IN February 2007, the Directorate General of Health Services (DGHS) in the Union Ministry of Health and Family Welfare came up with a 62-page document that laid out a plan to implement what was termed as the Indian Public Health Standards (IPHS). Its focus was on the sub-health centre (sub-centre), which, in the public sector, is the first contact point between the primary health care system and the community.
One sub-centre is established for every 5,000 people in the plains and for every 3,000 people in hilly/tribal/desert areas. The note pointed out that the current level of functioning of the sub-centres is much below the expectations. It went on to add that no concerted effort has been made so far to prepare comprehensive standards for the sub-centres and that the launching of the National Rural Health Mission (NRHM) in 2005 had provided the opportunity to frame the IPHS.
Put simply, the IPHS sought to provide basic primary health care services to the community and achieve and maintain an acceptable standard of quality of care. The note admitted that currently the IPHS for sub-centres has been prepared keeping in view the resources available with respect to functional requirement for sub-centres with minimum standards, such as building, manpower, instruments and equipment, drugs and other facilities.
Had the programmes in the document been implemented with some measure of success, it would certainly have helped contain the epidemic-like situation the country is facing on account of the influenza A(H1N1) virus. The panic-laced responses right from the Union Minister of Health to various State Health Ministers and countless officials across the country underline the fact that the primary contact point between the health care system and the people has in no way become an instrument of resistance in the battle against the pandemic. And herein lies yet another stark symptom of the deficiencies of Indias public health infrastructure.
According to a grassroots-level health activist of Bihar, that successive governments have neglected the national health care system is clear from the fact that they have refused to enhance the public expenditure on health to between 2 and 3 per cent of the gross domestic product (GDP).
The launch of the NRHM with the proclaimed objective of improving access to quality health care, especially for villagers, the poor, women and children, was expected to change this. But the experience of the past five years, public health activists say, has been far from satisfactory. The first United Progressive Alliance governments tenure did result in the designation of a senior Health Department official as the Special Director General of Health Services (Public Health). The Director of the National Institute of Communicable Diseases held the office. Until then, that is, for over five and a half decades since Independence, there was no special senior officer to take care of the Public Health Department in the Ministry of Health and Family Welfare.
But there is nothing surprising in this apathy. In 2004, just before the Lok Sabha elections that year, Jan Swasthya Abhiyan (Peoples Health Movement), an association of over 1,000 organisations working in health care and policy, organised a public dialogue with the representatives of political parties on the health scene in the country to discuss specific political initiatives in health care, including steps aimed at making health a fundamental right and increasing the budgetary allocation for public health.
Nearly 300 people and a clutch of party representatives attended the meeting. Representatives of the Congress and the Bharatiya Janata Party (BJP), the leader of the then ruling alliance, were conspicuous by their absence. The Communist Party of India (CPI) deputed its general secretary, A.B. Bardhan, for the meeting and the Communist Party of India (Marxist), its senior leader Nilotpal Basu. The Samajwadi Party and the Lok Janshakthi Party were represented by their senior leaders.
Five years later, the Jan Swasthya Abhiyan came up with yet another pre-election initiative through the Peoples Health Manifesto (PHM). The PHM advocated the right to comprehensive, quality health care at public expense in relevant health institutions to all, where everyone is entitled to the full range of guaranteed, free health services. It stated that this right not only includes the right to timely and appropriate quality health care but also to the underlying socio-economic and environmental determinants of health.
The PHM also took up issues relating to food security, malnutrition, safe drinking water, sanitation and a regulatory framework to address health concerns arising out of the use of genetically modified seeds and the import of GM foods. Its demands covered 54 specific points with regard to the enhancement of public amenities as part of public health care, improvement of the NRHM, availability of drugs and medicines, and the addressing of issues of gender and health, and those relating to mental health, child health and nutrition. The PHM was released with an appeal to political parties to incorporate it in full or in part in their own respective agendas.
None of the political parties cared to adopt the PHM in full though many points raised by political parties got reflected in it. An assessment of the election manifestos of all the major parties the Congress, the BJP, the CPI(M) and the CPI by the Centre for Budget and Governance Accountability, a Delhi-based advocacy group, reveals that they do contain a commitment by all the parties to a comprehensive health programme ensuring health security for all.
The Congress highlights the NRHM as the primary means to work towards this objective. Its manifesto promised the upgradation of every district headquarters hospital to provide quality heath facilities. Significantly, the party saw a major role for private players, too, in the health sector, even in health insurance schemes. The partys preference for schemes such as the Rashtriya Swasthya Bima Yojana, which tends to promote private participation in the provisioning of health services in the form of health insurance, was obvious.
The BJPs thrust was on strengthening the Janani Suraksha Yojana to care for delivering mothers and infants. It also expressed the commitment to make the availability of clean drinking water a fundamental right and promised to launch a massive programme to provide clean drinking water to every citizen. The CPI and the CPI(M) advocated an increase in the budgetary allocations for the health sector, 3 per cent and 5 per cent of GDP respectively. The CPI(M) highlighted the need to ensure regular supply of essential medicines through the public health system and to bring all essential drugs under price control. Both the left parties declared their firm opposition to the privatisation of health insurance schemes.
Notwithstanding the commitments laid out in the manifestos, the track record of the State governments run by the mainstream parties in terms of public health care and development of public health infrastructure is far from exemplary. Some estimates say that Bihar has made use of the NRHM to revive the defunct health care system. Obviously, all these fall far short of expectations.
Dr Amit Sengupta of the Jan Swasthya Abhiyan says what is required is a thorough reorientation of priorities in the current health policies and their implementation with the premise of providing quality health care for all and access to basic determinants of health as a basic right. To do that, he stresses, health should be given priority as a national political issue. But given the track record of Indian political parties over the past six decades, such a transformation in priorities may be too much to expect.
