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Universal health care: the barriers and the way forward

Dileep Mavalankar

Health targets fail as they are set without strategies. The 12th Five-Year Plan should be used to look at the changes needed in the public health system.

Health is currently a privilege in India. Not a right. Maternal and child health remains neglected even after countless plans, programmes and political proclamations. Every year, nearly 60,000 women die in pregnancy and childbirth, while approximately 1.7 million children less than five years of age also die. In absolute numbers, India outranks all other countries in both regards. Sadly, most deaths can be prevented with available technologies. Many diseases such as tuberculosis and pneumonia kill thousands every year. While infectious diseases are very much a concern, chronic diseases are now rapidly catching up. India has become the capital of diabetes, high blood pressure and heart disease. Health targets in plan after plan have not been achieved, yet there has been no systematic analysis of why health systems fail to achieve these targets.

The fundamental reason why our health targets are not achieved and will not also be achieved, unless we radically change our strategies, is that we set targets without setting strategies; without understanding what is preventing progress; and without putting adequate human and financial resources toward achieving targets.

First, we equate the number of buildings to available health services. The Planning Commission and Central and State governments only count the number of health centres, without bothering to find out what is happening at these centres. Many are without staff, electricity, a telephone, water, medicines or an ambulance. No wonder these centres do not have patients — mothers or children — to take care of. Surveys have shown the inadequacy of our health infrastructure and that health workers are not staying where they are posted. There are good reasons why health staff do not stay in villages. But health departments have not bothered to study this problem or remedy it. Not only are workers not staying, studies have also shown that they are quite frequently absent without reason. Such unaccountability is treated as routine and not discussed in health policy forums.

The second reason for a lack of services is underfunding and poor management of medicines, leading to a lack of availability. How can an army fight without ammunition? The lack of medicines forces poor patients to buy medicines from private pharmacy shops, which can be expensive. Often times, the quality of medicines available from these shops and government health centres is poor due to the government's weak oversight on pharmacies and poor procurement policies. Patients do not want to go to clinics where they do not get medicines or where they are of poor quality.

Managers

While planning and funding are major problems, the root of the health problem in India, I feel, is the lack of adequate numbers of well-trained managers. Many national health programmes cover millions of beneficiaries, yet they are managed by just two or three technical managers who are general or specialist doctors.

Most of the time these individuals are without any public health or management training. They learn this on the job. This is also true for health secretaries and ministers — they all learn on the job. We are obsessed with training an eighth standard-passed village health worker with six to seven modules — but there is no training or even orientation for top policymakers and managers in the health department before they take up such important managerial and policymaking jobs. Why isn't health systems management made compulsory before an officer takes up the job of director or secretary in the health department?

The way out

Fortunately, things can rapidly change in the next few years, if government and society pay a little more attention to health. During the last five years, the government has put in significant resources into the National Rural Health Mission (NRHM). At the same time, many States are also using local solutions to various problems. Preparations are underway for the 12th Five Year Plan (FYP), and thus we should be looking at what radical changes are needed in the public health system.

Budgets for health services will need to increase by a factor of three to five times. The national government is committed to take health funding from less than one per cent to two to three per cent of the GDP. This is critical. The government must chart out how the Centre and States will increase these budgets over the next five years. This will also require advocacy on behalf of the health community. And we must also be more smart in how to spend the money that is already available. Money remains unspent in health because the regulations around spending are so complicated and confining that doctors and health works cannot spend the money. Many times, money does not arrive in time for it to be useful.

Health care is provided by humans. Not by buildings or physical infrastructure. We need to get doctors and nurses to go to remote and rural areas and work there. This means paying them much higher wages, providing much better housing and other amenities, and making the working environment conducive to their lives.

Appreciation of the doctors and nurses who work in remote areas will ensure that younger doctors go to rural areas and serve the poor. Another solution could be to contract private providers, where government providers are unavailable and unwilling to provide services. Gujarat did just this through its much acclaimed “Chiranjeevi Scheme.” Here, the government pays private doctors a fixed fee for conducting child birth services for poor women in their private hospitals. “Rashtriya Swasthya Bima Yojana” also provides financial access to care in private and public services to the poor throughout the country. This is truly innovative and revolutionary.

Technology and drugs

While improving health systems is critically important, we cannot afford to wait until such changes are made before also improving the technological base for health systems. This means better machines and newer drugs and vaccines. For example, new vaccines and diagnostic techniques that can prevent or diagnose early some of the diseases among children and women are currently available in the private sector, but these technologies remain out of reach for the poor. The health department must have a division of technology assessment that is responsible for identifying and rigorously evaluating potentially useful and cost effective technologies for adoption in national health programmes in India.

All this can happen if there is a high-level of political commitment and the Prime Minister and Chief Ministers take personal interest in health improvements.

Of course, more resources need much better management in order to deliver results. Health departments must have an adequate number of qualified programme managers and health planners to ensure better programme design and effective implementation. I strongly believe that we can do this in 12th FYP, and it will be a big step towards universal access to health.

( Prof. Dileep Mavalankar is Dean, Academics, Indian Institute of Public Health, Gandhinagar.)

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