India?s ailing public health services

The Eleventh Plan approach paper correctly notes that rural health care in most states in India is marked by absenteeism of doctors/health providers, low levels of skills, shortage of medicines, inadequate supervision/monitoring and callous attitudes. There are neither rewa-rds for service providers, nor punishments to defaulters. As a result, health outcomes in India are worse than neighbouring countries like Sri Lanka and Southeast Asian countries like China and Vietnam.

The failure of the health system is leading to a visible decline in outcomes. Immunisation rates in India were already low by international comparisons, worse than even those for countries like Bangladesh and Cambodia. A recent report shows that immunisation of children in India declined sharply from an already low 52% in 1998-99 to 44.6% in 2002-03. The two rounds of household surveys on the state of maternal and child health care, conducted by the Reprod-uctive and Child Health Programme of the World Bank, show serious failures in public health services in India. Out of 274 districts, child immunisation declined in 197 districts. Routine polio, DPT and measles vaccination declined in 191, 199 and 153 districts, respectively.

The data on antenatal care and assisted deliveries is appalling. Though the proportion of deliveries assisted by health workers went up from 39.6% in 1998-99 to 47.5% in 2002-03, the percentage of women delivering in public health facilities declined from 24% to 18.5%. The increase took place in deliveries in the private sector, where they rose steeply from 9.4% to 21.5%.

Ironically, women in ?better placed states?, which presumably have better access to public health facilities, are using these less. In Andhra Pradesh, the percentage of women delivering in public institutions declined by 9.8%, in Kerala by 28.9%, in Karnataka by 10.2%, in Maharashtra by 9.1% and in Tamil Nadu by 15.3%. Further, the number of women who received post-natal care by public health workers through home visits within two weeks of delivery also declined from 14.1% to 12.7%.

The maternal mortality rate in India?407 deaths per 100,000 live births? compared with 56 in China and 46 in Sri Lanka. There may be many factors that explain the evidence thrown up by the RCH report, such as literacy and empowerment of women. But, as recent studies on the health sector in India have shown, the biggest issue is job security of the health staff, which leads to a lack of interest in doing work for patients.

The Plan document notes that there is a shortage of health staff. But does hiring more public sector health workers contribute towards a more healthy population? A study in Udaipur titled, Wealth, health and health service in rural Rajasthan, by Banerjee, Deaton and Duflo, conducted between January 2002 and August 2003, shows high absenteeism by public health workers. Nearly 45% of medical personnel are absent in subcentres and aid posts. And 36% are absent in the (larger) primary health and community health centres.

An absent nurse meant that the subcentre had to be closed, because sub-centres are often staffed only by a nurse. Hence, sub-centres were closed 56% of the time during regular hours. Sub-centres were open not merely infrequently, but also unpredictably. Patients, thus, often choose not to walk the approximate half-an-hour from the average village to the closest public health centre.

The consequence is predictable. As the Planning Commission?s mid-term appraisal of the Tenth Plan observes, ?when people first seek treatment, an estimated 70-85% visit a private sector provider for their health care needs.? However, as the appraisal says, ?the poor avail of the costlier services provided by the private practitioner, even when they have access to subsidised or free public health care, due to reasons of distance, but most importantly, on account of the unpredictable availability and very low quality of health care services provided by the rural public primary health sector.?

The 11th Plan approach paper suggests that the way out may be to empower panchayati raj institutions to manage, administer and be accountable for health services in community levels. The success of this strategy may hinge on whether health workers continue to have permanent government jobs, or get paid by the health care they provide and patients they see.