Unhealthy state

Published : Oct 05, 2007 00:00 IST

The latest National Family Health Survey states that nearly four out of five children in the age group of 6 to 35 months were anaemic. Here, a file picture of a malnourished child in Maharashtras Nandurbar district. - VIVEK BENDRE

The latest National Family Health Survey states that nearly four out of five children in the age group of 6 to 35 months were anaemic. Here, a file picture of a malnourished child in Maharashtras Nandurbar district. - VIVEK BENDRE

Indias health system is iniquitous and inefficient. Only cooperative and communitarian solutions can lead to sustained growth and development.

The latest National

IT seems fairly obvious that a healthy population is not only a desirable attribute in itself, it is also a minimum necessary condition for any sort of sustained economic success. The role of public intervention is especially obvious in the case of communicable diseases, which are passed either directly among humans or indirectly through the physical environment. Clearly, ensuring better nutrition for more immunity and providing clean, safe water and immunisation against c ommunicable diseases generate direct health benefits for all of society through reduced rates of disease and reduced probability of any individual being affected.

Yet, this basic truth somehow eludes our policymakers, or at least does not impinge sufficiently on them to make this an important policy priority. Both the Central government and the State governments have become increasingly remiss about ensuring minimal expenditure and basic precaution for health.

Even in the mid-1980s, the health expenditure of the Central and State governments taken together was more than 1 per cent of GDP (gross domestic product), but since then it has been declining and is now only around 0.9 per cent. Central government expenditures on health alone have been completely flat at only 0.1 per cent of GDP, which is one of the lowest ratios in the developing world.

Although India accounts for 16.5 per cent of the worlds population, it contributes to more than 20 per cent of the worlds share of diseases. And far from getting better, this burden of disease is projected to increase considerably in the near future. Even as diseases and deaths on account of malaria, tuberculosis (TB), diarrhoea and other infectious diseases may reduce, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and TB and drug-resistant malaria are projected to increase.

One important reason for this is because we continue to perform so poorly in terms of ensuring better nutrition and making available better sanitation for the bulk of our people. Given the high aggregate GDP growth rates, it would be normal to expect calorie consumption and nutritional indicators to show some improvement. But data from the National Sample Survey (NSS) rounds on consumption expenditure reveal that far from rising, the per capita calorie consumption has actually decreased, even for the poorest groups.

Calorific consumption per capita declined from just over 2,200 calories a day in 1987-88 to less than 2,040 calories a day in 2004-05. In the period between 1993-94 and 2004-05, per capita calorie consumption declined by 5 per cent in rural areas and around 3 per cent in urban areas.

This cannot be entirely a sign of people moving towards different (and qualitatively better) consumption patterns through different food choices, as some analysts have argued. Instead, it is more likely to reflect changes in wage incomes, relative prices and increasing costs of health and other essentials that have reduced the ability of households to spend more on food. This unhappy conclusion is confirmed by outcome indicators on nutrition in terms of underweight children and low body mass index (BMI) among adults, especially women.

The results of the latest National Family Health Survey (NFHS-3) conducted in 2005-06 provide disturbing information in this regard. The proportion of underweight children under the age of three was 47 per cent in 1996-97; according to the 2005-06 survey it has fallen to 46 per cent.

In some of the more economically backward States it was even higher, such as Madhya Pradesh with 60 per cent, Bihar with 58 per cent, Jharkhand with 59 per cent and Chhattisgarh with 52 per cent. In several of these States, the proportion of underweight children actually increased between 1996-97 and 2005-06. In Bihar, it went up from 54 to 58 per cent; in Jharkhand from 54 to 59 per cent.

The more surprising fact is that such degeneration was not confined to the poorer and more backward States, but happened even in some of the more prosperous States. Thus, in Gujarat, which is one of the richest States and has shown one of the highest rates of economic growth over this period, the proportion of underweight children increased from 45 to 47 per cent.

Data on anaemia provide some evidence of the quality of nutrition and therefore address the point that some analysts try to make about calorie consumption or even weight for age/height not being correct indicators. According to the NFHS-3, the prevalence of anaemia is not only alarmingly high but has actually got significantly worse since the mid-1990s.

In the latest survey, nearly four out of five children in the age group of 6 to 35 months had anaemia, while nearly three out of every five ever-married women and pregnant women also were anaemic. The prevalence of severe anaemia also remains high.

Poor nutrition obviously increases vulnerability to disease and, therefore, preventive health services would have to be even more active in order to prevent the adverse tendencies arising from worsening nutrition. But here too the evidence is not really of improvement but suggests some deterioration. While the pattern obviously varies across States, a number of State governments have actually shown declines sometimes significant in per capita health expenditures, especially in public health areas such as immunisation.

This is now showing in the most worrying changes in basic indicators such as immunisation rates of small children. The percentage of children in the age group of 12 to 23 months who have been immunised fully (by receiving vaccines for BCG, measles, and three doses each of polio/DPT) has gone up very slightly between 1996-97 and 2005-06, but it is still only 43.5 per cent. That means more than half of the children in India still do not receive full immunisation and are, therefore, prey to completely eradicable diseases.

In three of the richest States Maharashtra, Punjab and Gujarat per capita public spending on health has declined in constant price terms after 2000. And the NFHS-3 results indicate that in these three States, immunisation rates of children in the age group of 12 to 36 months have actually fallen in 2005-06 compared with 1998-99.

In some cases, the decline is dramatic from 78 per cent to only 59 per cent in Maharashtra, for instance.

This is not just a severe indictment of public heath policies, but poses grave risks for the future. Lack of full immunisation can turn into a future public health disaster, with the possible re-emergence and spread of diseases polio, tetanus and diphtheria all of which are easy to prevent with proper public health management.

And when these and other communicable diseases do strike, they have to be dealt with mainly through private spending, even by the poor. The decline in government provision has meant that most health spending is by households, rather than by the government. India has among the lowest ratios (at less than 1:5) of public to private health expenditure among a large number of countries, including the poorest countries. Further, all the private expenditure in India is constituted by out-of-pocket expenses. This is inherently regressive and puts a disproportionate burden for health care on poor households.

Health care services are now characterised by the most extreme duality, with the rich opting for deluxe institutions with world class infrastructure (although not necessarily better medical attention). The poor are forced to go to either very overcrowded public facilities or private medical shops where they are routinely exploited and often provided with inadequate care. In all this, the concept of public health has been somehow forgotten and this unhealthy state of affairs is reinforced.

Among the rich in India, there is little recognition that the health conditions of a community affect each member of it, and the health of each member also affects the community at large. This, in turn, means that the health system in India is not only unfair and iniquitous but also completely inefficient. To achieve any kind of sustained growth and development, there must be cooperative and communitarian solutions to health problems and much more public resources have to be provided for dealing with the basic conditions affecting health.

Sign in to Unlock member-only benefits!
  • Bookmark stories to read later.
  • Comment on stories to start conversations.
  • Subscribe to our newsletters.
  • Get notified about discounts and offers to our products.
Sign in

Comments

Comments have to be in English, and in full sentences. They cannot be abusive or personal. Please abide to our community guidelines for posting your comment