Far from healthy

In a remote village in Chhattisgarhs Bilaspur district, children wait for food under the midday meal scheme. A file picture.-V.V. KRISHNAN

THE 25 years since the launch of Frontline have been an eventful period in the life of the Indian republic. As the 60th year of the republic approaches, it is only appropriate that we reflect collectively on where we are along many of the key dimensions of development and how far we have progressed in the journey of independent India that began more than 60 years ago. To its credit, Frontline has pursued consistently this theme of the well-being of the nation and its people in all aspects throughout the period since it began its journey. Over a period when Indian print journalism in the English language did not generally distinguish itself by concerning itself seriously with the lives of the people and the state of the republic, Frontline has been a significant exception. On the issue of the health of alone, I found on a search of the back issues of Frontline a surprisingly large number of articles of import.

Since about 1980, the Indian economy has grown, in terms of its gross domestic product (GDP), at over 6 per cent per annum compound, as against an average for the period 1950 to 1980 of around 3 to 3.5 per cent. More recently, between 2003-04 and 2007-08, the rate of growth of Indias GDP even breached the 8 per cent barrier, giving rise to breathless celebrations in sections of the media about India being rapidly on its way to being a superpower or at the very least an economic powerhouse.

While the current global economic crisis has led to some muting of the rhetoric, it is important not to lose sight of some basic and disturbing features of our track record of development even through these years of rapid GDP growth.

The scale of mass deprivation remains immense despite years of high growth and has even worsened in some respects. Perhaps the most disturbing aspect of the nature of Indias development over the past two decades, especially since the start of neoliberal economic reforms in 1991, has been a rise in inequality in all indicators of development and well-being. We shall focus here on one key feature of this record, namely the dismal state of health and nutrition of the mass of the Indian population.

Since Independence, India has made significant progress in many fields, and these include some of the key indicators of health. Thus, the infant mortality rate (IMR), defined as the number of infants dying before reaching the age of one year per 1,000 live births, a key and sensitive indicator of the state of health in any society, declined from around 150 at the end of colonial rule (a grim reminder of how terrible the colonial dispensation was) to 53 for the year 2008. Similarly, the expectation of life at birth was 32 years at the time of India attaining Independence, but was close to a little over 63 years for the period 2002-06.

India has built up, over the decades, a large infrastructure in terms of health facilities in the public sector. Thus, as of March 2008, there were 1,46,036 health subcentres (HSCs) and 23,458 primary health centres (PHCs) as against 84,376 and 9,115 respectively at the end of the sixth Five-Year Plan in March 1985. Similarly, the number of community health centres (CHCs) rose over the same period from 761 to 4,276. There were 1,813 first referral units (FRUs) district and sub-district hospitals as of March 2008.

There has also been progress in immunisation of children and pregnant mothers and in provision of ante-natal care as compared with the situation at the time of Independence though in recent years, under the neoliberal regime, there have been some setbacks. Indias record in areas such as control of malaria has been rather mixed, though, and the recent resurgence of infectious diseases across the developing world has found the country relatively unprepared.

It would be fair to say, however, that the progress in the public provision of health as well as the health status of the citizens has been extremely modest. On the eve of Independence, the Bhore Committee made a comprehensive set of recommendations for a health policy with a clear focus on public health and rooted in the emphasis on preventive care. Over the years, India has consistently failed to implement those recommendations though official rhetoric continued to pay lip service to the crucial importance of public health and preventive medicine.

Even as late as 1983, the National Health Policy document echoed many of the Bhore Committee recommendations and its rhetoric was consistent with the famous Alma Ata declaration of 1978 of Health for All by 2000. A few years earlier, the Jaisukhlal Hathi Committee had called for a rational drug policy and price control on a large number of drugs and pharmaceuticals to prevent profiteering by multinational drug companies and ensure affordable prices of essential drugs for common people. The Indian Patents Act, which was passed in 1970, provided space for the growth of the Indian pharmaceutical industry by ensuring that patenting did not lead to the monopoly of transnational pharmaceutical giants in the market for drugs and chemicals.

But by the mid-1980s, with the promulgation of the New Economic Policy and the New Drug Policy by the Rajiv Gandhi government (along with several other New policies announced for education, textiles, and so on), the course of even the rhetoric of policy changed. By 1991, when the economic reform policies of liberalisation, privatisation and globalisation (LPG policies, as they are popularly known) were accelerated under the tutelage of the World Bank and the International Monetary Fund (IMF), the nation was set on a course entirely different from what had originally been envisaged. It would no longer be the case that the government was obliged to ensure the health of the citizens. Instead, health was to become a commodity like any other, and its provision was to be determined increasingly by market forces.

Over the period of reforms, public provision of health care and health services has been undermined both at the level of practice and at the level of ideology and policy. Provision of health through public sector institutions has been impacted negatively by budgetary cuts driven by the presumed need to rein in the fiscal deficit. The State governments, which bear the main burden of public provision, have been hamstrung by a fiscal regime that increasingly deprives them of access to adequate resources. Besides, most of them have also happily gone along with the neoliberal policy regime. The corporate private sector in health care has boomed, even as India is being sold as a favourite destination for medical tourism. With increasing commercialisation of health care, the access of ordinary people to health care has become more difficult. The weakening of the public health system has left the country very poorly equipped to handle public health emergencies.

It is a well-known scandal that India is practically at the bottom of a list of more than 170 countries in terms of the proportion of total health expenditure that is financed by government. Public spending on health in India was around 1.05 per cent of the GDP during the mid-1980s and is currently at 1.35 to 1.4 per cent of the GDP. The commitment given in the Common Minimum Programme (CMP) of the United Progressive Alliance (UPA) government in 2004 that the total expenditure on health by the Centre and State governments combined would be raised to between 2 and 3 per cent has remained unfulfilled. While there is a substantial rise in the outlay on health and family welfare in the 11th Plan to Rs.1,40,135 crore from Rs.58,920 crore in the 10th Plan, it still remains way below the levels required to meet the CMP commitment. Now that the second UPA dispensation is not dependent on the support of the Left parties for its survival, the prospect of a rise in government expenditure to the levels promised in the CMP in 2004 seems bleak.

While government spending on health remained at about 1 per cent of the GDP in 2001-02, the total of health and health-related expenditures amounted to 5.2 per cent of the GDP at factor cost. The share of the government in total health expenditure has been less than one-fifth. What is worse is that the reform policies have led to greater commercialisation of health, and health costs have risen rapidly. Since the mid-1990s, household health expenditure has risen at 14 per cent per annum. A conservative estimate of the rise in the poverty ratio on account of rising health expenditures of households, even when calculated using the disputed official methodology, is around 3.6 percentage points for rural areas and 2.9 percentage points in urban areas.{+1} It is also known that rising health and education costs have forced poor households to cut back expenditure on food to meet these costs, something that could worsen an already scandalous nutrition situation.

There are, of course, large inter-State variations in the public and private provision of health care services and in health outcomes. For instance, at one end we have a State like Kerala with an IMR of 12 (urban 10, rural 12) and at the other Madhya Pradesh with an IMR of 70 (urban 48, rural 75). Policy needs to address these disparities, with a far greater focus on the poorly performing States. However, it needs to be emphasised that health and nutrition outcomes across the country have worsened during the reform period. This is shown dramatically by the data on nutritional outcomes from the National Family Health Surveys (NFHS). The third of these surveys, relating to 2005-06, after more than a decade of neoliberal reforms, tells us that in urban India between 1998-99 and 2005-06

the percentage of women with anaemia rose from 45.7 per cent to 50.9 per cent;

the percentage of women with chronic energy deficiency (CED) rose from 22.1 per cent to 25 per cent; and

the percentage of children in the age group of 6 to 36 months who are stunted rose from 35.6 per cent to 39.6 per cent.

The situation in rural areas is equally alarming, though it shows some improvement between 1998-99 and 2005-06 in respect of both child stunting and women with CED. The percentage of women with CED declined marginally from 40.6 per cent to 38.8 per cent for India as a whole, while that of children stunted declined substantially from 48.5 per cent to 40.7 per cent, but still an unconscionably high level. However, the percentage of women with anaemia in rural India actually increased between 1998-99 and 2005-06 from 53.9 per cent to 58.2 per cent.

The dismal health and nutrition situation, implying a poor state of food and nutrition security in both rural and urban India, needs to be addressed on a war footing. But one finds little sense of urgency on the part of a government firmly anchored in a neoliberal mindset to address Indias permanent state of nutritional emergency even after more than two decades of a compound annual growth rate of GDP exceeding 6 per cent. Instead, a completely unregulated, commercial private sector in health is allowed to run riot, even hijacking medical education in the process and playing with the lives of millions of poor people.

The slogan of public-private partnership, in most instances a euphemism for partnership for private profit, has become the mantra of the government to implement all programmes. The enormous mess in urban health, on top of a dismal rural health care situation, cries for urgent attention, but unless health is seen and provided as a basic human right little will change. That does not seem to be on the agenda of the government, now or in the foreseeable future.

While it is true that the issue is not merely one of enhancing outlays but also one of improving health delivery systems to obtain desired health outcomes, outlays constitute the basic prerequisite. A government that is able to provide a largesse of nearly Rs.5 lakh crore per annum over the past two years to the corporate sector in the name of fiscal stimulus has no excuse for not raising health funding to the levels required to address the countrys health crisis. Where there is a will, there is a way. But there is no will.