Whose Business Is Public Health Anyway

Updated: Apr 30 2004, 05:30am hrs
In Muzaffarpur district of Bihar, a 54-year-old woman, who has been operated for cataract, is resting with one eye bandaged in a corner of a small room at a local hospital. At the other end of the same room, a buffalo rests on a pile of hay. Aseptic hospital conditions are hardly known here, as water from the bathrooms fills the length of the corridor. Move through government-run hospitals in Uttar Pradesh, Rajasthan, Orissa, Madhya Pradesh and the picture might only be a shade different.

The reality is that even though India is nearing the completion of the fifth decade of its Independence and is emerging as an economic power, public health continues to be at the lower rung of the countrys priority ladder. With barely 0.9 per cent of gross domestic product (GDP) going into the sector, there is little evidence that the impact of investing in health for economic and social development is realised fully. The goal of Health for All by 2000 has long been forgotten. In over 50 years of Independence, Indias public health institutions have crumbled. People have stopped questioning the states responsibility in providing even basic health services as they desperately turn to the unregulated private sector.

So, when those who have an in-depth knowledge of the health system, lay bare all its inadequacies, it draws total attention. The India Health Report, authored by former Union health secretary, Rajiv Misra, along with principal secretary to the Andhra Pradesh government, Sujatha Rao, and health secretary to Andhra Pradesh, Rachel Chatterjee, makes absorbing reading as one goes page after page lifting the veil off the Indian health sector. The report is particularly significant as planners willingness to discuss these issues threadbare could itself portend change.

Indeed, the objective of the report was to examine the various challenges and suggest reforms in the sector. A beginning was made with the commission on macroeconomics and health set up by the World Health Organisation to assess the importance of investing in health to promote economic development and reduce poverty in the Third World. The Indian Council for Research on International Economic Relations (ICRIER), which undertook to study various aspects of healthcare in India, commissioned several background papers in consultation with the World Bank, WHO, UNDP, UNICEF, UNAIDS and representatives of major pharmaceutical companies in India, researchers and NGOs active in health-related fields and public health care experts. The report presents some of the key results of these studies.

But the report itself is more than a set of papers put together by experts as it analyses issues and comes up with a set of far-reaching reforms for the sector. The knowledge of the authors throws light on some lesser-known aspects of the functioning of the sector, even to a more informed reader.

With barely 0.9% of GDP going into the sector, there is little evidence that the impact of investing in health for economic and social development is realised fully
For instance, an appendix by Misra calling for a serious restructuring of the Union health and family ministry minces no words in conveying the chaotic functioning of the present structure. In a castigation of the system, Misra points out that a ministry of three secretaries, two additional secretaries, eight joint secretaries and 30 officers of the rank of director, excluding technical advisors, the cost of administration alone is Rs 14 crore a year. He points out that the ministry currently commands a budget of Rs 6,000 crore, of which Rs 3,400 crore goes into the maintenance of institutions and Rs 1,600 crore on the expansion of national programmes and centrally-sponsored schemes.

It would not be an exaggeration to say that the main preoccupation of the ministry is managing itself rather than providing stewardship to the national health system, says Misra. The responsibility of the government is one line that the authors, quite refreshingly, do not let go off. And it is made clear that this is not even a debatable issue. If the state exists to safeguard the right of its citizens to the fundamental prerequisites of survival, it must also own up its responsibility to protect them from illness and premature mortality, they point out. This sets the tone for the book, as it goes on to discuss various issues, such as poverty and the inequities, the changing burden of disease, HIV/AIDS, maternal survival, private and public health care, health finance, external assistance to the sector, drug policy as also the Indian systems of medicine.

Commenting on the growth of the unregulated private sector, it again looks at the responsibility of the government. Not only has it (the state) failed to provide health care to the majority of its population through the public sector, it has also countenanced a large and thriving private sector to grow practically without regulation. In the context of a public health system that does not deliver health services to those who need them, the private sector has grown to be the main provider of curative health care.

The 200-odd pages may contain, as expected, some amount of officialese, but it is still welcome, as it is perhaps the first comprehensive assessment of the Indian public health system. While making a case for reforms, the report puts forth the hard facts: the level of public investment will have to be more than doubled to reach the average of lower middle-income countries or 2.2 per cent of GDP. There are solutions. The authors suggest a 50 per cent increase, or roughly an additional Rs 2,000 crore can be made available, partly from the general revenue and partly from other programmes that have failed to make the desired impact.

The wide-ranging reforms would have no meaning in the absence of a strong leadership from the ministry of health and family welfare. Past experience has shown that the quality of leadership suffers because of the low profile of the ministry and the high turnover of ministers and secretaries. The ministry has often been used as a dumping ground for civil servants.

The report points this out as it guides the reader through what kind of reshaping the ministry requires. Earlier reports to this effect have been buried under the official heap. Authors of this report have dug out those recommendations, while adding their own. For instance, the Administrative Staff College, Hyderabad, had recommended that the ministry and the directorate-general health services be combined and regrouped into six programme divisions and two functional divisions. The Centre for Policy Research, a decade later, submitted another set of recommendations which emphasised decentralisation. It suggested integration of the three departments and converting CGHS into a fully autonomous organisation managed by its own board. The authors emphasise that the obvious need for the ministry is to shed most of its executive functions and to focus on policy making, planning and monitoring. Whether these reforms will ever be implemented is a subject of national debate. As of now, all those interested in development, economic growth, poverty reduction would do well to read this book.

India Health Report
Rajiv Misra, Sujatha Rao & Rachel Chatterjee
Oxford University Press
Rs 545, 320 pages