Unhealthy trend

WHAT is the state of the nations health? The findings of the third National Family Health Survey (NFHS-3), a household survey carried out during 2005-06, should put the political class to shame. The country may be witnessing an 8-9 per cent economic growth and the government may think that India is a world power in the making, but these findings tell the real story of where all that growth is headed.

When the United Progressive Alliance (UPA) came to power in 2004, some of the health-related declarations it made as part of the National Common Minimum Programme (NCMP) are as follows:

The government would increase public expenditure on health services from around 1 per cent of GDP to around 2-3 per cent;

While focussing on primary health care in a substantial manner, all efforts shall be made to provide health insurance to all rural families;

In order to tackle all communicable diseases, the government would increase investment in health services;

The government would make all life-saving drugs affordable to all;

The government would ensure that all sections of the population can afford and avail themselves of health services.

In the context of these promises, how does the national health profile look?

The infant mortality rate (IMR), the number per 1,000 children before one year of age, is 57, which means over one in 18 infants die before they are one year old. While the figure is a marginal improvement over the IMR of 68 of NFHS-2 (1998-99) about 1 in 14 this is unacceptably high.

The same is true for children under five, wherein the child mortality rate (CMR) is 74 (one in 13) as compared to 92 of NFHS-2. This is a far cry from the Millennium Development Goal (MDG) of a CMR of 42 by 2015. More tellingly, this is equal to the average of all the Least Developed Countries (LDC), 2.5 times that of China and eight to 10 times higher than that of developed countries. Clearly, the IMR target of 30 by 2010 set by the 2002 National Health Policy (NHP-2002) is unlikely to be achieved.

What is particularly disquieting about these figures is that much of these deaths are preventable through childhood immunisation. But the reach of the countrys Universal Immunisation Programme (UIP) continues to remain low, which is the result of a weak public health care system. The NFHS-3 data show no significant improvement in immunisation coverage between 1998-99 and 2005-06 (Figures 1 and 2): 42 per cent coverage in NFHS-2 and 44 per cent now. The coverage has actually worsened in Andhra Pradesh, Gujarat, Maharashtra, Punjab and Tamil Nadu. The objective of introducing the pulse polio programme (PPP) over and above the routine immunisation programme was to make India polio-free. That goal has not been achieved because the PPP is being done at the cost of routine immunisation, in terms of deployed resources. The budgetary allocation for routine immunisation has been roughly a third of that for the PPP. The number of Acute Flaccid Paralysis (AFP) cases, an indicator of the success of polio vaccination, which prevents limb paralysis in children, has actually increased enormously, from 3,047 in 1997 to 31,973 in 2006.

The UIP suffered a major blow during 2008-09 because of the highly misplaced decision to shut down the three vaccine-producing public sector undertakings (PSUs) on grounds of non-compliance with the World Health Organisation (WHO) norms on good manufacturing practice (GMP). With the government unable to ensure adequate supplies from the private sector at affordable prices, vaccine shortage has worsened. While these PSUs never had any problem with their vaccine quality, there have been recent reports of vaccine from GMP-qualified private sector companies failing in quality checks (story on page 114).

India is fast earning the dubious distinction of being the hunger capital of the world. The nutritional status of children has not improved over the past five years, which means the Integrated Child Development Services (ICDS) aimed at promoting child health and nutrition is not working.

The outreach and delivery of ICDS is extremely poor. As per NFHS-3 data, the services of an anganwadi are available only to a third of the children and the supplementary food scheme reaches only 26 per cent. As a result, nearly half the children under the age of five are stunted, which reflects their childhood nutritional status. Nearly one-fifth are underweight for their height, an indicator of both chronic and acute undernutrition. These figures are nearly double the levels of undernutrition even in sub-Saharan Africa.

Undernutrition extends to adults as well (Figure 3). Over half the women and nearly one-fourth of the men are anaemic. This is a direct consequence of the continued lack of balanced nutrition from childhood into adulthood, especially among women.

Women are the worst hit in terms of access to health services. According to NFHS-3 data, only 17.3 per cent of women have ever received any service from a health care worker. Only 17.9 per cent of the public health centres (PHCs) have a woman doctor. As a direct consequence, 56.2 per cent of women (aged 15-49) are anaemic, which actually represents an increase from the NFHS-2 data of 51.8 per cent. The percentage of pregnant women who are anaemic has also increased from 49.7 per cent to 57.9 per cent.

Around 52 per cent of childbirths take place in the absence of a qualified health worker. This, coupled with womens intrinsic poor health and poor nutritional status, causes the death of over 120,000 mothers following childbirth. The maternal mortality rate (MMR), the number of women dying of childbirth-related problems per 100,000 deliveries, is a high 300, according to NFHS-3, still way beyond the NHP-2002 target of 100 by 2010.

The burden of disease on the population continues to be high and takes a heavy toll of life. Recent years have witnessed a resurgence of various communicable diseases such as tuberculosis (TB), malaria, chikungunya, dengue, kala-azar, encephalitis and leptospirosis.

India bears one-fifth of the worlds burden of TB. About 3.7 lakh people die of TB in India every year, the highest in the world, and this figure is only likely to go up with increasing evidence of the widespread prevalence of multi drug-resistant TB (Figure 4). Since NFHS-2, the reported cases of TB have declined by 18 per cent, but the level of medically treated cases of TB has not changed (Figure 5).

The number of malaria cases remains at around two million annually, but the disturbing aspect is the increasing trend of drug-resistant falciparum malaria (nearly half the cases), which causes the highly fatal cerebral malaria. Poor surveillance and the lack of access to hygiene, sanitation and drinking water among the poor, coupled with a weakening public health system, have contributed to this.

About six lakh children die of diarrhoea, a disease that is easily preventable by providing access to potable water and sanitation. Infected children can be prevented from dying if they have access to the simple household remedy of Oral Rehydration Solution (ORS). According to NFHS-3, only one-third of urban diarrhoeal cases get ORS, while less than a fourth of rural cases get it (Figure 6). The situation, according to NFHS-3, has actually worsened; only 29 per cent of households have access to improved toilet facilities. Besides, about 200 million people still do not have access to clean drinking water.

Notwithstanding the controversy in the number of Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) cases and the prevalence rate of infection in the country, and the recent downward revision of estimates for these, they are still significant. With the latest estimate of 25-31 lakh cases (depending upon the study and the agency), India has the third largest number, after South Africa and Nigeria. This constitutes a serious threat and a major challenge for the health care system in the country. Though treatment and access to health care facilities for the disease have improved in recent years, these need to improve further.

Having said that, one should bear in mind that the allocation for HIV/AIDS is skewed greatly in its favour because of foreign funding for the National AIDS Control Programme (NACP), from agencies such as the Melinda Gates Foundation. The allocation for the NACP is roughly of the same magnitude as the combined allocation for the control of TB, leprosy, trachoma, blindness and iodine-deficiency disorder. The neglect of the routine immunisation programme for women and children, in terms of inadequate finance, manpower and cold-chains and other infrastructure, only compounds the problem of tackling communicable diseases.

In terms of the growth of infrastructure in the public health sector in rural areas, even as per 2001 population norms, there is a shortfall of 21,983 subcentres, 4,436 PHCs and 3,332 community health centres (CHCs). Though the increase in the number of subcentres from the 9th Plan period to the 10th Plan period (6 per cent) has been significantly higher than that from the 8th Plan period to the 9th Plan period (0.8 per cent), this is still insufficient given the population growth.

The PHCs have actually registered a 2 per cent drop between the 9th and 10th Plan periods. There is a substantial increase only in the number of CHCs, but these suffer from staff and resource shortages.

As many as 807 PHCs have no doctor, 1,188 PHCs and 1,647 subcentres function without electricity or without regular water supply. According to the Rural Health Statistics of the Ministry of Health and Family Welfare (MoH&FW), 50 per cent of subcentres, 24 per cent of PHCs and 16 per cent of CHCs function out of rented or temporary premises.

Availability of skilled personnel even for standard medical care is woefully inadequate in the public health system. More than one-fifth of the sanctioned posts for doctors are vacant, while over 40 per cent of the PHCs have no laboratory technicians and nearly one-fifth have no pharmacists. This is a direct fallout of the nature of our medical educational system, which is largely based on the Western model, is urban-centric and does not produce the right kind of health workers. Only 20 per cent of the medical professionals are available for 70 per cent of the countrys population, in rural India.

The nature of hierarchical health governance, administratively, financially and technically, also contributes to the poor state of the public health sector. Further, public health and sanitation, hospitals and dispensaries are State subjects. Health should be brought under the Concurrent List in the Constitution, which gives a role to both the Centre and the States.

The National Rural Health Mission (NRHM), which is a flagship programme of the UPA government, has certainly brought in some reforms, but they are not enough. Also, there are several shortcomings in the NRHM, as discussed below.

The NRHM was launched in April 2005 with the objective of providing universal access to equitable, affordable and quality health care. However, the findings of the second Common Review Mission (CRM) of the MoH&FW, released in November 2008, show that much of the NRHMs focus has been to increase institutional deliveries despite most of the States having poor infrastructure. For instance, in Karnataka, institutional deliveries increased from 60 per cent in 2005 to 79 per cent in 2008-09, while the First Referral Units, the PHCs and the CHCs remained underutilised. It also revealed that the PHCs and the CHCs continued to lack basic facilities and faced a shortage of technicians and doctors.

In 2007-08, the Jan Swasthya Abhiyaan (JSA) and the Peoples Rural Health Watch (PRHW), citizens fora that raise health issues, conducted a survey in the high-focus States of Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Jharkhand, Orissa, Bihar and Rajasthan to analyse the impact of the NRHM on rural health care.

The survey found that only married women were selected to serve as accredited social health activists (ASHAs), the lynchpin of the NRHM. The ASHAs were found to be trained mainly for reproductive and child health services (read family planning) and not as community health workers, which is what is envisaged under the NRHM.

Nearly 75 per cent of the ASHAs spoken to in the survey said they had received no money. In fact, according to the CRM report, payments for the ASHAs and the Janani Suraksha Yojana (JSY) scheme were poor. It added that introducing incentives for the JSY and sterilisation compensation had deleterious effects.

The JSA-PRHW survey concluded that no genuine steps had been taken to recruit doctors at all levels of the public health services, retain them and make the health system functional; that despite a massive shortage of infrastructure, no measures had been taken to address the issue. The incentives under the JSY needed to be reviewed as they were leading to conflict and corruption between auxiliary nurse midwives (ANMs), ASHAs, dais and anganwadi workers.

All of the above are pointers to inadequacies in the public health care system, in terms of resources deployed and hence in its outreach and coverage.

India has the most privatised health care system in the world. According to NFHS-3, for 70 per cent of urban households and 63 per cent of rural households the unregulated private sector is the chief source of health care. Only 5 per cent have any kind of insurance cover for at least one member of the household. As a result, people bear over 80 per cent of medical expenses through out-of-pocket expenses, pushing the already poor to below-poverty-line status.

According to the 2004 data of the National Sample Survey Organisation (NSSO), 40 per cent of the respondents did not take treatment for their serious ailments because of financial constraints. According to the Planning Commissions Steering Committee Report on health, the average cost of private health care is about eight times the cost in the government sector.

Not only does the private sector need to be regulated, it must also be integrated into the public health system where possible and in certain situations be required to perform the role of the public health system. Health care, being predominantly private-sector driven, makes the system urban-oriented with a bias towards tertiary-level health services. Profitability becomes the bottom line, ignoring equity and rationality.

Against the WHOs recommendation of 10 to 15 per cent Caesarean deliveries, today in urban India 45 to 50 per cent of childbirths are by Caesarean. This situation is attributable to a profit motive, which has also led to an undesirable growth in medical tourism, with indirect government support for patients from West Asia and the developed world who have the money to pay.

Even medical education has become private-sector dominated. The Medical Council of India (MCI), responsible for maintaining standards in medical education and in the medical profession, has increasingly become subservient to the interests of private enterprise.

Over the years, with the increase in the number of private medical colleges, the MCIs powers have grown greatly. In November 2002, the Delhi High Court ordered its president, Ketan Desai, to step down on various charges, including corruption. But, despite the courts observations, the Centre has done nothing to correct the irregularities within the MCI. Recently, it turned a blind eye to Ketan Desais re-election as the MCIs president.

In an environment of private-sector-dominated health care, irrational treatments abound. It is estimated that in India two-thirds of the money spent on medical treatment goes towards buying unnecessary drugs because of irrational prescriptions by private practitioners. Such an environment has enabled the pharmaceutical industry, which comes under the Ministry of Chemicals and Fertilizers, to thrive. There is a proliferation of brand names in India, with as many as 80,000 brands around. Even so, only 20 to 40 per cent of the people have access to all essential drugs they need.

Many drugs are sold at huge profit margins of 200 to 400 per cent, thus putting essential drugs beyond the reach of the common man. The prices of drugs have grown at a disproportionately high rate when compared with the Wholesale Price Index (WPI). This has actually worsened during the UPA regime. Yet, policymakers are reluctant to impose any price control because of the industry lobby prevailing over politics. The existing price control regime is far from effective as most essential medicines are outside its purview.

There is also the issue of the spurious drug market, which the Drug Controller General of India (DCGI) appears ill-equipped or unwilling to tackle. Therefore, a national drug authority under the Health Ministry becomes necessary.

As regards investment during the past five years, the average spending on health was 0.86 per cent of the gross domestic product (GDP) as against the 2 to 3 per cent that the UPA promised. Even as a fraction of the total expenditure, the spending on health has dropped to 2.9 per cent from 3.4 per cent.

Public health expenditure in India as a proportion of total health expenditure is only 16 per cent, according to the JSA. This is less than that in Ethiopia (36 per cent), Burkina Faso (31 per cent), Nigeria (28 per cent) and Pakistan (23 per cent). In 1974, around 80 per cent of hospital units and 80 per cent of hospital beds were in the public sector. Post-liberalisation, in the 1990s, the trend reversed and only 38 per cent were in the public sector. The situation now could be far worse.

In addition to this is the fiscal management pressure from the Centre on the States, resulting in massive budgetary cuts in the socio-economic sectors, including the already deprived health services. The overall health expenditure by States declined from 4.5 per cent in 1999-2000 to 3.6 per cent in 2008-09.

Besides, the government subsidy for health also does not reach the poorer sections of the population. According to a WHO report, only 10 per cent of the total subsidy goes towards the benefit of the poorest 20 per cent of the population, whereas the richest 20 per cent avails itself of 33 per cent of the subsidy.

Access to quality health care is a basic human right and should be viewed as a fundamental right of every citizen. A healthy nation is a prerequisite for social and economic development. Mere economic growth measured in gross financial terms, as is evident, does not ensure that. To make the public health care system work requires determined political leadership, adequate investment and appropriate policy instruments rooted in ground realities.

Therefore, in the run-up to the general election, from the perspective of the electorate, peoples health should be accorded top priority along with education and food security. Public health must be brought to the top of the political agenda, which, unfortunately, has not been in evidence in the past 60 years of independence.