Last week saw the publication by BS Books of the India Health Report 2010 (henceforth referred to as IHR10), edited (and mostly written) by Ajay Mahal, Bibek Debroy and Laveesh Bhandari. For anyone interested in India’s health status, access to health care and medicines, emerging health problems, the infrastructure of health services, medical ethics, health-care financing, government programmes and regulations and key issues in health sector reform, this 138-page report is an excellent introduction-cum-survey. Here I provide a highly selective summary to whet the appetite of readers to peruse the full report.
The first chapter makes the case for much greater policy attention to health issues. For many years, analysts have noted the close positive correlation between a country’s per capita income and the life expectancy at birth (LEB) of its people, as also the close negative correlation between per capita income and the infant mortality rate (IMR). Until 20 years ago, the general presumption was that economic development and the associated improvement in living standards led to lower IMRs and higher LEBs. Over the past two decades, research has accumulated, indicating that health conditions could be improved substantially even at low income levels through appropriate policy interventions. Thus, China’s IMR in 1980 was only two-fifths the level of India’s at a time when many believed their average incomes were quite similar (Table 1). Basically, China had already reaped the fruits of sustained attention (during the Maoist decades) to primary health care and integrated rural development with substantial focus on improved water supply and sanitation. In contrast, Indian government policy had accorded much less resources and attention to health care, including public health.
It is also somewhat shaming to note that Bangladesh has achieved a much steeper reduction in IMR between 1980 and 2007 than India, despite significantly lower growth in per capita income in the former.
Health and nutrition go together, especially for children. Table 2 presents comparative data for undernutrition over time. While child nutrition has certainly improved in India since 1980, the IHR10 emphasises that the rate of improvement is much less than in Latin America and Asian countries such as China, the Philippines and Sri Lanka.
The IHR10 describes the well known diversity in the socioeconomic record across India’s states. Thus, in 2005-07, the IMR in Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh was around 65-70 per 1,000 live births, as compared to 13 in Kerala, 34 in Maharashtra and 35 in Tamil Nadu. Indeed, IMRs in backward Indian states are quite comparable to many sub-Saharan African countries; not what one might expect from an aspiring economic superpower.
The chapter on access to health care presents very useful data which support a number of important (if not novel) conclusions. First and most obviously, the overwhelming majority of Indians have inadequate access to quality health care. Access is particularly poor for rural households, scheduled tribes and women. Second, private health-care providers predominate in both institutional and non-institutional services. Third, “unqualified” practitioners are in the majority among service providers. Fourth, and distressingly given the above, the bulk of ailments among the poorest quintiles are treated at private facilities. Fifth, about 7-8 per cent of households drop below the poverty line because of medical expenses. Finally, there are critical gaps in healthcare infrastructure, especially in terms of health centres and trained staff.
The fourth chapter provides a succinct review of the status on major “inputs” for good health of a population: adequate supply of trained and motivated health-care providers, an adequate and equitably dispersed network of health-care centres and hospitals, a good water supply and sanitation system, decent nutrition and widely prevalent hygienic practices. Predictably India is found grossly wanting in all these dimensions. The chapter concludes, “Whatever the input, however, all suffer from one key constraint: the lack of a public health focus.” It rightly notes that much of what needs to be done to promote better planning and execution of public health policies lies outside the domain of the Ministry of Health and Family Welfare (MoHFW).
While this is a reasonable conclusion, it does not go far enough. In particular, the IHR10 does not recognise adequately the crucial role of states in promoting good public health and the varied record across states in this regard. Last year, I had drawn attention (BS, December 24, 2009) to new studies documenting the unusually good organisation, staffing, planning and execution of public health policies in Tamil Nadu, which may be well worth emulating by other states. Perhaps the next IHR could make public health its theme.
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In chapter seven, we get a short but educative summary of the evolution of government regulations and programmes. It is instructive to know that the MoHFW runs 42 centrally sponsored programmes, ranging from individual diseases like AIDS, TB, leprosy and cancer, to various initiatives to support Indian systems of medicine and homeopathy. The chapter provides an useful summary of the National Rural Health Mission (NRHM) and reports on the Planning Commission’s broadly positive mid-term appraisal of this initiative as well as the important suggestions for improvement. Noting that a quarter of India’s poor are in urban centres and that the IMR amongst urban poor is nearly 73 (compared to 52 for the average urban population), the IHR10 is supportive of the proposed National Urban Health Mission, which was drafted in 2008 but is awaiting implementation.
The final chapter places efforts to reform India’s health sector in historical perspective. It notes that since the Bhore Committee of 1946, there has been no fewer than 21 committees and commissions looking into major facets of the health sector. The IHR10 does a great service to scholars, policy-makers and practitioners in providing thumbnail summaries of each of these reports. What they show beyond doubt is that there has been no lack of diagnosis and recommendations for reform of this key sector. The problem lies in forging ahead with the many sensible recommendations. The chapter highlights some institutional impediments in taking reform forward, including a veritable procession of weak ministers of the MoHFW, in the last 20 years and a more general lack of priority to health in other policy organs like the Planning Commission, the Prime Minister’s Office and the Ministry of Finance.
However, the relatively recent efforts through the NRHM and certain other initiatives suggest that long overdue reforms may be gathering some political and administrative support in the public policy system. For the ailment-plagued people of India, let us hope so.
The author is honorary professor at ICRIER