[india-drug] Indian Express: India is sick

["gopal dabade" <dabade_pal@yahoo.com>]

Dear all,

An excellent article.

Best wishes
From
Dr GOPAL DABADE

URL: http://www.indianexpress.com/full_story.php?content_id=86481

THEINDIAN EXPRESS
Tuesday, January 24, 2006   
 
India is seriously sick
  
Will Budget 2006 apply a healing touch, Mr
Chidambaram? 
 
Pamela Philipose 
  
 Finance minister P. Chidambaram began his budgetary
peroration last year with a quote from the Tamil saint
poet, Tiruvalluvar: ?Health, wealth, produce, the
happiness that is the result, and security. These five
the learned say are the ornaments of apolity.? So far
so good. Unfortunately, in the course of the budget
he then presented, health as a concern got the standard
treatment: it was put on a drip. The net result was
that the one initiative in that document that held the
shadow of a promise on this front ? the National Rural
Health Mission ? was hardly provided for. 

Today, the consequences of successive finance ministers
failing to spend adequately on health have resulted in
some disturbing trends. For one, public health
expenditure has steadily headed south. In 1990, it was
1.3 percent of GDP, a decade later the figure stood at
0.9 per cent. The huge gap created by the poor public
provisioning of healthcare has been filled by an often
indifferent and rapacious private sector. In 2002,for
instance, the private sector accounted for 78.7 per
cent of total health expenditure, while public
expenditure made up just 21.3 per cent.To see this in
perspective, consider this: it?s the other way around
in prosperous Britain! Worse, even the little public
money made available to healthcare has not reached the
people who need it the most. Three times the sum that
goes to the poorest quintile of the population(living
below the poverty line), reaches the richest quintile,
and an estimated four-fifths of the money goes in
paying salaries. 

This lack of adequate and effective public provisioning
has seen a decline by 30 per cent in the proportion of
patients seeking public healthcare between 1986-96.
Ultimately, those who can afford it the least, end
up spending the most on health ? and it is one of the
most important factors for the sale of personal assets
and rural indebtedness. Also, while India has been able
to bring down its mortality level, its morbidity (ill
health) levels have been consistently rising. This
means that less Indians die, but ? equally ? less
Indians live. That is to say, less Indians live fully
enabled lives, without having to cope with serious and
periodic bouts of ill health. This, obviously, is a
huge drain on national resources. 

Apart from endemic morbidity, India also has the
largest number of maternal deaths in the world ?
over 1,25,000 every year, with nearly one in seven
women developing life-threatening complications during
pregnancy. But one stark fact more than any other
speaks of India?s inadequate attention to health:
the country?s decline in the Infant Mortality Rate
(IMR) is threatening to plateau. It had fallen by 27.27
per cent in the ?80s; by the ?90s, the decline was only
15 per cent. At the present rate, India will fail
to meet its national/international commitments on
infant mortality. As Dr Vinod Paul of the All India
Institute of Medical Sciences pointed out at a recent
symposium on children and the 11th Plan, the
Millennium Development Goals commitment requires us to
achieve an IMR level of 27 by 2015, our Tenth Plan
target was to reach a target of less than 30 by 2010.
But unless things change drastically, India?s IMR will
be around 45 by 2015. 

Placing public health on the front burner has never
been more urgent. And the finance minister, when he
puts on the hat of the Congress activist as he did at
the AICC session in Hyderabad, even acknowledges this.
The question is whether Budget 2006-2007 will
reflect that concern. Health is a state subject. At
present, states contribute 85 per cent and the Centre
15 per cent of total expenditure. But the Centre has
nevertheless the important responsibility in giving
a normative direction to the revival of the health
system. A significant instrument it has for this
purpose, as health experts like Ravi Duggal have
pointed out, is the budget document. 

There can be no two ways about it. The decision to
increase public spending on health ? the National
Common Minimum Programme commits to raising it from
the present 0.9 per cent to 2-3 per cent of GDP ?
cannot be postponed any longer. But this project
requires more than an infusion of capital. In
fact,some initiatives that can immediately help do not
even require huge spending. Dr Abhay Bhang and his team
has proved in Gadchiroli,Maharashtra, that a
low-technology intervention of providing
home-based healthcare delivered through trained female
community health workers could bring the IMR rate of 76
in 1993-95 to 30 in 2001-03. 

So how can the country make up for lost time? The
National Rural Health Mission(NRHM) that the finance
minister touched upon in his budget last year could be
the catalyst for such a revival and deserves
careful provisioning to achieve optimal efficiency. At
the heart of NRHM is the strategy to train at the
household level some three lakh Accredited Social
Health Activists (or ASHAs); getting panchayati raj
institutions to assume ownership of the health delivery
system; and strengthening the existing triad of
sub-centres, primary health centres, and
community health centres. Getting these mostly defunct
health centres to function would require not just the
presence of suitably incentivised and trained medical
professionals, it demands close supervision by
local communities, an expansion of existing
infrastructure, a system of regulation and a credible
health information system. 

The first step then is to revive the basic health
delivery system. Everything else depends on this. Even
the silver bullet solutions that are sometimes offered
? like the expansion of public-private partnerships in
health, and a public health insurance ? will require
the secure foundation of a functioning system. China,
incidentally, dismantled its earlier system of free
clinics and came up with an insurance plan in which
rural residents contribute a sum of a little over a
dollar to access health services. It has not worked
precisely because the earlier system of healthcare
delivery was dismantled. Only an estimated 21 per cent
of China?s population is medically insured today in a
country that once had universal coverage, leaving large
numbers extremely vulnerable ? as the SARS epidemic
demonstrated. 

India has stopped thinking about public health and has
paid a very heavy price for that. It now needs
to seriously re-imagine strategies. The health-wealth
equation cannot just remain an idea in a Tiruvalluvar
verse, Mr Chidambaram. It demands not just linguistic
but budgetary translation.
 
URL:http://www.indianexpress.com/full_story.php?content_id=86481