In a critical condition

With the public health system in a shambles and private hospitals beyond their reach, basic health care proves to be a luxury for a majority of Indians.

UNION Minister for Health and Family Welfare Dr. Anbumani Ramadoss has his task cut out. Basic health indicators in the country are far from encouraging. The infant mortality rate is 68 per thousand live births every year. The rate of decline in infant mortality has slowed down in the last decade. About 130,000 mothers die during child birth every year. The maternal mortality rate has increased from 424 maternal per 100,000 live births to 540 maternal deaths per 100,000 live births. Social and environmental dislocation along with a weakening public health care system has led to a resurgence of communicable diseases such as malaria, dengue, encephalitis and kala azar. According to the latest National Family Health Survey, half of all Indian children are undernourished and half of all adult women suffer from anaemia.

Government expenditure on public health care has declined sharply since the beginning of `reforms' and structural adjustment in 1991. Only 17 per cent of all health care expenditure in India is borne by the government, making it one of the most privatised health care systems in the world. The capital expenditure in the health budget of the Central government has declined from Rs.45.09 crores in 1996-97 to just Rs.7.3 crores in 2001-02. The current annual per capita expenditure on public health care is only Rs.160. Since health is a State subject under the Constitutional framework, States are expected to contribute to a major part of the finances allocated to the health sector. But the budgetary allocation of States for health has declined form 7 per cent to 5.5. per cent in the period between 1990 and 1999. The Central government's contribution to public health investment in the country is only 15 per cent. The National Health Policy, 2002, suggests that this be increased to 25 per cent by 2010.

Dr. Mira Shiva, Director of Women's Health and Development and Rational Drug Policy of the Voluntary Health Association of India and founder-member of the People's Health Movement said: "The health budget has to be looked at as an investment in people's health and should be used to address the morbidity and mortality pattern of the country. It is unforgivable that even today six lakh children a year should die of diarrhoea when it can be prevented by safe drinking water and sanitation and by the timely administration of oral rehydration solutions."

The government will have to look carefully at how resources have been allocated within the existing budget. Dr. C. Sathyamala, epidemiologist and member of the Medico Friends Circle added: "The Tenth Five Year Plan has allocated most of its funds towards programmes dealing with contraception and the Pulse Polio Programme. What is the point in asking for an increase in the budget if the government does not look at where the resources are going?"

Increasingly, community and public health care experts in the country have begun to point out that vertical programmes such as the pulse polio and tuberculosis (directly observed treatment - short course) vaccination programmes have been given too much emphasis. "Vaccination is looked at as a solution instead of improving nutrition, safe drinking water and sanitation, which will automatically raise resistance levels to diseases. The focus on vaccines has meant that routine health services and basic health facilities have suffered," says Dr. Ravi D'Souza, consultant in community health. The previous government paid no attention to the Supreme Court's order of November 2001, asking to provide for a functioning anganwadi in every `settlement'.

The Common Minimum Programme (CMP) of the United Progressive Alliance (UPA) says that public expenditure on health care will be increased from the current 0.9 per cent to 2 to 3 per cent of the gross domestic product (GDP) over the next five years, which is far below the 5 per cent recommended by the World Health Organisation (WHO). The CMP says that a `national cooked nutritious mid-day meal scheme' will be introduced in primary and secondary schools. The UPA will also universalise the Integrated Child Development Services (ICDS) scheme to provide a functional anganwadi in every settlement and ensure full coverage for all children.

THE privatisation of health care has accelerated since 1991 with the unprecedented expansion of the private medical sector, the entry of private insurance in health care and the introduction of payment for medical services or "user fees" in the government sector. The last decade has seen the country move towards a dual system of health care - a high technology-based medical service on a par with what is available internationally to cater to the elite from India and abroad, while for the poor, the government is obliged to provide a minimal clinical package as suggested by the World Bank Report in 1993.

According to Dr. Sathyamala, while the proclaimed objective of user fees is to generate resources for the public sector, it has resulted in people being weaned away from public to private hospitals as people do not want to settle for what appears to be `second best' if money has to be paid in both cases. It has also meant that a large number of people are not seeking help from anyone. This has led to a paradoxical situation where the standard of medical care in public hospitals is degenerating even as user fees are introduced as a source of income.

The National Health Policy (NHP) of 2002 omits the concept of comprehensive and universal health care, thus departing from the National Health Policy of 1983 and India's obligation under the Alma Ata Declaration on Primary Health Care of 1978. Instead the NHP makes out a case for privatisation of existing public hospitals, creating new private hospitals and abdicating the government's responsibility to non-governmental organisations (NGO).

The Jana Swasthya Abhiyan, a national network of organisations that work in the area of health, organised a meeting with parliamentarians just before the elections to the Lok Sabha. The policy document that was released at this meeting, points out clearly that the health care system has been weakened by the policies of successive governments since 1991. The document points out that the proportion of those who are unable to afford health care has increased from 10 to 21 per cent in urban areas and 15 to 24 per cent in rural areas in the past decade. Forty per cent of those who are hospitalised are forced to borrow money or sell their assets to pay for the expenses resulting in two crore people being pushed below the poverty line every year, the report says. Only 38 per cent of all Public Health Centres (PHC) have all the critical staff. Health facility surveys conducted by the International Institute of Population Sciences(Mumbai) show that only 69 per cent of PHCs have at least one bed and 20 per cent have a telephone.

THE government needs to re-examine the current drug pricing policy. Most countries have some form of price controls to make sure that essential drugs are available to the public at an affordable rate. In India this is done through the Drug Price Control Order (DPCO). The number of drugs that are under price control have come down from 347 in the 1979 DPCO to the current 74. The National Pharmaceutical Policy of 2002 suggests that this be further reduced to 34. Dr. Anurag Bhargav, who is involved with this issue, said: "The pharmaceutical companies' logic that the market will act as a regulator of prices is a myth. Though Indian drugs are touted as the cheapest in the world; they are overpriced and unaffordable. In the pharmaceutical industry, it is the doctor who makes the choice for the consumer and the consumer has no easy way of evaluating the doctor's prescriptions. Both the assumptions of a free market and that of competition reducing prices are contestable."

The criteria for drug price control in the Pharmaceutical Policy of 2002 have been challenged in court by LOCOST, which is a non-profit trust that produces generic drugs at low prices; the Jana Swasthya Sahyog; the All India Drug Action Network and the Medico Friends Circle. Anurag Bhargav adds: "The criteria of the Pharmaceutical Policy 2002 have little to do with how essential the drugs are, the therapeutic importance of the drug or its importance in national programmes. As a result drugs that have escaped price control are overpriced and the monitoring agency of the government, the National Pharmaceutical Pricing Authority (NPPA) has no transparent methodology to identify and monitor drugs that need to be put under price control."

Spurious drugs are a major concern that the government has to tackle. The previous government, alarmed by the growing market for fake medicines in the country, set up the Mashelkar Committee to look at the various aspects of the menace. The committee found existing laws were too soft and called for death penalty for makers and stiff punishment for sellers of spurious medicines that could cause death or serious suffering. At the moment the issue is governed by the Drugs and Cosmetics Act, 1940, which provides for stringent punishment to those manufacturing, promoting and selling fake and substandard drugs. The Mashelkar Committee Report observes that the Drug Control Authority under the Health Ministry, which is the appropriate body for dealing with this issue, has not used the existing provisions effectively. The committee has recommended that a single drug administration authority must be set up to monitor the segment.

The CMP says that the government will `provide leadership to national Acquired Immune Deficiency Syndrome (AIDS) control efforts'. Previous governments have not integrated their responses to the Human Immunodeficiency Virus /AIDS problem within the public health care system in the country. According to National AIDS Control Organisation (NACO) estimates, there were 3.97 million people living with HIV/AIDS in the country at the end of 2001. Most HIV/AIDS initiatives are funded by international agencies which have the resources but in return exercise control over the HIV/AIDS discourse in the country.

Says Vivek Diwan from the Lawyers Collective HIV/AIDS Unit: "Though the common perception is that there is a lot of money for HIV/AIDS, the fact is that the government spends a very small amount on addressing HIV/AIDS. The government needs to invest in surveillance mechanisms so that it is possible to estimate accurate numbers of people who are HIV positive. People have to be encouraged to test themselves by making sure there are enough voluntary testing and counselling centres (VTCTs) that have qualified counsellors who are adequately paid. There must be a genuine attempt to understand people who are affected the most, such as sex workers and homosexuals and to remove legal barriers that make it impossible to deal with the epidemic."

Till recently, the Indian government did not support ARV (anti-retroviral) treatment because of its prohibitive cost. Previous Health Minister Sushma Swaraj initiated a programme by which ARVs were provided free to one lakh HIV/AIDS patients in six States. It was launched in April this year but there are questions about where the money to sustain it is going to come from. The government is hoping that Indian pharmaceutical companies like Cipla, Ranbaxy, Hetero and Matrix will continue to provide ARVs at a lower cost to the government. But this may not be possible when the Third Patents (Amendment) Act that will bring patent law in India in compliance with the Trade Related Aspects of Intellectual Property Rights (TRIPS) comes into force. Akshay Khanna, a lawyer who has dealt with HIV/AIDS issues and is a student of medical anthropology, said: "The government has to explore options on how to use the Doha Declaration to continue to produce cheaper drugs. The government also needs to look at the possibility of using the `public non-commercial use' exception in TRIPS to enable public sector pharmaceutical companies to produce ARVs."

The previous government had initiated an effort to draft a law on HIV/AIDS, which is still at the stage of consultations. The Health Ministry and NACO had engaged the Lawyers Collective's HIV/AIDS unit to draft the law and has been trying to engage as many stakeholders as possible. According to Vivek Diwan: "The draft is expected to be ready by August. Its emphasis will be on anti-discrimination and will cover the privates sector too. It will address issues of informed consent and confidentiality." The challenge before the Health Ministry is to continue its efforts to make the drafting process as consultative as possible.