Friday, June 26, 2009

For a healthy Bharat

HEALTH must no longer be considered as a separate, stand-alone entity. Sustainable improvement in health status can occur only in conjunction with overall development in the community. At the same time health is a prerequisite for economic and social development. In our vision, are the one billion plus an asset to be fostered or a liability to be tolerated? This paper, though limiting itself to conventional ‘health’ aspects, argues that health is both the precursor to and the product of development. Fortunately, unlike the period soon after India became independent, there is today a great deal of data available from both independent researchers and, more importantly, government sources. Much of the data quoted in this report is from official government sources.
It is important to realize that in the sixty years since independence, the health status in India has shown a remarkable change. To enumerate just a few of the gains: a baby born in India today can expect to live twice as long as one born in 1947; the expectation of life at birth was under 30 years then, today it is 62.3 in men and 63.9 in women. The infant mortality rate, the chances of a newborn dying in the first year of life, has decreased from around 150 per 1000 to 57 per 1000. Though still too high, we must not lose sight of the fact that significant changes for the better have occurred. There are similar gains in other health related parameters, including number of hospital beds, primary health centres, the numbers of doctors and nurses available, the number of medical colleges and students admitted each year and so on.
Over the same period the density of population has almost tripled from 117 in the 1951 Census to 325 in 2001, with India’s population increasing from under 400 million then to over a billion in 2001, nullifying many of the gains made in all sectors, including infrastructure, education, health manpower and facilities. The latest available economic figures (2004-2005) indicate that 28.3% of the rural and 25.7% of the urban population remains below the poverty line; 56.5% of the rural households (and 12.5% of the urban) do not have electricity in their homes. The story as regards basic amenities such as the availability of piped water or toilets is equally depressing.
Looking at health status and access to health care, there seem to be two totally different population sets in India. One India consisting of the affluent and urban population has much better health related amenities, better health status and access to truly world class tertiary health care. It is noteworthy though that preventive care is not available at the same standard of excellence even to this affluent cohort.
Another India, perhaps better differentiated as Bharat, is still burdened with limited access to even primary health care as also effective promotive and preventive care. This neglect would not hurt so much were it not for the fact that with even the limited availability of money, materials and human resources, things could be much better.
In the sea of poor health care there are many islands of excellence where health care is characterized by good access, effective prevention of disease, equity and early detection and management of actual and impending disease outbreaks, together with a partnership between health care providers and the people. The rural out-reach programmes of the All India Institute of Medical Sciences at Ballabgarh in Haryana, the community health programme run by CMC Vellore, the superb efforts by the Abhay and Rani Bang at Gadchiroli near Nagpur, the efforts of dedicated individuals and NGOs such as the late Dr. Antia and the Foundation for Research in Community Health and many others have demonstrated that good, equitable and affordable health care is possible even in the most peripheral areas of the country.

An important source of data are the findings of the National Family Health Survey. Though the indicators generally show gains over the successive surveys, the changes expected have not really materialized, largely because the figures for Bharat often offset the gains in India! Immunization coverage, for example, only increased from 42% of children between 12 to 23 months reported as being completely immunized in the NHFS-II report (1998-99) to the current NFHS-III (2005-06) report that only 44% children of the same age have received complete immunization. More than half of the children supposed to be immunized are in fact not protected against one or more of the vaccine preventable diseases.
Less than half of the pregnant women received antenatal care during the first trimester of pregnancy and only 51% got three or more antenatal care opportunities. Only 23% mothers consumed iron and folic acid tablets for the recommended 90 days during pregnancy and three out of every five mothers delivered their babies at home. Only 37% of all mothers had a postnatal checkup as recommended, and this figure fell to 15% for those that delivered at home. These figures provide depressing evidence of the failure of the public sector health system to deliver even the most basic of preventive services.

Child nutrition figures provide damning evidence of the situation regarding the determinants of health. In the period between NFHS-II and NHFS-III, the percentage of children under three years of age with wasting (low weight for age) actually increased from 20% to 23%. It is not only children; 25% of urban women are too thin (underweight) and this proportion increases to 41% in the rural areas. Anaemia has been a big problem in our country. Even 60 years after independence, 55% women, 24% men and a massive 70% of children are anaemic, this despite a large ongoing national programme to control anaemia. NFHS-III has shown that anaemia has actually increased in women and children by about 5% since the previous survey!
If we believe the reports periodically released by the health ministry, awareness efforts about HIV/AIDS have been successful. However, the picture presented by NFHS-III is not so sanguine. Only 36% of women knew that condoms helped prevent the spread of HIV/AIDS. The role of fidelity and even abstinence as measures for preventing HIV and other sexually transmitted disease was known to only 45% and 40% of women respectively. NFHS-III also points out that one in three women suffer from domestic physical violence. Health is governed by biological, social and environmental determinants. Bharat, it is apparent, needs attention on all three counts.

The gains of reducing infant and child mortality and the control of diseases causing major epidemics have resulted in a great increase in the lifespan of people in the country – more in India but also in Bharat, thereby changing the demographic profile of Indians. There are today many more elderly persons alive than ever before. As populations grow older the disease patterns change; those diseases that affect older persons become more common. Already the non-communicable diseases (NCD) such as diabetes, heart disease, hypertension, stroke and cancers are responsible for close to 60% of mortality.
Unfortunately, while the disease profile has changed, the structure of the public sector health system has not kept pace with the altered priorities. Very little is being done to prevent, diagnose early and treat the NCD. Studies have shown that the risk factors for the NCD are common not only in the affluent urban India but are rapidly increasing in the poorer rural populations. Tobacco use, obesity, lack of exercise and diabetes are now increasingly on the upswing in our rural populations – and we are not yet geared to preventive and promotive interventions to affect the so called lifestyle diseases.
The National Commission for Macroeconomics and Health avers that though attempts have been made to prioritize programmes keeping in view the decision-makers’ perceptions of what is needed, the people’s expectations from the health system are very different. No wonder, when asked about the PHC building in their village is, they never say it is their health centre, but rather the government’s family planning centre!
The commission also points to the highly skewed distribution of resources, especially in the private sector. 88% of towns have (health) facilities compared to only 24% of villages and the private sector has 75% of specialists and 85% of technology in their facilities. It points out that though the most cost-effective way of influencing health status is to focus on preventive and promotive interventions, the total expenditure on these services constitutes a mere 0.5% of public (sector) health funds!

Another major factor that influences the state of health of the people, especially the poorer and less literate segments, is the governance of health. The people of Bharat are less able to afford private sector health care (though they may well have to because of their lack of access to public sector health care) and in any case most private, for profit, health care is really medical or curative care and not preventive and promotive care. The issue of funds available to the public sector health system needs serious consideration. Comparison of health status and funds available for health in countries across the globe has clearly established a linear relationship between the health budget and health status. It also shows that pro-poor public health choices impinge more favourably on health status than investing unduly on curative care. Preventive and promotive interventions pay bigger dividends than fancy curative palaces.
We have also known for a long time that unless a basic minimum of resources is available to the health sector, the health status of those in need is not likely to improve, nor will it be sustainable. The Commission on Macroeconomic and Health for India estimates that the minimum necessary requirement for basic medical care is US $34 per capita annually. Currently only 16% of the estimated absolute minimum, Rs 215 is available to Bharat.

This is not to say that fiscal efficiency in the manner in which interventions are selected and money spent and accounted for is unimportant. But that is not going to be enough. It is worth recalling that Transparency International, a global body, in its last report targeted health as the second most corrupt public sector in India. Further, it is the poorest of the poor that are most hit by corruption. But all said and done, a greater investment in health is critical and we must wake up to this reality.
The current health allocation of Rs 1200 per capita is ludicrous and remains far below the minimum effective level. That is the total allocation. The portion spent on public health is only a quarter of the total health expenditure (THE). This too is not evenly distributed. Uttar Pradesh for example only spends 7.5% of the THE, while the suggested proportion is 50%. The expenditure on tertiary care is disproportionately high and the primary care sector has inadequate funds. It is recommended that primary care sector should get at least 55% of the allocation.

Health receives only 1.2% of the GDP. Even as the amount in rupee terms has increased, so has the GDP and the current allocation is a miserable 0.95%. India’s health allocation is lower even than its neighbours. Various authorities have suggested that 3% of the GDP is a more reasonable figure. While the government has made more funds available through the National Rural Health Mission, the indications at this time are that the total fund availability for Bharat remains abysmally low. Much more money is invested in providing health care to the 30% of the population living in urban India than for the 70% that lives in rural Bharat.
We must realize that it is not only those below the poverty line who cannot afford health care. A single catastrophic illness can drive even those who are above the poverty line into a never ending spiral of poverty and debt.
Another area that highlights a serious failure of governance relates to the posting of health manpower in the less popular rural areas. It is well known that there are many PHCs in the more disadvantaged parts of Bharat without doctors. People are rightly concerned about this. The usual government knee jerk reaction is that India needs more doctors. Some even seriously advocate a return to the process where the health system produced ‘doctors’ with lesser training for service in rural areas. The concept seems to defy logic. Surely a doctor who has to practice medicine in the absence of laboratory and diagnostic tools needs to have a higher degree of expertise than one who has all the support and backup of specialist colleagues and a variety of diagnostic aids. Yet the current thinking is that doctors for Bharat can be trained for a shorter period and with a lower level of training and skill than those who have to work in India!
While it is true that our country can do with more doctors (and many times more nurses) it must be realized that the reason that there are no doctors in many of the more disadvantaged PHC’s is that neither the politicians nor the other health decision-makers are willing or able to take rational decisions and enforce regulations. Let us illustrate the nature of the problem using government data.

Rajasthan has 130 PHCs without any doctors. This is undoubtedly an untenable situation and needs change. However, it must be noted that 193 PHCs in Rajasthan have four or more doctors! Even if one doctor each was relocated from those 193 over-staffed PHCs, the problem as far as that state is concerned would be solved. Similarly Andhra Pradesh has 93 PHCs with no doctor but 16 PHCs with four or more doctors, and another 126 with three doctors. What is stopping the health authorities from ensuring that a geographical redeployment is carried out to ensure that every PHC, not matter how deep in Bharat, has at least a doctor? Or even that all staff, including doctors must physically be present in the post from where they draw their salary.
The shortage is not of doctors; in many states there are already enough doctors in government service and working at PHCs. What is in short supply is political will and the government’s willingness to enforce its orders. To my mind this is yet another manifestation of the festering corruption that Transparency International alluded to when it stated that the health department was the second more corrupt department in India.
Besides the above mentioned issues relating to governance, a systems change is needed in the structure of the public sector health system. There are many disciplines and specialities under the broad canvas of medicine. There are cardiologists, paediatricians, anaesthesiologists and the like. There is also a speciality of Public Health with its own body of knowledge and specialized skills. This includes subspecialities such as epidemiology. Public health with all its broad spectrum of skills is the speciality that is concerned with aspects such as the delivery of health care in the community, preventive and promotive health care, the early detection and response to disease outbreaks, the collection, tabulation and analysis of data to convert it to usable information. In theory, public health is not an unknown speciality in India. The Medical Council of India has decreed that every medical college will as a compulsory subject, teach public health by any of its names (preventive and social medicine, community medicine, community health and the like). Besides undergraduate education in many medical colleges in India, this academic department also trains postgraduate students and awards the MD degree.

Specialists of public health should logically staff any position that deals with health care as distinct from medical care – positions such as that of medical officers whose prime responsibility is to organize and deliver health care to a community. The inexplicable fact is that except in Tamilnadu and Gujarat, a medical graduate from any speciality can occupy these posts. An eye surgeon or a neurosurgeon can be responsible for planning, organizing and delivering health care to a district, a region or even the state or the country as a whole. While we would never allow anyone other than a trained and qualified eye specialist to be involved in caring for individual patients with eye ailments, we happily accept that an eye surgeon can take care of a district’s health needs without any training in public health.
The gravity of this neglect of a basic medical speciality is best gauged by the fact that in our nation of well over a billion people there are only 78 positions in the public health cadre. While any medical graduate, of any specialty can fit into a public health position, a public health specialist cannot be considered as qualified to fit into the jobs for any other specialty.

The people of Bharat pay the price. The consequent inefficiency in looking after the community goes unquestioned because of the sheer inability of persons in vital positions to take informed decisions as they do not have the requisite knowledge and skill. Every health policy and planning body such as the Planning Commission and the Central Council of Health and Family Welfare has time and again reiterated the need for micro-planning for efficient, site specific health plans. Yet we have never managed to do this for the simple reason that the incumbents at the district level downwards do not have the skills needed to make sense of the data collected, much less to conduct information and evidence based planning.
Unfortunately the term public health means many different things to different people – the health of the people, programmes relating to the health status, or just about anything to do with health and the community. The lack of understanding of the term is best exemplified by the recent publication, The Public Health Standards of India. Released recently with much fanfare by the health ministry, it has nothing to do with the discipline of public health, nor with people’s health status since it sets out no targets for health status. It merely lays down the physical standards, equipment and drug lists and enumeration of staff for public sector health facilities! And yet the government seems to feel it has done something for public health.

Health decision-makers seem blissfully ignorant of the fact that not only is there a well-defined medical specialty of public health, but that this specialty is desperately needed at the community level to efficiently organize appropriate health care delivery. Hospitals largely cater to the failures of the health system to prevent illness and foster positive health. Thus, merely increasing the number of hospitals will not improve health status in the community. Only efficient use of the skills and knowledge of public health can improve health status and cut down health system costs by focusing on preventing illness and the rapid response to actual and impending disease outbreak threats. These are the skills of public health.
Because of the downgrading of the discipline, most medical students are loath to opt for this speciality. A chicken and egg situation – there are no dedicated jobs or career prospects so students do not opt for public health. And since there are no public health specialists, there is no incentive for creating a cadre.
Arguably the most effective health care to the community is in Tamilnadu. Though not more affluent, it does however, have a better administered health system. It also has a qualified public health specialist in every district. If we want the health status to improve in Bharat, the skills of public health must be made available to the people of Bharat. Otherwise, the addition of other inputs in terms of money, materials and even manpower will not be utilized efficiently.

Some solutions are self-evident. In a welfare state like ours, the government must face the fact that it has the responsibility to provide access to basic minimum essential health care for the population. Unfortunately access to health care is not a fundamental right under our Constitution. A strong case can be made to justify making this change. Only if access to health care is so guaranteed will health care providers be accountable. I am not advocating more litigation but an evident and immutable priority to providing basic minimum health care to all sections should be the underlying driving force for the health system.
It is also undeniable that budgetary allocations need to be increased. Our nation has one of the lowest health allocations, lower than many much less affluent nations. We need to ensure that the money available for health care per capita meets at least what our own Commission on Macro-economics and Health has estimated as the absolute minimum required to provide basic essential health care.
The responsibility of the public sector health system to provide preventive, promotive and basic curative health care is undeniable. The private sector is not responsive to the needs of preventive and promotive care – at this time there is no profit in it. To quote the commission, ‘Shifting from the curative, techno-managerial approach to a biomedical public health approach and stepping up prevention of disease and health promotion for behavioural change is imperative to reduce disease burden.’
It is also clear that political will to provide health care to the people must be generated. As an example there is no way that the anomalies pointed out in the posting of doctors at PHCs could continue without patronage from the decision-makers. Something in the neighbourhood of 73% of health care costs are already being born by the individual; the people of Bharat are suffering enough without the extra burden of paying a premium for corruption.

We must establish a public health cadre. This does not involve vast sums of money, only the political will to do whatever it takes to improve the efficiency of health care in the community. I am not advocating a completely new cadre with the creation of hundreds or thousands of positions. What is needed is the bifurcation of the existing health cadre into two separate streams – one concerned with the provision of medical or curative clinical care, the other with public health. Both these cadres (or sub-cadres) must have identical career structures that have identical end-points – the senior most designation in each cadre being of equivalent rank. After a suitable period of initial relaxation, persons in the public health cadre must have suitable formal qualification in one of the disciplines of public health.
Tamilnadu and Gujarat have done it with notable health benefits to their populations; other states too can as easily aim at achieving a similar standard if they have the will. Whether the population of Bharat benefits from modern medical knowledge depends upon the will of health decision-makers. Some opportunities for political patronage will be lost, but if the objective is equity in essential health care in the health system at all levels, particularly when catering to the poor population in the hinterland, then the skills and science of public health will have to become available at the district and lower level.

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