Health matters

Print edition : April 28, 2017

Vaccination at a primary health centre in Bengaluru. The author argues persuasively for an interventionist role for the state in all aspects of health care. Photo: K. Murali Kumar

The book offers an overview of India’s health-care system from the vantage point of the author’s two decades of service in the sector, including as Union Health Secretary.

K. SUJATHA Rao’s Do We Care? India’s Health System is a call for action in an area that has been neglected by politicians and policymakers for far too long. It is a comprehensive account of India’s patchy, confusing and systemically iniquitous health-care system written from the author’s vantage point of two decades of service in government departments relating to the health sector and as the Union Health Secretary, from which post she retired in December 2010.

Beginning with the origins of the country’s public health care delivery system, Sujatha Rao points to the extensive Health Survey and Development Report prepared in 1946 by Joseph Bhore of the Indian Civil Service over a three-year period. “The Bhore Committee made recommendations based on principles that must guide a health system: being close to the people, provision of care regardless of the ability to pay, and the active promotion of positive health through community engagement and linking ill health to environmental hygiene. It envisioned an ambitious architecture consisting of one bed for every 500 people and one doctor for every 4,600 people to be provided in every district that was to be the unit of implementation.” The recommendations in the report hold good even today.

Sujatha Rao goes on to explain why India “relegated health to the Directive Principles of the Constitution” as against making it a fundamental right and why 70 years later this attitude continues.At that time India faced multiple challenges. Along with the need to address famine on the eastern front and mass migration in the west, it had to tackle malaria, which had affected three-quarters of the population. The Nehru government sought help from the United States to deal with the epidemic.Help came in the way of a “techno-managerial approach to disease control”, which did not address the causative factors such as lifestyle, social conditions and hygiene. “The more damaging impact of this early approach was seen in the neglect in building the foundation of the health system in accordance with the Bhore Committee recommendations,” says the author.

Tackling AIDS

Sujatha Rao makes anecdotal references to her stint as the Director General of the National AIDS Control Organisation (NACO) in order to explain the overbearing influence political will has had over India’s health architecture. She headed NACO between 2007 and 2010, when India hugely benefited from a worldwide effort to tackle HIV both by way of funds and by way of the Congress-led United Progressive Alliance government’s eagerness to shed the image of ceding excessive space to the private sector in vital areas such as health and education.

India accounted for the third largest number of those infected with HIV in 2005, but according to Sujatha Rao, the spread of the infection was reduced by 57 per cent by 2012, the sharpest fall any country was able to achieve. Staggered over three stages, India’s AIDS control programme spanned two decades from 1993. It was largely donor-funded, peaking with a U.S. $2.5 billion commitment in its final stage between 2007 and 2012. Sujatha Rao explains how thanks to sustained empirically driven interventions and institutional mechanisms, coupled with the active engagement of civil society, the last stage of the programme was a major success. Indeed, she remains widely recognised for her hands-on approach through the time she headed NACO.

She talks of the two instances that “changed the course of the epidemic”. The first was on December 1, 2003, observed as World AIDS Day, when Sushma Swaraj as Union Health Minister made a surprise announcement of free antiretroviral treatment “overruling bureaucratic objections and apprehensions, though she vehemently opposed condom advertisements being aired on TV during primetime except ‘after 11 p.m. when children have slept’”.

The second was when NACO disagreed with the Home Ministry over repealing Section 377 of the Indian Penal Code. As a respondent in a case filed by a non-profit organisation in the Delhi High Court, NACO called for the repeal of the law, which criminalises homosexual acts. The Home Ministry opposed it.

Recalling why NACO stayed consistent with its position in the High Court, Sujatha Rao writes: “One afternoon the Minister of Home Affairs called the Health Minister Anbumani Ramadoss [Health Minister from May 22, 2004, to May 22, 2009] to his house for a discussion to reconcile their respective positions. Naresh Dayal, the Secretary of Health, and I accompanied the Minister. Heated arguments followed, with [Union Home Minister] Shivraj Patil vehemently arguing against the position. But Ramadoss did not give in. If today the NACO affidavit stays unchanged and if it helped in the favourable outcome in the High Court in any way, a lot is owed to the outright support Ramadoss gave to the issues of MSM (men having sex with men) and transgenders.”

Sujatha Rao is an ardent supporter of health care as a public good. She argues persuasively for a strong and interventionist role for the state in all aspects of health care, but particularly in primary health—the first point of reference for the sick. She says “barefoot doctors” like those in China and Thailand worked for decades to put in place a public health care system that ensured doctors stayed within the communities they tended to and promoted health and wellness and lifestyle changes, which had an impact on infectious diseases and could also delay the onset of age-related ailments.

As the author says, 90 per cent of health care can be attended to at the primary, outpatient level. It is the other 10 per cent that culminates in long-term or hospitalised care. She has marshalled vast amounts of data to make her case. She says despite the government’s experiment of funding state-run insurance plans such as the Rashtriya Swasthya Bima Yojana or its several offshoots such as in Andhra Pradesh and Tamil Nadu, out-of-pocket expenses have not reduced for the vast majority of Indians. The intended beneficiaries continue to be neglected as private health care is almost “non-existent” in rural India. These insurance policies have ironically encouraged hospitalised care when not required and bolstered the unregulated growth of private hospitals, which provide care at a cost five times that of public institutions. The thrust on liberalisation has resulted in a fivefold increase in the number of private hospitals, which constituted just 16 per cent of hospitals in the country in 1963-64.

Sujatha Rao says that out-of-pocket expense continues to push an alarming 42 million Indians into poverty every year. Public funding, both Central and State governments, accounts for 28.6 per cent of the total health expenditure, with households incurring nearly 70 per cent of the costs, including insurance premiums. She says that providing outpatient care for free alone will bring about a sevenfold decrease in impoverishment.

Sujatha Rao does not shy away from being critical of giant donors such as the Bill and Melinda Gates Foundation (BMGF), which was at one point given the charge of running the NACO programme with strict controls/overview by NACO. By then NACO had created a robust participatory and decentralised programme. But the BMGF attempted to take credit for what followed. This kind of foreign donor participation, according to Sujatha Rao, created discontent and disparities within the programme as some of the foreign funders paid a lot more than what the Indian government could afford, compromising the state’s position and weaning away publicly spirited care providers to donor-driven programmes. Her comparison of NACO with the functioning of another major government intervention—the National Rural Health Mission (NRHM)—and why it has not been as successful as NACO makes for an excellent understanding of how government programmes work on the ground.

Her prescriptions for the future for public health are pretty simple: decentralised revenue generation and decision-making, a thrust on cooperative federalism with the active involvement of civil society and stakeholders; revamping of the delivery system, or timely disbursement of funds and drugs; stable postings for government doctors with incentives for further specialisation, research and growth, and regulation of private practice; regulation of the private sector and minimising its role to tertiary care as much as possible; and enhanced government spending for whatever it takes to provide primary health care for free for all Indians. Is anybody listening?