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Tuesday, Jun 08, 2004

Opinion

Opinion - Leader Page Articles

How healthy is our system?

By Kalpana Sharma

There is an urgent need to overhaul and strengthen the public health system.

RENUKA CHOWDHURY, the new Minister of State for Tourism at the Centre, wants to promote "health tourism." As India can offer to people from other countries high-end health interventions such as heart transplants at lower costs, she sees great scope in promoting this method of enhancing our foreign exchange earnings. In principle, there is nothing wrong with the concept. The real problem is that it hides the reality of the state of health care in the country. It is a bit like the previous Government's `India Shining' campaign. A small section of Indians was convinced that the improvement in their lives extended to the rest of the country. Similarly, the growth of five-star health care in our cities, with facilities that match some of the best in the world, can easily delude us into believing that India's health is improving.

The reality, of course, is very different. Despite having over 17,000 hospitals, 24,000 primary health centres (PHCs) and 140,000 sub-centres as well as over five-and-a-half lakh registered allopathic doctors, 18 lakh children die every year before they reach five years of age. Most of these deaths are avoidable. In addition, 130,000 women die each year during childbirth and from pregnancy-related problems. Instead of declining, the Maternal Mortality Ratio has increased in the last decade from 424 deaths per 100,000 live births in 1991-92 to 540 maternal deaths per 100,000 live births in 1997-98. This is inexcusable.

"Health tourism" is for those who can afford health care. In India, the problem is that millions of people cannot afford it. In its Common Minimum Programme (CMP), the ruling United Progressive Alliance at the Centre has said that it will raise public spending on health to at least 2-3 per cent of GDP over the next five years with the focus on primary health care. It has also stated that it will pay special attention to the poor in the area of health care.

This is encouraging but may not be enough. Several studies on health care in India, including a policy brief prepared by the Centre for Health and Allied Themes (CEHAT) before the elections, have clearly shown that improving health care in a poor country depends not so much on the proportion of GDP spent on it as it does on the extent of public funds that are invested in health care. In Sri Lanka, for instance, health expenditure constitutes 3 per cent of the GDP. But of the total, 45.4 per cent is public health expenditure. Under 5 mortality in Sri Lanka is just 19. In comparison, India's health expenditure is 5.2 per cent of its GDP but only 17 per cent of the total is public health expenditure. And Under 5 mortality is 95.

Despite an extensive public health system, the major part of health care in India is in the private sector. This is a fact that often does not register with most people. They presume that the poor access and use public health facilities. In reality, these facilities are run-down or inaccessible, forcing them to turn to the growing private sector in cities and villages. The health sector in India is one of the most privatised in the world.

Over the last decade, the reduction in public spending on health has taken its toll on the public health infrastructure. According to the CEHAT brief, only 38 per cent of all PHCs, which form the bedrock of the rural health care structure, have all the critical staff. Despite the high maternal mortality ratio in India, eight out of every 10 PHCs had no Essential Obstetric Care drug kit. Only 34 per cent of them offered delivery services and only three per cent could offer safe abortion facilities. Eight of 10 had no paediatrician and seven out of 10 had no obstetrician.

CEHAT estimates that between 1986 and 1995, the number of people unable to afford health care had doubled. It had increased from 10 to 21 per cent in urban areas and from 15 to 24 per cent in the villages. More shocking is the fact that 40 per cent of the people in hospitals are forced to borrow money to pay for their expenses. This kind of expense, on unavoidable health interventions, is pushing over two crore Indians below the poverty line every year.

Apart from the fact that people are forced to pay for health care because the public health system is in such a bad way, many private practitioners resort to irrational prescribing, giving patients a long list of totally unnecessary and expensive medications for fairly routine problems. For the uninformed, this results in an additional financial burden. Most ordinary people are not in a position to assess whether they are the victims of over-prescription. They blindly accept what the doctor orders and go out and buy every single drug that is on the prescription.

Thus it is not surprising that the about Rs. 30,000 crores pharmaceutical industry has grown so phenomenally in the last five years. There are now over 70,000 branded drugs marketed in India. Barring 25 drugs that are named as essential under the Drug Policy and are therefore bound by price controls, drug companies can charge what they like for the rest. The hole in the pockets of the poor is evidence of the way this untrammelled profiteering on people's health has affected the life of the poor. Many drugs are sold at 200 to 500 per cent profit margins.

The other problem thrown up by the decline in the public health care system and high drug prices is the growing disparity in the health status of the rich and the poor. For instance, the infant mortality rate among the poorest 20 per cent of India's population is two and a half times higher than the richest 20 per cent. The same difference persists when one looks at any of the other health indicators including attended births. The ratio of hospital beds to population is 15 times lower in rural areas than in urban areas. The ratio of doctors to population is six times lower in rural areas than urban areas. Government health spending in rural areas is seven times lower than in urban areas.

Thus the new Government has to address both the inequities in the prevailing health care system and the state of the public health system that is supposed to serve those most in need of basic health care. Studies have clearly established that the poor use public health facilities if they are accessible and functioning properly. Although most States have managed to provide one PHC for every 30,000 persons and a sub-centre for 5,000, the poor are forced to resort to private health care because these facilities are not fully functional. Thus there is an urgent need to overhaul and strengthen the public health system.

Also, despite numerous health interventions by the government, communicable diseases continue to spread at a frightening rate. We have the largest number of tuberculosis cases in the world with one million to two million new cases being reported every year. Malaria continues to strike over 2.6 million people each year, with over 20,000 people dying from it. And HIV/AIDS is spreading faster than can be estimated. Dealing with these diseases does not require five-star facilities. It needs higher investment in public health programmes.

Whenever there is a health scandal, we wake up to the lack of regulation of the private health sector. The most shocking revelation in recent times has been the use of technology to detect the sex of the foetus. Despite a law, sex selection has prevented millions of girls from being born and skewed the sex ratio in some of the most prosperous districts in the country. Apart from quacks and outright fakes, even qualified medical practitioners know that they can get away with malpractice because patients do not know their rights. With the exponential growth of the private health sector, there is an urgent need for regulation to protect health users.

Drug pricing is another area that needs to be looked at. Imports of cheap bulk drugs has resulted in the closure of indigenous units producing these drugs. The CMP suggests reviving some of the public sector units set up to manufacture critical bulk drugs. Even if this is not possible, we have to find a way to provide essential drugs at reasonable prices.

India's health status is defined by the state of health of its most vulnerable citizens. To say this is to state the obvious. But it is amazing how often even the most enlightened leaders overlook this fact.

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