(Study Material for IPS LCE) Socio Economic Development in India: Health Care In India – Vision 2020 Issues and Prospects

Important Materials on Socio Economic Development in
India for IPS LCE Examination
Health Care In India – Vision 2020 Issues and Prospects

Courtesy: Ministry of Information
and Broadcasting publication division

Health Care In India – Vision 2020 Issues and Prospects

INTRODUCTION

Key Linkages in Health

Health and health care need to be distinguished from each
other for no better reason than that the former is often incorrectly seen as a
direct function of the latter. Heath is clearly not the mere absence of disease.
Good Health confers on a person or groups freedom from illness – and the ability
to realize one’s potential. Health is therefore best understood as the
indispensable basis for defining a person’s sense of well being. The health of
populations is a distinct key issue in public policy discourse in every mature
society often determining the deployment of huge society. They include its
cultural understanding of ill health and well-being, extent of socio-economic
disparities, reach of health services and quality and costs of care. and current
bio-mcdical understanding about health and illness.

Health care covers not merely medical care but also all
aspects pro preventive care too. Nor can it be limited to care rendered by or
financed out of public expenditure- within the government sector alone but must
include incentives and disincentives for self care and care paid for by private
citizens to get over ill health. Where, as in India, private out-of-pocket
expenditure dominates the cost financing health care, the effects are bound t be
regressive. Heath care at its essential core is widely recognized to be a public
good. Its demand and supply cannot therefore, be left to be regulated solely by
the invisible had of the market. Nor can it be established on considerations of
utility maximizing conduct alone.

What makes for a just health care system even as an ideal?
Four criteria could be suggested- First universal access, and access to an
adequate level, and access without excessive burden. Second fair distribution of
financial costs for access and fair distribution of burden in rationing care and
capacity and a constant search for improvement to a more just system. Third
training providers for competence empathy and accountability, pursuit of quality
care ad cost effective use of the results of relevant research. Last special
attention to vulnerable groups such a children, women, disabled and the aged.

Forecasting in Health Sector

In general predictions about future health – of individuals
and populations – can be notoriously uncertain. However all projections of
health care in India must in the end rest on the overall changes in its
political economy – on progress made in poverty mitigation (health care to the
poor) in reduction of inequalities (health inequalities affecting
access/quality’), in generation of employment /income streams (to facilitate
capacity to pay and to accept individual responsibility for one’s health ). in
public information and development communication (to promote preventive self
care and risk reduction by conducive life styles ) and in personal life style
changes (often directly resulting from social changes and global influences). Of
course it will also depend on progress in reducing mortality and the likely
disease load, efficient and fair delivery and financing systems in private and
public sectors and attention to vulnerable sections- family planning and
nutritional services and women’s empowerment and the confirmed interest of me
siat-e 10 ensure just health care to the Largest extent possible. To list them
is to recall that Indian planning had at its best attempted to capture this
synergistic approach within a democratic structure. It is another matter that it
is now remembered only for its mixed success.

Future of State Provided Health Care

Historically the Indian commitment to health development has
been guided by two principles-with three consequences. The first principle was
State responsibility for health care and the second (after independence) was
free medical care for all (and not merely to those unable to pay), The first set
of consequences was inadequate priority to public health, poor investment in
safe water and samtati on and to the neglect of the key role of personal hygiene
in good health, culminating in the persistence of diseases like Cholera.

The second set of consequences pertains to substantially
unrealized goals of NHP 1983 due to funding difficulties from compression of
public expenditures and from organizational inadequacies. The ambitious and far
reaching NPP – 2000 goals and strategies have however been formulated on that
edifice in the hope that the gaps and the inadequate would be removed by
purposeful action. Without being too defensive or critical about its past
failures, the rural health structure should be strengthened and funded and
managed efficiently in all States by 2005. This can trigger many dramatically
changes over the next twenty years in neglected aspects or rural health and of
vulnerable segments.

The third set of consequences appears to be the inability to
develop and integrate plural systems of medicine and the failure to assign
practical roles to the private sector and to assign public duties for private
professionals.

To set right these gaps demanded patient redefinition of the
state’s role keeping the focus on equity. But during the last decade there has
been an abrupt switch to market based governance styles and much influential
advocacy to reduce the state role in health in order to enforce overall
compression of public expenditure an reduce fiscal deficits. People have
therefore been forced to switch between weak and efficient public services and
expensive private provision or at the limit forego care entirely except in life
threatening situations, in such cases sliding into indebtedness. Health status
of any population is not only the record of mortality and its morbidity profile
but also a record of its resilience based on mutual solidarity and indigenous
traditions of self-care – assets normally invisible to he planner and the
professional. Such resilience can be enriched with the State retaining a
strategic directional role for the good health of all its citizens in accordance
with the constitutional mandate. Within such a framework alone can the private
sector be engaged as an additional instrument or a partner for achieving shared
public health outcomes. Similarly, in indigenous health systems must be promoted
to the extent possible to become another credible delivery mechanism in which
people have faith and away fond for the vat number of less than folly qualified
doctore in rural areas to get skills upgraded. Public programs in rural and poor
urban areas engaging indigenous practitioners and community volunteers can
prevent much seasonal and communicable disease using low cost traditional
knowledge and based on the balance between food, exercise medicine and moderate
living. Such an overall vision of the public role of the heterogenous private
sector must inform the course of future of state led health care in the country.

KEY ACHIEVEMENTS IN HEALTH

Our overall achievement in regard to longevity and other key
health indicators are impressive but in many respects uneven across States, The
two Data Annexure at the end indicate selected health demographic and economic
indicators and highlight the changes between 1951and 2001. In the past five
decades life expectancy has increased from 50 years to over 64 in 2000. IMR has
come down from 1476 to 7. Crude birth rates have dropped to 26.1 and death rates
to 8.7.

At this stage, a process understanding of longevity and child
health may be useful for understanding progress in future. Longevity, always a
key national goal, is not merely the reduction of deaths as a result of better
medical and rehabilitative care at old age. In fact without reasonable quality
of life in the extended years marked by self-confidence and absence of undue
dependency longevity may men only a display of technical skills. So quality of
life requires as much external bio-medical interventions as culture based
acceptance of inevitable decline in faculties without officious start at sixty
but run across life lived at alt ages in reduction of mortality among infants
through immunization and nutrition interventions and reduction of mortality
among young and middle aged adults, including adolescents getting inform about
sexuality reproduction and safe motherhood. At the same time, some segments will
remain always more vulnerable – such as women due to patriarchy and traditions
of infra-family denial), aged (whose survival but not always development will
increase with immunization) and the disabled (constituting a tenth of the
population).

Reduction in child mortality involves as much attention to
protecting children from infection as in ensuring nutrition and calls for a
holistic view of mother and child health services. The cluster of services
consisting of antenatal services, delivery care and post mortem attention and
low birth weight, childhood diarrhoea and ARI management are linked priorities.
Programme of immunization and childhood nutrition seen in better performing
stats indicate sustained attention to routine and complex investments into
growing children as a group to make them grow into persons capable of living
long and well Often interest fades in pursuing the unglamorous routine of
supervised immunization and is substituted by pulse campaigns etc. Which in the
long run turn out counter-productive. Indeed persistence with improved routines
and care for quality in immunization would also be a path way to reduce the
world’s highest rate of maternal mortality. In this context we may refer to the
large ratio-based rural health infrastructure consisting of over 5 lakh trained
doctors working under plural systems of medicine and a vast frontline force of
over 7 lakh ANMs, MPWS and Anganwadi workers besides community volunteers. The
creation of such public work force should be seen as a major achievement in a
country short of resources and struggling with great disparities in health
status. As part of rural Primary health care network lone, a total of 1.6 lakh
subcenters, (with 1.27 lakh.’ ANMa in position) and 22975 PHCs and 2935 CHCs
(with over 24000 doctors and over 3500 specialists to serve in them) have been
set up. To promote Indian systems of medicine and homeopathy there are over
22000 dispensaries 2800 hospitals Besides 6 lakh angawadis serve nutrition needs
of nearly 20 million children and 4 million mothers. The total effort has cost
the bulk of the health development outlay, which stood at over Rs 62.500/-
crores or 3-64 % of total plan spending during the last fifty years.

On any count these are extraordinary infrastructural
capacities created with resources committed against odds to strengthen grass
roots. There have been facility gaps, supply gaps and staffing gaps, which can
be filled up only by allocating about 20% more funds and determined ill to
ensure good administration and synergy from greater congruence of services, but
given the sheer size of the endeavor thee wilt always be some failure of
commitment and in routine functioning. These get exacerbated by periodic
campaign mode and vertical programme, which have only increased
compartmentalized vision and over-medicalization of health problems. The initial
key mistake arose from the needless bifurcation of health and family welfare and
nutrition functions at all levels instead of promoting more holism. As a result
of all this the structure has been precluded from reaching its optimal
potential. It has got more firmly established at the periphery/sub-center level
and dedicated to RCH services only. At PHC and CHC levels this has further been
compounded by a weak referral system. There has not been enough convergence in
“escorting” children through immunization coverage and nutrition education of
mothers and ensuring better food to children, including cooked midday meals and
health checks al schools. There has also been no constructive engagement between
allopathic and indigenous systems to build synergies, which could have improved
people’s perceptions of benefits from the infrastructure in ways that made sense
to them.

One key task in the coming decades is therefore to utilize
fully that created potential by attending to well known organizational
motivational and financial gaps. The gaps have arisen partly from the source and
scale of funds and partly due to lack of persistence, both of which can be set
right. PHCs and CHCs are funded by States several of whom are unable to match
Central assistance offered and hence these centers remain inadequate and operate
on minimum efficiency. On the other hand over two thirds cost of three fourths
of sub-centers are fully met by the Center due to their key role m family
welfare services. But in equal part these gaps are due to many other
non-monetary factors such as undue centralization and uniformity, fluctuating
commitment to key routines at ground level, insufficient experimentation with
alternatives such as getting public duties discharged through private
professionals and ensuring greater local accountability to users.

MAJOR DISEASE CONTROL EFFORTS

A careful analysis of the Global Burden of Disease (GBD)
study focusing on age-specific morbidity during 2000in ten most common diseases
(excluding injuries) shows that sixty percent of morbidity is due to infectious
diseases and common tropical diseases, a quarter due to life-style disorders and
13% due to potentially preventable per-natal conditions. Further domestic R&D
has been so far muted in its efforts against an estimated annual aggregate
health expenditure in India ofRs- 80,000/-crores R&D expenditure in India for
public and private sector combined was Rs 1150 crores only. India must play a
larger part in its own efforts at indigenous R&D as very little world-wide
expenditure on R&D is likely to be devoted to infectious diseases. For instance
out of the 1233 new drugs that came into the market between 1975 and 1997 only
11 were indicated specifically for tropical country diseases,
We have already the distinction of elimination or control acceptable to public
health standards of small pox and guinea worm diseases. In the draft National
Health Policy -21 It has now been proposed to eliminate or control the following
diseases within limits acceptable to public health practice- A good deal of the
effort would be feasible.

  • Polio Yaws and leprosy by 2005 which seems distinctly
    feasible though the removal of social stigma and reconstructive surgery and
    other rehabilitation arrangements in regard to leprosy would remain
    inadequate for a decade or more.

  • Kalaazar by 20I0 and Filalriasis by 2010 which also seems
    feasible due to its localized prevalence and the possibility of greater
    community based work involving PR institutions in the simple but
    time-limited tasks or public health programs-

  • Blindness prevalence to 0.5% by 2010 sees less feasible
    due to a graying population. At present the programme is massively supported
    by foreign aid as there are many other legitimate demands on domestic health
    budgets-

  • AIDS reaching zero growth by 2007 appears to be
    problematic as there are disputes even about base data on infected
    population. On most reckonings, affordable vaccines re not likely to be
    available soon nor anti-retro viral drugs appear likely at affordable prices
    in the near future. Further the prevalence curve of Aids in India is yet to
    show its shape. There is also larger unresolved question of where HIV/ATDS
    should be fitted in our priorities of public health, especially in this
    massively foreign aided programme what happen if aid does not become
    available at some point.

Unfinished Burden of Communicable Diseases

Apart from the above, there remains a vast unfinished burden
in preventing controlling or eliminating other major communicable diseases and
in bringing down the risk of deaths in maternal and peri-natal conditions.
Endemic diseases arising from infection or lack of nutrition continue to account
for almost two thirds of morality ad morbidity India. Indeed eleven out of
thirteen diseases recommended by the Bhore Committee were infectious diseases
and at least three of them may well continue to be with us for the next two
decades Baring Leprosy which is almost on the path to total control by 2005, the
other key communicable diseases will be TB Malaria and Aids- to which diarrhoea
in children and complicated and high risk maternity should be added in view of
their pervasive incidence and avoidable mortality among the poorer and under
served sectors,

Tuberculosis

Tuberculosis has had a world wide resurgence including in
India. It is estimated lhai about 14 million persons are infected, i.e. 1.55 of
total population suffer from radio logically active Tuberculosis. About 1.5
million cases are identified and more than 300 000 deaths occur every year
Between NFHS 1 and NFHS 2 the prevalence has increased from 4678 per lakh
population to 544. Unfortunately, prevalence among working age adults (15-59) is
even higher as 675. All these may well be underestimates in so far as patients
are traced only through hospital visit. Only about half reach the hospital.
Often wrong diagnosis by insufficiently trained doctors or misunderstood
protocols is another key problem both public and private sectors. TB is a wide
spread disease of poverty among women living and working in ill ventilated
places and other undernourished persons in urban slums it is increasingly
affecting the younger adults also in the economically productive segments. No
universal screening is possible. Sputum positive test does not precede diagnosis
but drugs are prescribed on the basis of fever and shadows as a result
incomplete cure becomes common and delayed tests only prove the wrong diagnosis
too late. Improved diagnosis through better training and clear protocols and
elimination of drug resistance through incomplete cure should be priority.
Treatment costs in case of drug resistance can soar close to ten times the
normal level of Rs. 3000 to 4000/-per person treated. Similarly even though the
resistant strain may cover only 8% at present, it could suddenly rise and as it
approaches 200/o or so, there is a danger that TB may get out of control. The
DOTS programme trying for full compliance after proper diagnosis is settling
down but already has some claims of success. More tan 3000 laboratories have
been set up for diagnosis and about 1.5 lakh workers trained and with total
population coverage by 2007 cure rates (already claimed to have doubled) may
rise substantially. There is reason to hope that DOTS programs would prove a
greater success over time with increased community awareness aeneration. The key
issue is how soon and how well can it be integrated into the PHC system and made
subject to routines of local accountability, without which no low cost regime of
total compliance is feasible in a country as large as India.
An optimistic assessment could be that with commitment and full use of
infrastructure it will be possible to arrest further growth in absolute numbers
of TB cases keeping it at below 1.5 million till 2010 even though the population
will e growing. Once that is done TB can be brought down to less than a million
lie within internationally accepted limits and disappears as a major
communicable disease in India by 2020.

Malaria

As regards malaria, we have had a long record of success and
failure and each intervention has been thwarted by new problems and plagued by
recrudescence. At present India has a large manpower fully aware of all aspects
of malaria about often low in motivation. It can be transformed into a
large-scale work force for awareness generation, tests and distribution of
medicine. In spite of past successes, there is evidence of reemergence with
focal attacks of malaria with the virulent falciparum variety especially m
tribal areas. Priority tnbal area malaria stands fully funded by the center.
About 2 millioncases of malaria are recorded allover India every year with
seasonal high incidence local failures of control. Drug resistance in humans and
insecticide resistant strains of mosquitoes present a significant problem. But
there is a window of opportunity I respect ofDDT sensitive areas in eastern
India where even now malaria incidence can be brought down by about 50% within a
decade and be beneficial for control of kalazaar and JE. There is growing
interest and community awareness of biological methods of control of mosquito
growth. Unfortunately diligent ground level public health work is in grave
disarray n these areas but can be improved by better supervision greater use of
panchayatraj institutions and buildings on modest demonstrated successes. As
regards a vaccine, there seems t be no sufficient incentive for international
R&D to focus on a relatively lower priority or research. Roll back malaria
programmes of the WHO are more likely to concentrate on Africa whose profile of
malaria is not similar to ours. The search for a vaccine continues but has
little likelihood of immediate success.
In spite of various difficulties, if the restructuring of the malaria work force
and the strengthening of health infrastructure takes place, one can expect that
the incidence can be i educe by a third or even upto half in the next decade or
so. For this it is necessary that routine tasks like timely spraying and
logistics for taking blood slides testing and their analysis and organic methods
of reducing mosquito spread etc. Are down staged to community level and penormed
under supervision throLigh panchayais wiih comaiLiniLy participation public
education and local monitoring. Malaria can certainly be reduced by a third even
upto a half in ten years, and there is a prospect of near freedom from malaria
for most of the country by 2020.

The Case of AIDS

There is finally the case of HIV AID. The magnitude in the
numbers of HIV infected and of AIDS patients by 2025 can be known only as trends
emerge over a decade from now. when better epidemiological estimates are
available but at present these figures are hotly contested. ‘We cant start with
the number infected with HIV as per NACO sentinel surveillance in 2000 a
cumulative total 3.86 million, a figure disputed in recent public health debate.
We can then assume that about 10% will turn into full-blow cases of severe and
intractable stage of Aids. There is as yet no basis to know how many of those
infected will become AIDS patients, preventive efforts focused on behavior
change will show up firmly only after a decade or so. During this period one can
assume an additional 10% growth to account for new cases every year. The Draft
NHP 2001 seeks to stop further infection by educating and counseling and condom
supplies to level it off around 2007, which seems somewhat ambitious. We have
yet to make a decisive dent into the problem of awareness with the broader
population and so far we have been at work only on high risk groups. NFHS2 shows
only a third of woman reporting that they even knew about the HIV/AIDS. Further
such awareness efforts must be followed by multi-pronged and culturally
compatible techniques of public education that go beyond segments easier to be
convinced or behaviour changed. There are voices already raised about the
appropr lateness of IEC mass media content and of the under emphasis of face to
face counseling, calling for innovative mobilization strategies rooted in
indigenous belief systems.

What it implies is that we may be carrying by 2015closeto 5
million infected and upto a tenth of them could turn into full blown cases. We
may not be able to level off infection by 2007 Further these magnitudes may turn
out m actual fact to be wildly off the mark. On any account it is clear that
AIDS can lead to high mortality among the productive groups in society affecting
economic functioning as also public health. Even if 10% of them say 50 to 60000
cases becomes full blown cases the state has the onerous and grim choice to look
at competing equities and decide on a policy for free treatment of AIDS patients
with expensive anti-retro viral drugs. And if it decides not to, the issue
remains as to how to evolve humane balanced and affordable policies that do not
lead to a social breakdown. In about a decade vaccine development may possibly
be successful and drugs may by more effective but they may not always be
affordable nor can be given free.

There would hopefully be wider consultation with persons with
caring sensibilities including AIDS patients on how to counsel in different
eventualities and to get the balance right between hospital and home care and
how to develop a humane affordable policy for anti retroviral drugs for AIDS
patients. Is there a case for providing them with drug free of cost merely to
extend their lives for few years? The matter involves a true dilemma, for public
health priorities themselves certainly argue for more funds should address
diseases constituting bigger population based hazards. Investments made m such
expensive interventions can instead be made in supporting hospice efforts in the
voluntary and private sectors.

Whatever position may emerge in research or spread of
infection of case fatalities, a multi pronged attempt for awareness, must
continue and tough choices must get discussed openly without articulate special,
often urban middle class interests denying other views and especially public
health priorities of the poor. The promotion of barrier protection must increase
but has to related to a system of values, which would be acceptable to the
people’s beliefs. We need to strengthen sentinel surveillance systems and
awareness effort. We also need sensitive feed back on the effects they leave on
younger minds for a balanced culturally acceptable strategy. All this is
feasible and can be accomplished if we are not swept away by the power of
funding and advocacy and fear of being accused to be out of line with dominant
world opinion.

In any case many of the ill cannot afford the high prices or
have access to it from public agencies. The strict patent regimen under TRIPS is
bound to prevail, notwithstanding the ambivalently worded Doha decision of WTO
that public health emergencies provide sufficient cause of countries to use the
flexibility available from various provisions of TRIPS. A recent analysis
reveals that the three drug regimen recommended will cost $10000 per person per
year from Western companies and the treatment will be lifelong. Three Indian
companies are offering to Central Government anti retro; viral drugs at $600/ Rs.
30,000/per person per year and to an international charity at an even lower
price $ 350/ Rs. 13,000/per year provided it was distributed for humanitarian
relief free in S. Africa. It has been public policy in Brazil that the drug is
supplied free to all AIDS should be no exception. If drugs are supplied acting
on a public health emergency basis and prices can stabilize at Rs. 1000/- or so
per year the public health budget should be able to accommodate the cost weighed
against true public criteria. But the aim of leveling off infection of 2007
still seems unlikely.

Maternal and Parental Deaths

Maternal and parental deaths are sizeable but the advantage
here is that they can be prevented merely by more intensive utilization of
existing rural health infrastructure. Policy and implementation must keep steady
focus on key items such as improved institutional deliveries better trained
birth attendants and timely antenatal screening to eliminate anaemia and at the
same time isolate cases needing referral or other targeted attention. After all
Tamil Nadu has by such methods ensured closed to 90% institutional deliveries
backed by a functional referral. Firm administrative will and concurrent
supervision of specified screening tasks included in MCH services can give us a
window of opportunity to dramatically bring down within a few years alarming
maternal mortality currently one of the highest in the world. From NFHS I data,
it was estimated at 424 per lac births it has risen to 540 per lac births in
NFHS II, but the WHO estimate puts it higher at 570. There can be a systematic
campaign over five years to increase institutional deliveries as near as
possible to the Tamil Nadu level, also taking into account assisted, home
deliveries by trained staff with doctors at call. For the interim TBAs should be
relied on through a mass awareness campaign involving Gram Panchayats too. Over
a period of time there is no reason why ANMs entitled benefits of children to
help in their growth and not remain as welfare measure. Using the
infrastructures fully and with community participation and extensive social
mobilization many tasks in nutrition are feasible and can be in position to make
impact by 2010.

Child Health and Nutrition

Associated with this is the issue of infant and child
mortality, (70 out of 1000 dying in the first year and 98 before vide years) and
low birth weight (22% UW at birth ands 47% EJW at below 3 years) most mortality
occurs from diarrhoea and the stagnation in IMR in the last few year is bound to
have a negative effect on population stabilization goals. A recent review of the
Ninth plan indicated that even with accelerated efforts we may reach at best IMR/50
by 3002, but more like IMR/56. since the easier part of the problem is taking
child mortality is over every pomt gain hereafter will deal with districts at
greater risk and needing better organizational efficiencies in immunization. At
the same time, more streamlined RCH services are getting established as part of
public systems and through private partnerships Therefore there is every reason
to hope that the NPP 2000 target of 30 per thousand live births by 2010 will be
met barring a few pockets of inaccessible and resource lean areas with stubborn
persistence of poverty and dominantly composed of weaker sections (e g in part
of Orissa as seen from NFHS II).

As regards childhood diarrhoea, deaths are totally
preventable simple community action and public education by targeting children
of low birth weights and detecting early those children at risk from
malnutrition through proper low cost screening procedure, the present
arrangement has got too burdened with attempting total population coverage
getting all children weighed even once in three months and making ANMs depots
for ORS and for simple drugs for fever and motivating the community to take
pride in healthy children are the lessons of the success of the Tamil Nadu
Nutrition Project, If this is done there is a reasonable chance of two thirds
decline in moderate malnutrition and abolition of serious grades completely by
2015. The success can be built upon till 2025 for reaching levels comparable to
China.

Concentration on preventive measures of maternal and child
health and in particular improved nutrition services will be particularly useful
because it will help that generation to have a head start in good health who are
going to be a part of the demographic bonus. The bonus is a young adult bulge of
about 340 million (with not less than 250 million from rural population and
about 100 million born in this century). The bonus will appear in a sequence
with South Indian States completing the transition before North Indian States
spread it over the next three decades- To ensure best results aL this stage the
present nutritional services must be converted into targeted (and entitled)
benefits of children to help in their growth and not remain as welfare measure.
Using the infrastructures fully and with community participation and extensive
social mobilization many tasks in nutrition are feasible and can be in position
to make impact by 2010.

Mild and moderate malnutrition still prevalent in over half
of our young populaaon can be halved if food as the supplemental pathway to
better nutrition becomes a priority both for self reliance and lower costs.
There has been a tendency for micro nutrient supplementation to overwhelm food
derived nourishment. This trend is assisted by foreign aid but over a long run
may prove unsustainable- By engaging the adolescents into proper nutrition
education and reproductive health awareness we can seamlessly weave into the
nutritional security system of our country a corps of informed interconnected
and imaginative ideas can be tried out. Such social mobilization at low cost can
be the best preventive strategy as has been advocated for long by the Nutrition
Foundation of India (< Gopalan 2001) and can be a priority in this decade over
the next two plan periods.

Unfinished Agenda – Non Communicable Diseases and Injuries

Three major such diseases viz,, cancer cardiovascular
diseases and renal conditions – and neglect in regard to mental health
conditions – have of late shown worrisome trends. Cures for cancer are still
elusive in spite of palliatives and expensive and long drawn chemo – or radio
-therapy which often inflict catastrophic costs, In the case ot’CVD and renal
conditions known and tried procedures are available for relief. There is
evidence of greater prevalence of cancer even among young adults due to the
stress of modem livmg. In India cancer is a leading cause of death with about
1.5 to 2 million cases at anytime to which 7 lac new cases are added every year
with 3 lakh deaths. Over 15 lakh patients require facilities for diagnosis and
treatment. Studies by WHO show that by 2026 with the expected increase in fife
expectancy, cancer burden in India will increase to about 14 lac cases. CVD
cases and Diabetes cases are also increasing with an 8 to 11 % prevalence of the
latter due to fast life styles and lack of exercise. Traumas and accidents
leading to injuries- are offshoots of the same competitive living conditions and
urban traffic conditions Data show one death every minute due to accidents or
more than 1800 deaths every day- in Delhi alone about 150 cases are reported
every day from accidents on the road and for every death 8 living patients are
added to hospitals due to injuries. There is finally the emerging aftermath of
insurgencies and militant violence leading to mental illnesses of various types.
It is estimated that 10 to 20 persons out of 1000 population suffer from severe
mental illness and 3 to 5 times more have emotional disorder. While there are
some facilities for diagnosis and treatment exist in major cities there is no
access whatever in rural areas. It is acknowledged that the only way of handling
mental health problems is through including it into the primary health care
arrangements implying trained screening and counseling at primary levels for
early detection.

All these are eminently feasible preventive steps and can be
put into practice bv 2005 and we should be doing as well or better than China by
2020 considering the greater load of non communicable diseases they bear now.
The burden of non-communicable diseases will be met more and more by private
sector specialized hospitals which spring up in urban centers. Facilities in
prestigious public centers will also be under strain and they should be
redesigned to take advantage of community based approach of awareness, early
detection and referral system as in the mode) developed successfully in the
Regional Cancer Center Keraia. Public sector institutions are also needed to
provide a comparator basis for costs and evaluating technology benefits.’ For
the less affluent sections prolonged high tech cure will be unaffordable.
Therefore public funds should go to promote a routine of proper screening health
education and self care and timely investigations to see that interventions are
started in stages I and II.

HEALTH INFRASTRUCTURE IN THE PUBLIC SECTOR

Issues in regard to public and private health infrastructure
are different and both of them need attention but in different ways. Rural
public infrastructure must remain in mainstay for wider access to health care
for all without imposing undue burden on them. Side by side the existing set of
public hospitals at district and sub-district levels must be supported by good
management and with adequate funding and user fees and out contracting services,
all as part of a functioning referral net work. This demands better routines
more accountable staff and attention to promote quality. Many reputed public
hospitals have suffered from lack of autonomy inadequate budgets for non-wage
O&M leading to faltering and poorly motivated care. All these are being tackled
in several states are part health sector reform, and will reduce the waste
involved in simpler cases needlessly reaching tertiary hospitals direct These,
attempts must persist without any wavering or policy changes or periodic
denigration of their past working. More autonomy to large hospitals and district
public health authorities will enable them to plan and implement decentralized
and flexible and locally controlled services and remove the dichotomy between
hospital and primary care services. Further. most preventive services can be
delivered by down staging to a public health nurse much of what a doctor alone
does now. Such long term commitment for demystification of medicme and down
staging of professional help has been lost among the politicians bureaucracy and
technocracy after the decline of the PHC movement. One consequence is the huge
regional disparities between states which are getting stagnated in the
transition at different stages and sometimes, polarized in the transition. Some
feasible steps in revitalizing existing infrastructure are examined below drawn
from successful experiences and therefore feasible elsewhere.

Feasible Steps for Better Performance

The adoption of a ratio based approach tor creating
facilities and other mpuls has led lo shortfalls estimated upto twenty percent.
It functions well where ever there is diligent attention to supervised
administrative routines such as orderly drugs procurement adequate O&M budgets
and supplies and credible procedures for redressal of complaints. Current PHC
CHC budgets may have to be increased by 10% per year for five years to draw
level. The proposal in the Draft NHP 2001 is timely that State health
expenditures be raised to 7% by 2015 and to 8% of State budgets thereafter.
Indeed the target could be stepped up progressively to 10% by 2025. it also
suggests that Central funding should constitute 25% of total public expenditure
in health against the present 15%. The peripheral level at the sub center has
not been (and may not now ever be) integrated with the rest of the health system
having become dedicated solely to reproduction goals. The immediate task would
be to look deepening the range of work done at all levels of existing centers
and in particular strengthen the referral links and fuller and flexible
utilization ofPHC/CHCs. Tamil Nadu is an instance where a review showed that out
of 1400 PHCs 94% functioned in their own buildings and had electricity, 98% of
ANMs and 95% of pharmacists were in position. On an average every PHC treated
about 100 patients 224 out of the 250 open 24 hour PHCs had ambulances. What
this illustrates is that every State must look for imaginative uses to which
existing structures can be put to fuller use such as making 24 hours services
open or trauma facilities in PHCs on highway locations etc.

The persistent under funding of recurring costs had led to
the collapse of primary care in many states, some spectacular failures occurring
in malaria and kalazar control. This has to do with adequacy of devolution of
resources and with lack of administrative will probity and competence in
ensuring that determined priorities in public health tasks and routines are
carried out timely and in full. Only genuine devolution or simpler tasks and
resources to panchayats, where there will be a third women members- can be the
answer as seen in Kerala or M.P. where panchayats are made into fully competent
local governments with assigned resources and control over institutions in
health care. Many innovative cost containment initiatives are also possible
through focused management – as for instance in the streamlining of drug
purchase stocking distribution arrangements in Tamil Nadu leading to 30% more
value with same budgets.

The PHC approach as implemented seems to have strayed away
from its key thrust in preventive and public health action. No system exists for
purposeful community focused public information or seasonal alerts or advisories
or community health information to be circulated among doctors in both private
practice and in public sector. PHCs were meant to be local epidemiological
information centers which could develop simple community.

Tertiary hospitals had been given concessional land, customs
exemption and liberal tax breaks against a commitment to reserve beds for poor
patients for free treatments. No procedures exist to monitor this and the
disclosure systems are far from transparent, redressal of patient grievances is
poor and allegations of cuts and commissions to promote needless procedure are
common.

The bulk of noncorporate private entities such as nursing
homes are run by doctors and doctors- entrepreneurs and remain unregulated
cither in terms of facility of competence standards or quality and
accountability of practice and sometimes operate without systematic medical
records and audits. Medical education has become more expensive and with rapid
technological advances in medicine, specialization has more attractive rewards.
Indeed the reward expectations of private practice formerly spread out over
career long earnings are squeezed into a few years, which becomes possible only
by working in hi tech hospital some times run as businesses. The
responsibilities or private sector in clinical and preventive public health
services were not specified though under the NHP 1983 nor during the last decade
of reforms followed up either by government of profession by any strategy to
engage allocate, monitor and regulate such private provision nor assess the
costs and benefits or subsidization of private hospitals. There has been talk of
public private partnerships, but this has yet to take concrete shape by imposing
pubic duties on private professionals, wherever there is agreement on explicitly
public health outcomes. In fact it has required the Supreme Court to lay down
the professional obligations of private doctors in accidents and injuries who
used to be refused treatment in case of potential becoming part of a criminal
offence.

The respective roles of the public and private sectors in
health care has been a key issue in debate over a long time. With the overall
swing to the Right after the 1980s, it is broadly accepted that private
provision of care should take care of the needs of all but the poor. hi doing
so, risk pooling arrangements should be made to lighten the financial burden on
theirs who pay for health care. As regards the poor with priced services. Taking
into account the size of the burden, the clinical and public health services
cannot be shouldered for all by government alone. To a large extent this health
sector reform m India at the state level confirms this trend. The distribution
of the burden, between the two sectors would depend on the shape and size of the
social pyramid in each society. There is no objection to introduce user fees,
contractual arrangements, risk pooling, etc. for mobilization of resources for
health care. But, the line should be drawn not so much between public and
private roles, but between institutions and health care run as businesses or run
in a wider public interest as a social enterprise with an economic dimensions.
In a market economy, health care is subject to three links, none of which should
become out of balance with the other – the link between state and citizens’
entitlement for health, the link between the consumer and provider of health
services and the link between the physician and patient.

Courtesy: Ministry of Information and Broadcasting
publication division

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