Subir Roy: Elusive healthcare for the poor

VALUE FOR MONEY

India's poor health status, particularly in relation to a country like Bangladesh, which enjoys a lower level of income, has significant implications. If this continues despite high growth and decline in the percentage of people below the poverty line, it will mean that the income growth is not translating into improvements in the level of well being, given the fact that there is a strong correlation between the health status of an individual and her sense of well being.

The defeat of the NDA in 2004, despite the significant growth performance of the economy in the preceding six years, is not surprising, given the health status of the country revealed by the National Family Health Survey (2005-06). The period 2004-07 has witnessed exceptional near 9 per cent growth but the health implication of that will be clear only from the results of NFHS-4, which will not be available before several more years. So a definitive verdict, to be pronounced by number crunchers and academics, is still a long way off.

But the country will probably go to the polls next year when the sense of well being among large numbers of ordinary people will shape the overall verdict. Unlike the NDA government, the present Congress-led UPA dispensation has at least been conscious of the importance of the health status of the poor and a year from coming to power, launched with much fanfare the National Rural Health Mission in 2005. Two years down the line, with the day of reckoning round the corner, it can be useful to take a look at how this critical mission has fared.

The website of the mission paints an exciting picture of progress made. It says there has been a sharp rise in the number of out patients treated, institutional deliveries undertaken and children immunised. States now have a mechanism for buying medicines by emulating the model adopted by Tamil Nadu. Importantly, more than 4.35 Ashas (accredited social health activists) have been selected (presumably many have started working by now), 146,000 sub-health centres have been made functional, 2,230 primary health centres now work round the clock (of this 600 are in Tamil Nadu) and significantly over 800 Rogi Kalyan Samitis have been set up, all with their own bank accounts!

How up-to-date the website is cannot be gauged but there is unintended irony in the assertion that nearly all the 606 districts in the country will have their own health plans, important to decentralise healthcare, by "March 2007". The website also has a box headed "progress of programme", under which comes a page called "Monthly status report," which cannot be opened. However, the page "Status report received from states" can be opened and is revealing. Status reports have been received from all non-high focus states (those which are not laggards) in 2007, mostly till February-March, but the laggards tell a variegated story. The November report from UP and the February report from Jharkhand have not been received. Bihar and Chhattisgarh have sent reports till only November and October, respectively.

What do voluntary organisations have to say? According to Frontline, Jan Swasthya Abhiyan, a network of health NGOs, finds there is as yet little decentralisation. Collectors and government medical officials, and not village representatives, are still taking most of the decisions. The network is worried that according to the recruitment norms, Ashas need to have read up to at least class VIII, which is impractical when most rural women can barely read. More seriously, Ashas will get Rs 1,000 as remuneration in a whole year and Rs 50 a month for buying medicines! How far does that take you? There is a deeper structural problem. Seven of the eight health outcomes that the mission has identified belong to the reproductive and child health programme. Also the family welfare budget has been clubbed with the budget for the mission. Obviously, the system's fixation with family welfare (nee planning) continues, to the exclusion of most other health issues.

Perhaps the most troubling issue is the role of the Rogi Kalyan Samity which is a cornerstone of the mission. The website notes that over 800 such samitis or societies have been set up all over the country. The society owes its origin to a collector in Indore who headed a local initiative to clean up the main city hospital in the wake of the Surat plague in 1994. The model that resulted, with active encouragement from the then chief minister, is of public hospitals run by committees formed by local officials, elected representatives, doctors and citizens. The committees can levy user fees and use the proceeds to bring about improvements in a way which only managers on the spot can, without having to get state government sanction. The user charges made up critical additional funding for discretionary spending even as regular state funding takes care of recurring expenses like salaries.

A key aspect of this model, when it was initially honed and won an international prize, was that a poor person could come and get free treatment simply by self-declaration. But a World Bank study by Rajeev Sadanandan and N Shiv Kumar (SAGE, 2006) in Madhya Pradesh found the impact of user fees on the access of people below the poverty line "unclear". "Anecdotal evidence and patient satisfaction data seems to suggest that people have difficulties accessing subsidies. Targeting of the poor using self-certification... appears not to be working well... Presentation of BPL cards is being insisted upon and it is likely that this is not having a positive impact on the attendance of the poor. This is a serious cause for concern."

If private initiative within the state system, a very diluted form of public private partnership, is not working well for the poor and the better off are cornering the subsidies, what works? By all accounts, straight forward, publicly provided healthcare is working well in Tamil Nadu which is emerging as the next big human development success after Kerala. This has enormous policy implications.

subir.roy@bsmail.in