacement levels of fertility (under two children per woman). The focus, therefore, must be on the central and northern swathes. Nationally, since 70 per cent population growth will happen due to children born to reproductive age couples (51 per cent of the population), delaying age at marriage, age at first birth and birth spacing would be critical. Since poorer people see more number of children as help in old age, the government must evolve schemes to prevent child deaths.

Equally important would be to enforce a legal age of marriage for girls because healthy mothers have healthier kids. In high-population states, 65 to 80 per cent girls marry below 18 years, leading to early motherhood and a high mother mortality rate and infant mortality rate. A newborn is seven times less likely to survive if a mother dies during childbirth.

But much of the health costing would depend on the extent and quality of healthcare available in the coming times. Here medical education reform will play a crucial role. The Medical Council of India is working on a Common Entrance Test for all 299 medical colleges (158 are private and have no admission or fee regulation) from 2011, a revised curriculum and new norms to ensure quality and uniform growth of medical colleges.