Against the background of these inter-state and inter-regional differences, there are six points that need to be made. First, even among the poor, and especially in urban areas, there is a de facto privatisation of health services that is going on, except that because it is de facto rather than de jure, it functions in the absence of any satisfactory and comprehensive regulation. Second, in rural areas, public sector delivery is often the main recourse even now. Third, it is no longer the case, unlike in the 1950s, that physical access is the problem. For example, primary health centres ostensibly exist. Fourth, efficiency of public sector health expenditure is the key constraint and this is particularly acute in the backward states and regions, highlighting a general governance problem. A recent World Bank report states, Since the pioneering PROBE report on education in five Northern states raised the issue of teachers widespread absence and lack of attention to classroom activity, these findings have been replicated nationwide, extended to health, and confirmed over time. things were even worse in the health sector, as on average 40 per cent of health workers were absent altogether. One recent study in Rajasthan went further and carried out a continuous facility survey in which each of 143 public facilities was visited weekly during regular hours for an entire year. This study replicated the basics of previous findingsfinding 45 per cent of doctors absent from Primary Health Centersbut also found that at sub-centers and aid posts, the doors were closed 56 per cent of the time (and field visits do not account for this, as only 45 percent of the time could the researcher find the health worker in the village). Worse, the patterns of absences and facility closures were essentially unpredictable, so people could not even count on facilities being open on certain days or at certain times.
Fifth, there is the associated problem of corruption in public service health delivery. Contrary to what one might a priori assume, a study by Transparency International found that 27% of petty and retail corruption is due to the health sector, more than the police, taxation and land administration. Sixth, the demographic dividend, in terms of additions to the labour force and declines in dependency ratios, is going to occur in these backward regions and States. Since India doesnt perform that well on the health indicators, the demographic dividend can very easily turn into a demographic deficit. And the policy question remains. What can possibly be done to prevent this from happening
There is a large health infrastructure and there are several government programmes, with or without the involvement of the voluntary and private sectors. The National Health Policy (1983), the Drug Policy (1986), the National Nutrition Policy (1993), the National Population Policy (2000), the Revised National Health Policy (2002), the Policy on Indian Systems of Medicine (2002), the Pharmaceutical Policy (2002) and universal health insurance schemes for the poor (2003), all have something to do with health, directly or indirectly. A quote from the National Common Minimum Programme (NCMP), which drives many of the policies of the present government, is relevant. The UPA government will raise public spending on health to at least 2-3% of GDP over the next five years with focus on primary health care. A national scheme for health insurance for poor families will be introduced. The UPA will step up public investment in programmes to control all communicable diseases and also provide leadership to the national AIDS control effort. The UPA government will take all steps to ensure availability of life-savings drugs at reasonable prices. Special attention will be paid to the poorer sections in the matter of health care. The feasibility of reviving public sector units set up for the manufacture of critical bulk drugs will be re-examined so as to bring down and keep a check on prices of drugs.
Having diagnosed the nature of the problem, how does one resolve it If one uses the National Health Policy (2002) to track what the policy intentions are, one arrives at something like the following agenda. (1) Increase public expenditure on health from 0.9% to 2% by 2010; (2) Allocate public health investment in the ratio of 55% for the primary health sector, 35% for the secondary sector and 10% for the tertiary sector; (3) Barring TB, malaria and HIV/AIDS, converge all health programmes under a single administration; (4) For those who can afford to pay, levy user charges for some secondary and tertiary public health services; (4) Impose a mandatory two-year rural posting before awarding graduate medical degrees; (5) Implement health programmes through institutions of local self-government; (6) Set up a Medical Grants Commission to fund new government medical and dental colleges; (7) Increase post-graduate seats in public health and family medicine; (8) Establish a two-tier urban health-care system through a Primary Health Centre (PHC) for population sizes of 100,000 and a public general hospital for larger populations; (9) Increase government-funded health research to 2% of total health expenditure; (10) Allow private sector entry, with legislation to regulate private clinical establishments; (11) Formulate procedures for accreditation of public and private health facilities; (12) Co-opt NGOs in national disease control programmes; (13) Promote tele-medicine; (14) Operationalise a National Disease Surveillance Network; (15) Notify a code of medical ethics through the Medical Council of India; (16) Promote medical services for overseas users; (17) Encourage and promote Indian systems of medicine; and (18) Encourage private sector entry in medical insurance.
Per se, there is little that is objectionable in this agenda. However, a key question remains. Indias reforms have been driven by objectives of choice, competition and efficiency. Where is the emphasis on choice and competition in all this
The author is a noted economist