The ills of India's health sector

The book highlights the urgent need for reforming the health sector in India. If India continues on its present path, the mismatch between its health system and its health problems will become only more severe, warns the authors.

It doesn't provide any policy blueprint. Indeed, it acknowledges that "... the priority of issues and choice of options should vary according to the conditions in the various states and districts."

Given that most of India is still in the early part of the health transition (consisting of demographic, epidemiological and social transition), there is an urgent need for redoubling of efforts to attack the unfinished agenda consisting of preventable infections, pregnancy and childbirth related complications and under-nutrition.

However, as progress is made on these conditions, and in the basic infrastructure of public health services, the focus of public health policy should also change to meet the different types of care required in the health system, to provide financial protection to meeting high-cost per episode diseases, and to make the system more responsive to social demands.

Depending on the stage of health transition and the institutional capacity, the book categorises the states into four grades, with Kerala and Tamil Nadu in the relatively advanced stage of transition and higher capacity while states like Orissa, Rajasthan, Madhya Pradesh and Uttar Pradesh in the early transition stage and low institutional capacity.

A set of guidelines differs depending on the stage of health transition and the degree of capacity. For example, Kerala and Tamil Nadu have more compelling reasons to focus on introducing and expanding public health services for cardiovascular disease, mental health, and injuries, as these are now the prominent conditions facing their population.

The book is divided into two parts: part one discusses current conditions and policy options, and part two presents the theory and evidence to support the policy choices.

Part one focuses majorly on four critical sets of activities selected from the larger set of functions of the health system. These are: (i) health system oversight (ii) public health service delivery (iii) ambulatory curative services, and (iv) in-patient and health insurance.

In each of these four areas, the book examines a rationale for public sector intervention, the current and emerging policy challenges, and the actions needed for bringing about improvisation.

It provides some good practical insights on certain key policy issues, for example, on how to increase the measurability of healthcare providers and other actors; that public oversight not only means increased measurability which is of course a necessary ingredient but also empowering people who use the health system.

Given the prominent and growing role of the private sector, developing an oversight is extremely important. Part one also contains the structure and problems with both the public and the private healthcare sector.

Many regional and state level differences are also brought out in this book. For example, "the southern and western states tend to have better health outcomes, higher spending on health, greater use of health services, and more equitable distribution of services than other parts of India, particularly the poor north-central states."

Likewise, the states of Kerala, Punjab, and Tamil Nadu have double the per capita public health spending of Bihar and Madhya Pradesh. That public spending is lowest in the poorest states (Bihar, Madhya Pradesh, and Uttar Pradesh). The health status outcomes are better in states in which public spending on healthcare is more equitable.

Part two presents a framework of health system consisting of actors (people, the state, and private sector), functions (financing, management of non-financial inputs, health service delivery, and oversight) and outcomes (health status, financial status, and consumer responsiveness).

This framework is adhered to in analysing the health situation in India. The analysis is carried out at the national as well as state level, and with respect to public and private expenditure and along other dimensions. The focus however remains on the poor.

This part, though not as analytically rich as the first part, contains many interesting pieces of information. For example, the public sector plays the larger role in preventive services, delivering 60 per cent of prenatal visits and 90 per cent of immunisation doses. Public health financing is considerably low "" just around 1 per cent of GDP compared.

Moreover, the beneficiaries of this limited public health financing are not only the poor as one would expect in a limited public spending to be, but also the well-off section of society. Furthermore, over 80 per cent of the total health financing is private financing, much of which takes the form of out-of-pocket payments (i.e, user charges) and not any prepayment schemes.

One-quarter of all Indians fall into poverty as a direct result of medical expenses in the event of hospitalisation and more than 40 per cent of hospitalised patients depend on loans and the sale of assets to pay for hospitalisation. Given this, the authors point to an urgent need to convert this out-of-pocket spending into prepayment insurance scheme.

It is a must read for anybody wanting to know about the current healthcare situation in the country. For this book covers a range of issues affecting the Indian healthcare system. The irony is that in spite of such a good analytical study that shows the direction, gives useful tips on design of policy on a number of fundamental issues, the publication may not make much dent just because it comes with the World Bank tag.

(The reviewer is a Senior Fellow at the Indian Council for Research on International Economic Relations)

BETTER HEALTH SYSTEMS FOR INDIA'S POOR:

Findings, Analysis and Options

David H Peters and others

The World Bank, Washington DC

Pages: 347