A basket weaver at work with her baby at her side, in Tamil Nadu. The infant mortality rate is very high for working women, particularly those in the primary sector, a large proportion of whom are labourers.
AMONG the many reasons cited for India to proceed with the Unique Identification (UID) project – that it will facilitate delivery of basic services, that it will plug leakages in public expenditure, that it will speed up achievement of targets in social sector schemes, and so on – the most specious is perhaps the claim that it will help India reach its public health Millennium Development Goals (MDGs).
Despite impressive economic growth in the country, the huge load of preventable and communicable diseases remains substantially unchanged, in addition to starvation deaths. Although life expectancy has increased and infant and child mortality rates have declined, these declines have been relatively modest. Infant and child mortality take an unconscionable toll – 2.2 million children every year. We are yet to achieve the National Health Policy (NHP), 1983, target of reducing the infant mortality rate (IMR) to less than 60 per 1,000 live births in all the States. More serious is the fact that the rate of decline in the IMR has been decelerating, from 27 per cent in the 1980s to only 10 per cent in the 1990s. The same is true for the rate of decline in the mortality rate of children under five from 35 per cent in the 1980s to 15 per cent in the 1990s. It is clear that India will not reach the Millennium Development Goals of reducing IMR, U5MR and the maternal mortality rate (MMR).
India has higher maternal deaths than any other country. The NHP target for 2000 was to reduce the MMR to less than 200 per 100,000 live births. However, in 2000, between 115,000 and 170,000 women died in childbirth, accounting for about one-quarter of all maternal deaths worldwide. Far from declining over the 1990s, maternal and neo-natal morbidity and mortality rates in India have, at best, plateaued. High and unconscionable as these levels of maternal mortality are, it is nevertheless critical to bear in mind that they represent just a fraction of the morbidity and mortality load borne by women in the country. Thus, for instance, deaths caused by anaemia among women who are not pregnant are twice as many as among those who are. Similarly, communicable diseases take a much higher toll than that due to pregnancy and childbirth.
The reasons are complex and stem, above all, from the lack of political and financial commitment to build a public health system that can meet the challenges. As the National Health Policy (NHP) 2002 admitted, this is, at 0.9 per cent of the gross domestic product (GDP), the fifth lowest public expenditure on health in the world. The decline in public investments over the years was matched with growing subsidies to the private sector in health care in a variety of ways. Thus we have the largest, and one of the least regulated, private health care industry in the world. Evidence from across the country indicates that access to health care has declined sharply over the last two decades. As the government admits, the policy of levying user fees has impacted negatively upon access to public health facilities, especially for poor and marginalised communities and women.
High private medical expenditure
It is to be remembered that along with poor public financing, India has one of the highest private medical expenditures in the world: out-of-pocket expenditure accounts for 83 per cent of the total health expenditure in the country. It is thus not surprising that, as the NHP 2002 notes, medical expenditure has emerged as one of the leading causes of indebtedness. At the same time, the proportion of people not availing themselves of any type of medical care for financial reasons increased between 1986-87 and 1995-96 from 10 to 21 per cent in urban areas, and from 15 to 24 per cent in rural areas. It is not just the poor; even the middle classes – the upper echelons of which welcomed globalisation – are finding it increasingly difficult to meet medical care costs.
The short UID Working Paper on Public Health astonishingly sees the UID as helping create “demand” for public health in the country. If people are voting with their feet for the private sector, which they do not and cannot trust, it is precisely because the public sector does not offer them quality care. Nor, indeed, is whatever care offered free of cost. Why then go to a crumbling system that offers little other than immunisation and family planning? Indeed, there is a huge unmet demand. In other words, the critical shortfall in supply of quality comprehensive services. How does the UID help with that? The UID Working Paper on public health sets out what it calls “killer application” to provide citizens an incentive to obtain a UID card in order to meet health needs. This unfortunate language apart, the fact that we have not built a health care system for the population is hardly fortuitous.
The Working Paper highlights the fact that we lack good-quality health data or indeed even vital statistics. It is equally true that this should come from integrated routine health system and not ad hoc surveys. But how is the UID to rectify this? People are avoiding the public health system for a variety of reasons: lack of drugs, lack of doctors, having to pay for services, inconvenient hours, rude personnel, and so on. Unless these issues are attended to, data quality cannot be improved. The UID is no magic bullet.
Thus the UID is not designed to meet the public health challenges in the country and should not pretend to do so. On the contrary, given that many diseases continue to bear a stigma in this country, the UID scheme has the unique potential of increasing stigma by breaching the anonymity of health data collected. It thus violates the heart of the medical encounter, namely confidentiality. By making this information potentially available to employers and insurance companies, the scheme bodes further gross violations of health rights. It is this reason above all that persuaded many countries in Europe not to accept such schemes.
This maternity unit near the primary health centre at Sellamanthadi village near Dindigul in Tamil Nadu is not in use. Evidence over the past two decades shows that access to public health care has dwindled, spawning one of the world's largest private health care industries.
The justification that the launch of the Rashtriya Swasthya Bima Yojana provides a “killer” opportunity for the UID scheme to free ride is equally moot; an evaluation of the RSBY scheme in Kerala, a State with extremely good health indicators, shows a number of problems, in particular an inability to reach marginal groups (Narayana D., “Review of Rashtriya Swasthya Bima Yojana”, Economic and Political Weekly, vol.xlv, No.29, July 17, 2010). Anecdotal evidence from Kerala also indicates a huge increase in costs because of what are politely called “moral hazard” problems. Simply put, doctors in the private sector are subjecting patients to unnecessary tests and treatment now that they are assured of payments. In short, this creates an “effective demand” for the private sector in a segment of the population hitherto not availing itself of this because of poverty. It is for these reasons that the High Level Expert Group of the Planning Commission rejected recently such a model of health care universalisation.
The biometric health insurance cards issued to Delhi slum-dwellers under the State government's “Mission Convergence” scheme requires card-holders to identify themselves with a fingerprint before they can avail themselves of free hospital treatment. Non-governmental organisations (NGOs) involved in the scheme say that they are inundated with complaints about malfunctioning fingerprint readers, which fail to authenticate even after multiple swipes. Since the scheme is tied up with private health providers, users in need of emergency treatment often end up paying inflated fees for services that they could get at a lower cost, if not free, at a government hospital.
One area where the UID card would be extremely beneficial has, of course, to do with clinical trials. As is well known, since 2005, India has opened up as a market for clinical trials of drugs, and that this is a huge industry, with MNCs now rushing in. It is equally a well-known secret that the trials that are being conducted are not good trials that the MNCs want. These good wishes are being vitiated by the trial subjects, the poor guinea pigs. Again, the evidence is of necessity anecdotal, but given the poverty levels, one way of getting quick cash – or indeed cellphones – is to enlist in several trials simultaneously. We all know this is happening and this is one area where the UID would be useful. That is to say, the guinea pigs can be carefully monitored not to enlist on more than one trial. Will it help in identifying side effects? In obtaining compensation for side effects or death? Of course not: the card cannot help here.
While there are systemic problems for low health access and outreach (such as low – and falling – immunisation coverage), to pretend that the UID scheme offers a solution to the problem is dissembling at best, and dishonest at worst. The UID scheme has thus little to offer for improvement in the public health situation in the country. On the other hand, the UIDAI has much to gain from a link-up with the public health system.
As the UIDAI Working Paper on public health puts it, in amazingly bad language: “The demand pull for this needs to be created de novo or fostered on existing platforms by the respective ministries. Helping various ministries visualise key applications that leverage existing government entitlement schemes such as the NREGA and PDS will get their buy-in into the project .... and will also build excitement and material support from the ministries for the UID project even as it gets off the ground.”
Given the significant potential for misuse of data, human rights violations and breach of confidentiality of health information, one hopes that the Ministry of Health will restrain its “excitement” and undertake a rigorous analysis of the costs and risks of the scheme before providing “material support” to the UID project. Or is this expecting too much from a Ministry that routinely betrays people?
Dr Mohan Rao is Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.
(Letters to the Editor should carry the full postal address)
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