Too many to care
* The views expressed are personal and should not be ascribed to the authors’ employer.
THE generation that was born after Midnight, in the dawn of the Republic, cut its professional teeth in the late ’70s and early ’80s to the jingle, ‘Health for All by the Year 2000’. Alas, those who are still around will be sporting replacements before India is delivered by this mantra. The Year 2000 is over, but the goal of Health for All remains a distant dream, here as in much of the developing world. For the country’s health, the turn of the century is not a major landmark, nor even an inflexion point of any significance. At a stretch, the year may represent a half-way mark between 1950, when India embarked on creating its health future, and 2050, when we can still dream it could achieve a decent standard of health for most of its citizens and reach ‘population stabilization’.
These two subjects – health and population – are intimately linked, not because one ministry of the government deals with both, nor because demographic indicators such as mortality and fertility are used as measures of health, but because the country will not be able to provide better health unless it simultaneously addresses ‘the population problem’; and vice versa, population growth will not abate unless health is improved dramatically.
If you despair at this ‘Catch 22’ situation, consider the further complication that both ill-health and population growth are at once significant consequences and causes of the grave poverty in India. Neither will go away unless we address poverty, and we cannot reduce poverty without increasing health and reducing fertility. But all is not hopeless. This article attempts to help us steer through the morass that currently surrounds India’s health. Are we too many, too poor? Too poor to care? Too many to care?
India’s health achievements since 1950 fill half a glass. They include a doubling of life expectancy, a halving of mortality in the population at large as well as among infants, a highly susceptible group, and a reduction by two-fifths of fertility. These are significant accomplishments. We have also eliminated two important diseases: smallpox and guinea worm, and significantly reduced others such as kala azar (leishmaniasis) and leprosy. We have trained several hundreds of thousands of doctors and paramedics and built a public health system that is spread throughout the country. The state and market have fostered a private health system that is five times bigger than the public system, for better and for worse.
But there is half a glass yet to fill, and this is no buttercup, as the country’s health needs remain enormous. India’s population crossed one billion in 1999, nearly triple that of 1950. By 2050, it is expected to stabilize around 1.6 billion, a global first, as we will exceed the population of China around 2035. To stabilize largely connotes an equalization of births and deaths, necessarily at a low level since both longevity and birth control are aspirations of a modernizing society. A rate of about six deaths and six births per 1000 people would be acceptable. This means that the country’s current death rate (8.7 per 1000) would have to be cut back by about a third, and the birth rate (27 per 1000) by over three-quarters. Thus, despite the gains in survival and health since Independence, India’s mass of humanity – one-sixth of the world’s total – will continue to struggle against decimation and multiplication through the next several decades.
Where India must focus to bring about stabilization is obvious from a few simple statistics. The dead today still include a significant proportion of the very young. Of around 8.7 million deaths that occur annually, over two-thirds are of children under five years of age, and almost one in four, about 1.9 million, are of infants (under one year old). Reducing these deaths by half would achieve the necessary reduction in the mortality rate and, would also accelerate the decline in the birth rate, as the states that have been through the demographic transition – Kerala, Goa and Tamil Nadu – have shown. Poor people want their children to survive, and poor families all over the country are demonstrating their desire to have fewer children who can aspire to a higher quality of life. To achieve these hopes they need ready access to basic health goods and services, including an array of birth control methods.
Amajor cause of poor child survival is the pitiful state of health of Indian women. One-third of infants are born ‘low birth weight’ and hence at higher risk of death or physical underdevelopment because their mothers suffer from anemia, chronic malnourishment and/or infection. During their reproductive span (15-45 years), Indian women still die from pregnancy related causes at alarming rates, accounting for more than a quarter of the world’s maternal deaths. Underlying both child and maternal deaths are malnutrition and rampant infectious diseases.
About 53% of Indian children under five are malnourished and over 60% of Indian women are anemic. Diseases such as malaria, tuberculosis, diarrhoeas, respiratory illnesses, and other childhood infections are still widespread and affect the poor disproportionately. One person dies of TB and there are five new cases of malaria every minute in India. ‘Economic giant’ with half our population wasting away? Nothing short of a war against these diseases and hunger could set us on the path to superpower-hood.
‘Here in Brahmpur, we have nothing but snotty noses, fields of flies, starving children, and old men with hacking cough. We have so little water that nobody thinks of cleaning or treating it, except in the rainy season, when the field ditches fill up and everyone suffers from malarial fever. The nurse may come once a month, and she brings a few pills and condoms, and tells the women to go for the operation... Yes, we need to limit our number of children, but young wives today are ignorant and subject themselves to the knives of local men instead.’
India is hundreds of thousands of Brahmpurs. Far from being delivered from this ‘hell for all’, they are caught in the web of debates and dilemmas that continue to plague the health sector. At the dawn of this cyber-century, even the minimum essentials for health are unavailable to large numbers of rural and urban slum dwellers: little water, no sanitation, no vector control to deal with the swarming flies and mosquitoes, poor knowledge of hygiene, inadequate nutrition, little recourse to contraception, and unaffordable treatment – or worse, treatment in the hands of quacks and debtors. Listen to some more of Suraj Pal’s concerns:
‘Last week, Prakash Chand (a rich farmer) took his son to the hospital (the government Community Health Centre (CHC), about 40 kilometres away). It took them five to six hours by tractor and bus, and then they had to stay overnight to catch the return bus the next day. The teenage boy had been complaining of severe earache for about a week, and has now finished the medicines they bought for five days. To no avail. Even Prakash Chand cannot afford to go again – what to speak of any of us (poorer families) going at all! We could not even take our wives if they were dying...’
The health facilities that India has built with great fervour, and greater expenditure, over the past fifty years remain beyond the reach of the poor – indeed, beyond a sizeable proportion of rural residents, rich and poor. They have little access to health care beyond the occasional ‘check up’ or advice of the government ANM (Auxiliary Nurse Midwife) and the handful of ‘carocin’ found in a jar at the village petty-shop. Despite a large public and even larger private health sector, appropriate and affordable health care remains inaccessible to several hundreds of millions, particularly women and children. Large numbers of villages are unconnected by road or public transport within a reasonable time-distance norm of a health facility or ‘modern’ doctor, public or private.
Suraj Pal knew little about the CHC, but Prakash Chand was lucky that on the evening he journeyed to it there was a doctor in the house and a ‘medical shop’ open nearby to fill his son’s prescription. In addition to his travel expenses, food and some rupees to the chowkidar to allow him to sleep overnight in the verandah of the health centre, he spent 67 rupees on a strip of ‘new generation’ antibiotics. But nobody told him what to do next. The doctor was too pressured, and the medical caste system does not permit anyone else to provide appropriate drug advice – not even the ‘compounder’, had he existed.
Curative care without follow-up instructions or health education is about as good as sowing seeds and neglecting to water them. Either without public health and preventive measures is tantamount to sowing or sprinkling unploughed ground. While the government spends its limited resources infructuously, the poor are consigned to repeated cycles of illness, exploitation and dwindling physical, financial and psychological strength. Most of the knowledge we need to address the major diseases that affect them and prevent this vicious downward spiral, and the technology, exist. What is still missing in the health services is the managerial competence to deliver services of effective quality in the appropriate balance, and the politico-bureaucratic will to allocate the resources that are required to do so.
While health services alone will not solve all the extant problems, a system seriously committed to improving health would work with the food distribution efforts, notably the public distribution system and the integrated child development services (ICDS) to enhance nutrition, and with public health engineering departments to increase the health impacts of water and sanitation schemes. These four inputs – health care, food, water and sanitation, available together – are the minimum essential for recovering the country’s health.
So what prevents the health system from getting on with its job? One paralyzing problem that has resurfaced amid the birth of DALYs (disability-adjusted life years) as a measure of health, the growth of liberalization and privatization theory, and the mushrooming of NRI financed health facilities is the ‘equity versus efficiency’ debate. Although we have neither equity nor efficiency at the current time, the question being asked is: Should India really provide health care for all or be concerned mainly with the efficiency of its health spending? Although three-quarters of health expenditure in the country is borne by households, and a further 10% by other private entities, this debate chiefly surrounds the public sector. Acceptance of the private sector’s profit-making raison d’etre appears to exempt it from responsibility for providing low cost or ‘no cost’ care to those who cannot pay, as well as from supplying cost-effective services to paying patients.
Many believe that market mechanisms will iron out inefficiencies and distortions in due course. Suffice it to say that illness and the fear of death produce atypical consumer behaviour in the health care market. In their anxiety patients are rarely able to shop around, demand their choice, or ensure value for money, necessary conditions for making the market work honourably. Numerous studies have documented how households utilize, first local and low cost health care, but end up at expensive facilities when a patient is critical and the family in no state to bargain. We are too many, too poor and too rich, for health care to be anything other than a suppliers’ lair in the foreseeable future. In this context, government health services in both rural and urban areas are far from being the ‘provider of last resort’; they are a crucial intermediary to which the sick flock in the hope of getting effective and reasonable treatment.
But 50 years on, the public sector does not exercise this role satisfactorily. While committees and commissions have repeatedly attempted to commit the government to some form of ‘health for all’ and write the prescriptions for its discharge, the exchequer has never provided the resources necessary to build a system capable of concertedly delivering even the most crucial preventive and curative services. Over the years, there has been little managerial commitment to rationalizing available infrastructure and staff, and utilizing new resources strategically to fill critical gaps and maximize effectiveness in key areas – neither substantive areas such as child health nor geographic areas such as those endemic for a disease, or remote ones.
Political compulsions have led to resources being spread much too thin to make a difference, and population growth has resulted – to repeat a favourite image – in the health sector ‘running to stay in place’. The exception, of course, was the political compulsion of sterilization during the Emergency, which actually focused money and manpower on other men’s power (for money). Alas, the health sector got carried away, the people ran away, and it took the country two full decades – a generation – to overcome the sharm engendered by that effort.
In effect, there is very little strategic analysis or decision-making in the health sector – a major lacuna when you need to fight a war. To begin with, the public health system must decide who and what it will treat, referring to the macro or policy level rather than the micro, health facility level. Plagued by a guilty conscience about the poor and the continuing high levels of disease on the one hand, but unable to relinquish claims to medical miracles on the other, health policy continues to support the ‘dual’ approach that has been followed to date: primary health care for rural areas and super-sophisticated urban medical facilities. Unfortunately, there have never been enough resources to go around, leaving both ends of the chain frazzled. The insufficiency of public health and preventive measures and basic health care for the population at large puts an unseemly burden on higher-level health facilities.
This situation calls for a complete rationalization of the health pyramid, beginning with rectification of the problems at the base, where paramedics and doctors (where they exist) struggle to treat hundreds of millions suffering from the most common diseases with severe shortages of drugs and equipment. Then, effective systems should be developed to ensure that the apex district and urban hospitals, whose specialist facilities are currently wrongly and over-utilized, are efficaciously used. It is essential to reduce the country’s large disease burden through public health measures and better primary care for all in order for secondary and tertiary facilities to provide the appropriate services to those who require more specialized levels of care. In short, efficiency in India’s health sector cannot be achieved without equity considerations – and vice versa because of the continuing shortage of resources. Thus, the ‘either-or’ debate should simply be put to bed.
Such a rationalization of the health system would need two hard decisions to be taken soon by our policy-makers. First, overall resources to the health sector must be considerably increased and, second, these must be preferentially allocated to programmes and facilities that reach and address the most urgent health needs of the poor. India must not continue to pretend that it can produce health for all when the public sector spends less than one per cent of GDP on health. True that private spending increases this amount five times, to about 6% of GDP – but this was the percentage estimated in 1980 (by the ICSSR-ICMR Committee) as needed by the public sector alone to support the country’s health goals. We are really not too poor to care, we just do not care enough.
The Ninth Plan document, now some two years old, recognizes the gaps in health infrastructure and manpower, especially at the primary level, and the poor functioning of services and referrals. It also indicts hospitals for their lack of personnel, services and supplies. It talks of the escalating costs of health care, and the widening gap between what is possible and what is affordable by individuals and the nation. It recognizes that the availability and utilization of health services is poorest in the neediest areas of the country. And it points to people’s increasing awareness and expectations of health care, and to the increased potential for health interventions based on technological advances. To improve coverage and quality and ‘functional efficiency’, it commits the government to a Special Action Plan to expand and improve health services to meet health needs, eschewing the target approach that earlier directed the sector.
But alas, the plan does not allocate the kind of resources to health that are necessary to correct these ills. Equally, it fails to enunciate clearly what its choices would be among the numerous interventions listed, or even how these priorities would be identified. Until the size of the health pie is increased manifold, it will be necessary to make such choices. Measures aimed at childhood infections, malaria and tuberculosis, and women’s health would have the greatest impact in reducing ill-health among the poor.
These choices are underpinned by considerations of equity and social justice, and so differ from those made by a strictly DALYs approach. This would target resources to maximize the benefits gained, regardless of who gains, and thus would help those who can benefit the most, and most easily, over those who have the greatest need. As we are, indeed, too many to care for, the public system should focus on those who can least afford the private sector.
One mechanism proposed in the Ninth Plan could be useful to provide more and better services all round: levying user fees at hospitals and specialized institutions. Currently, even our post-graduate institutes and super-speciality centres fail to break even in the provision of services. They are subsidized well beyond their medical education and research budgets, and their benefits accrue largely to the rich and powerful. To increase health resources, user fees could be introduced in most public hospitals, levied on all who can afford them, including government servants, politicians and the like, while the poor are charged only nominal rates. The will to do this has to be substantially fortified, ensuring faithful application of means tests and appropriate distribution of revenues within and, where feasible, beyond the facilities raising them. These collections could cross-subsidize much needed services for the poor at both urban and rural centres and, concurrently, other public monies should be allocated to facilities that are unable to raise adequate resources for sound external reasons.
But creating health entails much more than increasing health spending and providing health services. There is a fundamental need in India to redress the unequal distribution of wealth that results in 35 to 40% of the population living below the poverty line. These almost 400 million people cannot afford the ‘two square meals a day’ that constitute basic nutrition, nor the clothing, shelter, environmental conditions, knowledge and care that are necessary to maintain health. Too many are, indeed, too poor.
They live in areas that are desperately short of water and food, far away from markets and service centres. They often lack the resources to send their children to school, which avenue might lead to socio-economic ‘uplift’ at least in the next generation. Women are disproportionately represented among them, just as they are among the ill and prematurely dying. That addressing poverty and income distribution is essential for the nation’s health is borne out by studies that show that infant mortality rates (IMR) are related to income distribution within countries. India could reduce its IMR (71 per 1000 people) by half at its current per capita GNP level if it were to reduce inequality in income distribution (measured by the Gini coefficient) by 40%. If this were to occur in the context of a doubling of per capita GNP, the IMR could be brought down to about 25 per 1000. We would then have won the war.
In addition to economic approaches to distributing wealth there are other aspects of our society that must be tackled to enhance well-being. Growing anomie is not good for anyone’s health – and the creation of social capital will be increasingly important to restoring and securing health. In fact, increased social capital is one of the ways in which relative equity in income distribution enhances survival. Societies with lower income inequalities usually have lower social tensions and higher levels of trust, which affect health outcomes directly (e.g., through reduced violence) as well as indirectly (e.g., through greater trust of health service providers who are usually of a higher social class than the poor). An example of the need for greater trust is found in a common complaint the poor in India have about the ANM who is responsible for providing them primary maternal and child care: they say she acts like a memsahib.
The idea that social capital is important for health is not new – it just keeps getting forgotten in the health sector’s preoccupation with numbers, technology and money. The value of the state investing in social capital underlay the community development programmes of the early Republic; India’s health planners have long been aware that family and community networks can be instrumental in maintaining or improving health, that health practices are imbedded in culture, and that other institutions, both formal and informal, affect health outcomes. Enhancing the social status of, say, women or tribal people, doing away with the stratifying caste system at least in service provision and preferably in the polity at large, expanding knowledge, and reducing social tensions, all underlie the development of social capital that is necessary for health.
During the ’70s and ’80s discussion focused on the roles of formal voluntary organizations in the provision of health care. Recognition that ‘Health for All’ could not be achieved by government alone led policy to provide a role for NGOs in the interface between government and poor communities. However, government-NGO relationships have remained weak, and an adequate institutional base has failed to develop even for those aspects of primary health care that the government finds difficult to provide. In discussions of health care provision today, NGOs occupy third place after the state and the private for-profit sector.
Contemporary concerns with social capital include the levels of people’s participation, social or civic trust, and groups or networks that cause cooperation or coordination for mutual benefit. Thus, from family and community mechanisms that have been a mainstay in health – recall the traditional knowledge and role of the grandmother in household health, the dai, and the community health worker – the focus today is on associations of poor people, especially women, and social movements, and how these can be instrumental in improving the health of members.
NGOs too have realized their limitations and increasingly work through community-based networks, or focus on campaigns and advocacy that reach larger numbers, leaving the development of social capital to those directly involved. Various forms of public communication, debate and discussion can also serve to influence health – from spreading health awareness, to pressuring government to allocate resources to the war on disease in preference to other imagined wars.
As state resources shrink, mechanisms of mutual aid and reciprocity, of collective efficiency and social ‘safety nets’ will become increasingly important in Indian society – among both rich and poor. It is worth considering where social capital might replace the state to achieve better health outcomes, and where state support could enhance the growth of such capital, investing now for the future. The development of social capital – from debates to networks – can improve the agency for survival, while the costs of isolation include illness and death.
In sum, India cannot lay legitimate moral claim to being a modern society unless it squarely addresses the primordial health problems it harbours and the underlying disadvantages that afflict ‘the other half’. Economic and social development are both intimately related to health and survival. It has been obvious for some time, and will remain true, that any society wishing to develop economically must improve its health. Health and well-being will not increase by growing wealth alone but the distribution of this wealth, i.e., the reduction of economic inequality and the diminution of social disparities are important for their attainment. Better health also requires investment in health care and in the basic goods that underlie health, food, water and sanitation.
Better health services, improved access to them, a more equitable and harmonious (‘caring and sharing’) society – all call for attention to social capital. Health policy in India has been tragically inconsistent in acknowledging these fundamental understandings and underpinnings, and developing them. Policy-makers thus need to take a new, long and hard look at where we are, and where we are heading on the health front.