Subir Roy: Making reforms less injurious to health

VALUE FOR MONEY

A functioning publicly-funded healthcare system for a good majority of the people should be a cornerstone of development policy in a poor country.

But such a system barely exists for most Indians. In the nineties, the period of reform and rapid economic growth, a bigger share of the national cake should have gone to public health. But the opposite has happened.

Such expenditure has declined from 1.3 per cent to 0.9 per cent of GDP. The UPA government wants to reverse this trend and raise the ratio to 2-3 per cent by 2012.

As over two-thirds of Indians live in villages and as the countryside bears more than its due share of poverty, the government has unveiled a national rural health mission.

The country is no stranger to missions. Rajiv Gandhi initiated several of them, including a drinking water mission, but lack of adequate drinking water is highlighted as a key reason for the disease burden of Indians.

But it is good to set goals and rationally work out milestones which have to be crossed to get there. Goals set may not be achieved but there is no hope at all of solving endemic problems if there is no goal to aspire to.

The now famous McKinsey report set a goal for India to reach""software and services exports of $50 billion, interestingly also in eight years, by 2008. That goal has galvanised the nation and the industry to try and put its best foot forward.

Right now there is little evidence that the educated classes will be as galvanised by the health goals outlined by the mission document covering areas like infant mortality, the total fertility rate, the malaria mortality rate, and tuberculosis.

Of these, only population control (fertility rate) is popular among the educated. An internet search indicated that through this month, Manmohan Singh's health mission competed with items that gloried at the prospects of India emerging as a global health tourism destination.

The basis for this is probably no more that two dozen visitors from rich countries undergoing complex surgeries. It is safe to assume that by next month the health mission will have mostly disappeared from the media.

In the old days friends at the Indian Express used to laugh at grassroots development stories by calling them "biogas journalism".

Not so long ago, when I tried to tell a secretary to the government of India that the job of the administration was not to run companies like Maruti but efficiently address the social sector, he replied with supreme contempt, "like family planning?"

But that should not detract from the sense and realism that mark most of the ideas contained in the mission document. It recognises that you cannot fight disease among the poor simply by targeting ailments.

Sanitation, hygiene, nutrition, and safe drinking water are ends which have to be addressed if a serious dent is to be made in morbidity levels.

So one goal is to integrate the efforts on the health front with those on others that critically affect health. (In fact, healthcare plays a key role in the overall fight against poverty because over 25 per cent of hospitalised Indians fall back below the poverty line because of hospital expenses.)

Such action on a wide front mostly depends on the efficiency of state governments. The latter account for 85 per cent of public expenditure on healthcare, of which of course 80 per cent goes in paying salaries of government healthcare personnel.

So even if you set right the funding, throw more public money at the job, the cardinal question remains: How will state governments handle the higher spending they are being exhorted to go in for?

In view of this, the mission has made its major focus the laggards""hill and northeastern states, and the Hindi heartland of the country stretching from Rajasthan right up to Orissa. Kerala, Tamil Nadu, Andhra Pradesh, and Karnataka (in that order) have forged far ahead of others in healthcare delivery.

So, in a sense, if you want to reduce the entire mission strategy to a single bullet, you can say: find out how the southern states can deliver despite having the same kind of politicians, and then do likewise.

A major element in the strategy is to encourage and enable the panchayati raj institutions to own, control, and manage rural public health services. A key new player who will help deliver this is the female health activist, named ASHA, in every village.

There will be a health plan for each village which will have at its apex a district health plan, linking schemes for things like drinking water, sanitation, hygiene, and nutrition.

In order to decentralise, the "vertical" health and family welfare programmes will be "horizontally" integrated at the block and district levels.

There will also be supplementary strategies to regulate the private sector and "informal rural practioners" (quacks, that is), promote public-private partnerships, and take the help of the IRDA to have schemes that pool risks and offer social health insurance at the village level.

These will let the poor pay what they can and get a degree of affordable and accountable hospital care which they have so far not known. There is even an item saying the ASHA will also have a drug kit that will be "replenished from time to time"!

All this should indicate that if you really want to have a rural healthcare programme, then common sense and a minimum administrative experience will be enough to outline most of its contours.

The mission document keeps mentioning the Rogi Kalyan Samiti as the mechanism through which larger government hospitals can be run by the stakeholders.

Now what happened to the IAS officer who was the collector of Indore during the time of the Surat plague and devised the model that went on to win an international award?

He recently ran into a batch mate at an inter-state conference on women and child welfare and asked him, "How come you too have landed up here?" They compared notes and realised that both were paying the price for being too high-profile during an earlier administration.

The vision document naturally does not have a bullet to tackle this sort of thing.