Abstract
The Social Development Report (SDR), 2014, the fifth in the series commissioned by the Council for Social Development, addresses the theme Challenges of Public Health. This fine volume with several detailed studies and substantial data has been edited by Imrana Qadeer and comes at a crucial time in the debate. The Human Development Report, 2013, which covers a range of attributes within and beyond the health sector, ranked India at a low 136 among 186 countries in its Human Development Index. At the national level, with a maternal mortality rate (MMR) of 167 deaths per 100,000 deliveries, we have not met the Millennium Development Goals (MDGs) of 109, and are looking at a Sustainable Development Goal (SDG) of 70 by 2030. With an under-five mortality rate (U5MR) of 49 we have not achieved the MDG of 42 deaths per 1,000 births and where the SDG is 25. Likewise, we have not achieved the MDG on reducing infant mortality rate (IMR) to 27 deaths per 1,000 live births. India has only reached 39 and is looking at a SDG for neonatal mortality of 12 deaths per 1,000 live births.
While maternal and infant mortality statistics may be limited in some ways, if we are looking for a simple measure of where we are as a functioning society, they serve very well. Certainly there have been improvements, many of which are results of actions within the health system. The past few years have also seen increased interest in the possibility of universal health care and of internal reform, but surprisingly little positive action. Where is the problem? Why, when there is a consensus which has grown in the world of public health, are we still shy of taking action? Why has this cause failed to attract political attention?
The string running through this volume—from the Introduction chapter by Prof. Qadeer to the Conclusion by Prof. Debabar Banerji—is a commitment to the classic definition of public health given by C.E.A. Winslow in 1920. It is worth reciting this in full.
Public health is the science and art of preventing disease, prolonging life, and promoting physical and mental health efficiency through organized community efforts for the sanitation of the environment, through control of communicable infections, education of individuals in the principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for maintenance of health.
In this spirit, the SDR correctly places the health situation within the larger context. Poor nutrition, especially poor child nutrition, the absence of clean potable water and sanitation, the growth of urban slums, environmental pollution and the growing agrarian crisis, all of these lead to poor health indicators and do not help the advancement of good physical and mental health. In a significant study, Usha Ramanathan and Bezwada Wilson condemn the deplorable social practice of manual scavenging and point to the poor health and high mortality to which it leads. The larger context could also have included major issues such as domestic violence, the abusive use of alcohol and smoking and chewing tobacco.
Vandana Prasad and Dipa Sinha state upfront that ‘children are living in dangerous and shameful situations of food insecurity’. They seem to suggest that there are possibilities in a reform of the government’s primary intervention, the Integrated Child Development Scheme (ICDS), but the sad reality is that the ICDS is doomed. From the outset, it has been plagued with the corruption and mismanagement that are endemic to a highly centralised programme. Inadequate attention has been given to the training and empowerment of the women who run the anganwadis, who largely remain poorly paid and on the fringes of government employment. We are told that Kerala, Odisha and Chhattisgarh have put in place alternative mechanisms for the provision of nutritious food, but on the whole it would have been even more useful if the question asked was: Is there a centrally funded, state-based alternative to ICDS which is less centralised, more participatory, privileging local diets? While we know that the ICDS has not impacted significantly on early childhood care, we know little about whether the ICDS has made any impact on early childhood education, also a part of its mandate.
The separate studies by Girija Vaidyanathan and Rakhal Gaitonde of Tamil Nadu confirm some well-known beliefs. Drawing on a heritage of social and political commitment to welfare activity, the state has robust health education and drug distribution programmes. Maternal and infant mortality are declining rapidly, there is a strong public health cadre in the districts, and state government resources to health have increased. However, there are quality concerns and despite a visible public health infrastructure, 60 per cent of all hospital admissions are still in private hospitals. Gaitonde observes a sharp caste differentiation in health outcomes, and a poorly functioning ICDS.
Private funding has flown into medical, nursing and allied health education, and continues to flow into private medical care. This is the most crucial question in the policy debate today. What is the role of private resources in promoting universal health care? The private sector has grown rapidly. At the national level, it is said that 60 per cent of outpatient care and 80 per cent of inpatient care is provided privately. Sen et al. trace the rampant commercialisation of health care to the influence of the World Bank in the early 1990s and the admission in the National Health Policy of 2002 of the inability of the state to meet the costs of health care. That the Clinical Establishments Act, 2010, has failed to make any impact merely vindicates what has always been known—that the government is either unable or unwilling to regulate the private sector in health.
Clearly, large sums are being paid out which, if we believe that it is the responsibility of the state to provide adequate health care, can only be regarded as out-of-pocket (OOP) expenditure. Sen et al. attribute this to ‘rising costs, reduced availability of public health provision, continued rural urban disparities, uncontrolled rise in the price of medicines and diagnostics combined with aggressive marketing by corporate providers’. It is argued that these huge costs will be covered by insurance schemes, with the government bearing the cost of the premium and private providers providing the treatment, but the evidence is mixed. The Rashtriya Swasthya Bima Yojana has been studied in some detail—by Sakthivel et al., Vasan et al. and Sen et al.—in this Report; the common finding is that its coverage is poor and unnecessary, surgical procedures are being carried out in largely private facilities with substantial payments to hospitals and no significant reduction in OOP expenditure for patients.
A weakness in the SDR is the complete absence of a discussion on the availability of human resources for health care; the requirement of trained professionals at every level; the facilities for their training and deployment; the regulation of medical, nursing and allied health education; the need for greater public investment in health education and for a robust strategy for developing human resources for health care in the country. No public health system can be built or sustained without qualified professionals to run it; every health worker from the Auxiliary Nurse Midwife (ANM) in her sub-centre to the super specialist in a medical college and hospital has to be planned for. Without addressing the issue of supply of health professionals trained to an appropriate standard and deployed at the right locations, universal health care is not about to happen.
It is not as if there have been no efforts. Over the period from 2010 to 2013, the Ministry of Health and Family Welfare worked on developing a structure and curriculum for a BSc Rural Health Care to be taught out of upgraded district hospitals or science colleges. The idea was to create cadres of public health workers deployed at the sub-centre and providing a very basic level of care and advice. It is presently not very clear where the matter rests or what the government’s current thinking is.
More ambitiously, the government also moved a bill in the parliament in 2011 to set up a National Commission for Human Resources in Health, an umbrella organisation presiding over three subsidiary organisations—each responsible respectively for curriculum and standards, accreditation of institutions and courses and the practice of the profession. This bill fell afoul of the Parliamentary Standing Committee which however left the door open for the government to reconsider the matter. It is again not clear what the current position is.
No move in the area of health education, whether small or big, is however possible unless we recognise the presence of the elephant in the room–the Medical Council of India (MCI) and its sister councils for nursing and dentistry. Under the present legislation, regulatory powers are substantially vested in the MCI, which is, at best, a conservative body dominated by hospital-based clinicians. Successive governments at the centre and at the state level have contributed to the crisis in medical education by facilitating the establishment of private, fee-charging colleges which, almost by definition, do not produce medical graduates available for public service.
Apart from other concerns, there are issues related to the undergraduate curriculum and syllabi, and to the development of new specialisations at the postgraduate level. India is not even close to having the required number of qualified doctors in psychiatry, geriatric care, palliative care and, crucially, family medicine, to name only a few areas. Even government colleges do not seem willing to invest in creating additional seats in these essential, if non-lucrative, disciplines.
Clearly, there are huge grey areas in the discussion on human resources and the SDR would have done well to commission at least one detailed study.
The SDR would also have been much strengthened by some discussion on our current knowledge of disease burden in the country and the nature and extent of epidemiological studies. Our understanding of the challenges in public health can only be enhanced by awareness of what we are fighting and at what levels. The recurrence of malaria, the spread of multiple drug resistant (MDR) tuberculosis and the annual visitations of dengue are reminders that we still need to address the most basic public health concerns such as sanitation, hygiene and housing. There are rumours that the publically funded AIDS control programme is being cut back but it is not clear if this is because of a clear indication that prevalence has reduced. We are increasingly recognising that severe mental illness affects approximately 3 per cent of our population. The illnesses of an aging population also tend to be ignored. An estimate of the size and varied nature of the health crisis would have been of much use in this Report.
Prof. Banerji’s strongly worded concluding essay traces the evolution of public health policy in the country, the significant commitments envisaged by the Bhore Committee and the inability of successive governments to honour those commitments, the ill-founded decision to abolish the Indian Medical Service and the lack of professional leadership within the health bureaucracies at the state and the centre. There is much to commend the case for a strengthened primary health centre-based model of care, largely driven by state governments, with a focus on free drugs and diagnostic services, but it is simplistic to ascribe as much blame as Banerji does to the civil servant establishment. The higher civil services in India have not often demonstrated leadership or dedication, there is no secret in that, but the promotion of health care and the greater allocation of public funds are political acts. As Sakthivel et al. say
Significant and sustained investment in public health system is the need of the hour. Several promises and commitments made in the past, to step up government investment in public health system, from the current 1.2 per cent of GDP to about 3 per cent, must be realized.
We need inspired political commitment and greater and more sustained funding to government medical, nursing and allied health training colleges. We also need strengthening of the network of primary and secondary health facilities with much greater attention to the skills and responsibilities of public health workers, such as Accredited Social Health Activists (ASHAs), anganwadi workers and ANMs. In placing greater public commitment at the heart of the public health debate, the SDR has shown the correct way ahead.