Publicness of health

On a summer day in Hyderabad. Safe drinking water is no longer considered something that must be provided by the civic authorities. While the rich buy bottled water or install water filters in their homes, the poor have no such means.-NAGARA GOPAL

IT should come as no surprise that we are an unhealthy society. There are typically three variables that directly affect general conditions of health among the people in a society: nutrition, sanitation, and the quantity and quality of government expenditure on health. In all of these, India performs miserably in relation to other countries in the world and in terms of the slow progress in these indicators in a period of relatively high GDP (gross domestic product) growth. And so we condemn a large part of our population to poor living conditions, high rates of recognised and unrecognised morbidity, and high susceptibility to a wide and growing range of infectious diseases.

Consider the figures: Out of the 175 countries ranked by the World Health Organisation (WHO), India is fifth from the bottom (or 171) in terms of public health spending as a proportion of GDP. It is, therefore, significantly below almost all sub-Saharan countries and other least developed countries that have much lower per capita incomes. Public health spending accounts for only 0.9 per cent of the GDP or even less.

Private spending (out-of-pocket expenditure by households), therefore, has necessarily to make up the rest and is as much as 85 per cent of the total health spending in the country. This does not only reflect the luxury health spending of the elite even poor households are forced to undergo such spending because of the paucity of public provision. In fact, sudden health expenditures are estimated to be among the main factors that push households into poverty.

The United Progressive Alliance (UPA) government promised in 2004 to increase public health spending up to 3 per cent of the GDP. This is a relatively modest target: after all, China spends nearly 6 per cent of its GDP on public health and is planning to increase this further in the next two years. But even this unambitious goal is nowhere near being met as State governments continue to shoulder the burden of most health expenditure despite their own serious budget constraints. The share of the Central government even in total public spending on health is very low and has stagnated since 2007.

In fact, the actual spending of the UPA government thus far belies its brave promises. In the budgetary allocation for the current year, the share of expenditure on Medical and Public Health is slated to remain unchanged from the previous year, at only 0.12 per cent of the GDP. In Family Welfare, the share of expenditure is to increase from 0.11 per cent of the GDP in 2008-09 to 0.12 per cent in 2009-10, which is no more than the proportion that was already attained in 2007-08.

This is why the attempt within the government health system is to do things on the cheap. Primary health centres and sub-centres do not have adequate equipment or medicines. Government hospitals have huge shortages of beds and basic facilities and increasingly make individual patients pay for extras such as medicines and operation room accessories. Overcrowding and overworked staff are the norm in all public health facilities.

The latest attempt at cost-cutting is through the simple expedient of lower wages for public health personnel and even unpaid work. Thus, the National Rural Health Mission (NRHS) seeks to transform the health conditions of rural India on the basis of the work of originally unpaid ASHAs (Accredited Social Health Activists) who are now given the princely sum of Rs.500 by the Central government.

It is not surprising, therefore, that our health outcome indicators are embarrassingly dreadful. The latest National Family Health Survey (conducted in 2005-06) provides grim evidence of very slow (even decelerating) improvement in infant mortality rates, persistently poor rates of child immunisation, low rates of institutional deliveries and other indicators. Shocking nutrition indicators, poor conditions of sanitation, and environmental degradation and pollution add to the overall factors determining public health outcomes.

How has this appalling situation come about? After all, India is apparently a vibrant democracy in which the media and public pressure ought to be forcing much more government attention and resources to basic matters such as public health. Yet both the absolute levels and the pattern of change on this front are truly awful. The reasons for this have much to do with the political economy of health in India.

For a while now, the notion of the public has gradually receded from the consciousness of the elite in India. Not only are private solutions found for most conditions, but even the very idea that there are still spaces (and indeed, places) that are universally accessible and have universal impact is barely recognised any more. It is true that the ruling classes are still affected by some of the most obviously public goods, such as road infrastructure. This is why the most common-middle class complaints in urban India relate to the state of the roads, since this is one area where they cannot simply opt out by accessing their own exclusive roads.

But for many other goods with high externalities, the rich in India have found ways of avoiding, bypassing or simply transcending the need to respond to external conditions or access public services.

tmospheric pollution, for example, has become the problem of the poor. Increasingly, those who can afford it travel in air-conditioned vehicles and live and work in equally protected environments, and go for walks in parks of colonies where there are no polluting units.

Similarly, safe drinking water is no longer considered something that must be provided by the civic authorities. Instead, the rich buy commercially bottled water or install special water filters in their homes and offices, while the poor have to make do as best they can with the inadequate and mostly polluted water available in public taps or through tube wells.

Another result of this process is that 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 either to avail themselves of overcrowded public facilities or to access 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. So, among the rich in India, there is now little recognition that the health conditions of a community affect each member of it, that there must therefore be cooperative and communitarian solutions to health problems and common approaches to dealing with the basic conditions affecting health.

It takes something like an epidemic, which affects the rich and poor alike, to bring home to this countrys elite the essential publicness of health. The peculiarity of the current swine flu epidemic it seems to disproportionately affect the upper-income groups as opposed to other diseases that are much more widespread among lower-income groups has led to it dominating the headlines, especially in the English language media. No matter that swine flu still kills far fewer people every day than tuberculosis, which is rampant. No matter that the rate of mortality is still lower for the A(H1N1) virus than it is for the other more common form of influenza.

But if the hysteria being bred by the media with respect to swine flu actually succeeds in creating increased public pressure for a better health care system and more public spending on health, even this ill wind would have blown in some good.