T C A Srinivasa-Raghavan: Analysing public health systems

OKONOMOS

Just check if the core functions are being performed or not.

India, as we all know, is a land of huge contradictions. It has a wonderfully comprehensive Constitution, which doesn't always work as intended. Ditto for Parliament and the judicial system.

It has an incomparable administrative system, which also seldom works these days. It has a great educational system, which, too, is breaking down.

And so on, for so many things.

So it comes as no surprise that Monica Das Gupta of the Development Research Group (DRG) at the World Bank and Manju Rani, a consultant to DRG, should say that it has an extensive network of public health institutions for research, training, diagnostics, and so on, which don't work.

Why? Because they say it is possible that "the health system may be mis-directing its efforts, or be poorly designed." That is, it is there, but either it is not what is needed or it is not wasting its time on the wrong things.

But how do you check if this is true? After all, if you ask the government, it will say there's nothing wrong because if there had been something wrong, don't you think we would have set it right?

To show in what respects the government is wrong, Gupta and Rani have used the instruments that the US and Latin America use to judge the performance of public health systems. The trick is simple: you look at all the things an effective public health system must fulfill.

The US has developed a framework for analysing its public health system as a part of the effort to upgrade the system. The authors say that this framework is beginning to be used in both developed and developing countries.

In a nutshell, the idea is to identify core functions. These are monitoring, disease surveillance, health promotion, public health regulations, and the development of policies that assure access to health services.

They find that the Indian health delivery system fails on five major counts.

First, it has not focused on the basics of public health.

Second, even what it does, it does not manage properly.

Third, these management flaws get in the way of an effective use of resources, learning and innovation.

Fourth, therefore, small but useful changes are never made.

Fifth, the Central government functions too much in isolation and needs to work much more closely with other key actors, like the state governments and the private sector.

Well, yes, all this is true, of course. But the fact that the authors worked only at the Central government level and did not go down to the state level has obscured several important aspects.

Thus, health-services delivery is a state subject and where management is concerned, that makes the Central government aloof almost ab initio as it were.

Second, what the states face is not weak management so much as altogether inadmissible wage bills. In most states the wage bill of the health department accounts for over 90 per cent of the state budget.

But this cannot be avoided either, because public health services are delivered by people, not machines. You need many more doctors and nurses and technicians. The paper does not throw any light on how this issue can be resolved.

A third aspect, which I regard as being the central problem, is what I call the Article 311 syndrome. Since all public health officials are government servants, they cannot be sacked even if they don't work at all.

The situation is identical to the one obtaining in education. The result is also identical: lots of employees who don't contribute. There is no penalty for not doing what you are paid to do.

In other words, this paper goes some distance, but nowhere near far enough in identifying the real underlying problems of the public health system in India.

India's Public Health System: How Well Does It Function at the National Level? World Bank Policy Research Working Paper 3447, November 2004