Public health is squarely a state responsibility and particularly so
in a developing country. It has to go hand-in-hand with sanitation, drinking
water, health education and disease prevention.
The challenges facing India’s health sector are
mammoth. They will only multiply in the years ahead. Surprisingly many of the
challenges are neither a result of the paucity of resources nor of technical
capacity. These hurdles exist because of a perception that the possible
solutions may find disfavour with voters or influential power groups.
The first malady has been the utter neglect of
population stabilisation in states where it matters the most.
The second is the monopoly that an elitist
medical hierarchy has exercised for over 60 years on health manpower planning.
The result has given a system where high-tech speciality services are valued and
remunerated far higher than the delivery of public health services. The latter
ironically touches the lives of millions.
Related to this is the third big challenge — how
to make sure that doctors serve the growing needs of the public sector when the
working conditions are rotten, plagued by overcrowding, meagre infrastructure
and a virtual absence of rewards and punishments.
Divergent Attitudes to Birth Control.
In the aftermath of the 1975 Emergency and the
odium of forced sterilisations, the emphasis on population control shrivelled in
most of North India. While countries like Korea and Iran which then had
fertility rates far higher than ours, embraced the joys of planned parenthood,
India dodged the subject. In 1994 the country adopted a target free policy and
the states were encouraged to implement a “cafeteria approach” while supplying
contraceptives.
However the southern states of Kerala and Tamil
Nadu unlike the rest of the country went full force to make family planning
their top-most priority. No matter which party came to power, political support
was there in abundance. In the mid- eighties the programme was spearheaded by no
less than the state Chief Secretary of Tamil Nadu, Mr.T V Anthony, (nick-named
Tubectomy-Vasectomy Anthony) which speaks for itself. With enthusiastic
politicians, civil servants and doctors joining hands, Kerala and Tamil Nadu
reduced fertility rates to equalise European levels. That was more than 20 years
ago. Meanwhile, North India (where most of the emergency driven sterilizations had taken place) recoiled from the very mention of family planning- a mind-set
that persists even to this day.
The Challenge of Reducing Maternal and Infant Mortality
There is a clear correlation between the health
of the mother and maternal and infant mortality. In the northern states more
than 60% of the girls and boys (respectively) are married well before the legal
ages of 18 and 21. The repercussions of early pregnancy and child birth have not
even dawned on the pair when they wed. The first child arrives within the year
when most adolescent girls are malnourished, anaemic and poorly educated. With
no planned spacing between the births, another child is born before the young
mother has rebuilt her strength or given sufficient nutrition and mothercare to
the first born. These are among the main causes of high deaths of young women
and infants. The chart and tables below clearly show the regional difference in
maternal, infant and child mortality. Narrowing the gaps poses one of the
biggest health challenges.
Regional Variations: Maternal Mortality Ratio* (MMR)
Extract from – Special Bulletin (June, 2011) on
Maternal Mortality in India 2007-09 (Sample Registration System) Office of
Registrar General, India
*MMR: Maternal deaths per 1,00,000 live
births
The regional variations in the deaths of mothers
in the states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Chattisgarh,
Odisha, Rajasthan and Assam show that the percentage of maternal deaths is 6
times higher than in the Southern states.
Source: Special Bulletin on Maternal Mortality in India
2007-09 (SRS, 2011) Office of Registrar General, India and Unicef SOWC,
2011
Taken together the EAG States and Assam account
for 62% of the maternal deaths. Schemes for nutrition, supplementary feeding,
literacy, the right to education and health care remain hollow expressions
without any meaning as long as women (and chiefly adolescents) have no control
over pregnancy. Unlike other South and South East Asian countries the use of IUD
and injectibles has not taken off in India -nor are these the thrust areas for
family planning anywhere in the country. Although long term, reversible methods
of preventing pregnancy are available, young mothers and children continue to
suffer or die. The challenge lies in bringing the issue to centre –stage and not
wait for incremental improvements to take place in the fullness of time. The
charts below show the colossal difference that has been achieved by the southern
states that invested heavily in family planning (albeit through the adoption of
terminal methods like sterilisation which can be avoided today.)
Source: Registrar General of India, Ministry of Home Affairs (SRS, 2011)
Source: Registrar General of India, Ministry of Home Affairs (SRS, 2011)
Health Management and Manpower Planning
The second challenge relates to a obsession for
exclusivity that has consumed the medical sector for too long. The Councils that
regulate education and register the practitioners (Medical Council of India
(MCI), Dental Council, Pharmacy Council, Nursing Council) were established with
laudable goals- to elect a cross section of doctors and other health
professionals democratically and to entrust to them the responsibility for
designing and executing professional corses. It was expected that the country’s
needs for professional health manpower would be met both qualitatively and
quantitatively. But because the Councils were constituted through a political
process of elections, the baggage of money, patronage and quid pro quos became a
predictable accessory. Today, gaining entry to professional colleges has become
highly commercialised-ultimately reflecting in the aspirations of the health
fraternity to reap back benefits from huge investments incurred. As the quest to
produce specialists and super specialists grows, the production of qualified
technical manpower has declined severely creating a mis-match which cannot be
corrected by people who work in silos and lack the understanding and vision to
think of the country’s health needs in totality.
The Challenge of Establishing NCHRH.
The neglect of public health is one of the
fallouts of the elitism that has pervaded medical education. Whereas cities and
towns at least have alternatives available- at a price- epidemics and acute
illnesses that occur in rural areas often leave people in the hands of fate. The
erstwhile elected MCI had relegated public health to the lowest rung of the
health hierarchy and the doctors that once decimated dreaded diseases like
malaria and smallpox are not to be found. The complement of technical staff,
nurses, pharmacists, dentists, lab technicians and operation theatre staff are
all in short supply outside the urban areas as the bodies that register them do
not work in tandem. More importantly no Council has a stake in health care of
any particular state- leave alone the country.
The proposal to set up a National Council for
Human Resources in Health (NCHRH), far from being a bureaucratic response was a
well thought out strategy having its roots in the recommendations of independent
think tanks and expert committees. The rationale for setting up such an umbrella
body was to see that the goals of health manpower planning, the prescription of
standards, the establishment of accreditation mechanisms and preservation of
ethical standards were served in a co-ordinated way, on the lines of structures
that operate successfully in other countries.
The Indian Medical Association in particular and
doctors in general have been arguing against the need for such a body because
they perceive it as a threat to their autonomy and a camouflage for political
and bureaucratic meddling. The fact that health manpower planning was simply
ignored, that there was a complete lack of coordination between the councils and
most important of all the fact that public health had become a low priority have
been overlooked in the fire and fury of opposing the NCHRH concept tooth and
nail. The challenge today is how to ensure that the health sector produces
adequate professionals as required for the primary, secondary and tertiary
sectors, both for the public as well as the private sector health facilities. If
the NCHRH Bill before the Standing Committee of Parliament does not see light of
day, the resurrection of the superseded scam-ridden MCI is a foregone
conclusion.
The Challenge of Allopathy and AYUSH.
Public health cannot be run on contract basis and
much less be farmed out to private insurance companies and HMOs (Health
Management Organisations) as a recent report on Universal Health Coverage seems
to suggest. Public health is squarely a state responsibility and particularly so
in a developing country. It has to go hand-in-hand with sanitation, drinking
water, health education and disease prevention. The National Rural Health
Mission (NRHM) which is a public-sector programme has registered an encouraging
impact in even the most intractable regions of the country. A UNFPA study has
shown that nearly three quarters of all births in Madhya Pradesh and Odisha had
been conducted in a regular health facility. The percentage of institutional
deliveries in Rajasthan, Bihar in Uttar Pradesh was lower but even so, accounted
for almost half the deliveries conducted in those states. Indeed these
achievements are immense.
Having said this, institutional deliveries alone
cannot be the answer to all the problems that beset the rural health sector. A
visit to any interior block or taluka in the Hindi belt states shows that most
primary health centres beyond urban limits are bereft of doctors, except
sporadically. Some state governments have taken to posting contractual AYUSH* doctors engaged under NRHM to man the primary health centres. These doctors
dispense allopathic drugs, prescribe and administer IV fluids, injections and
life-saving drugs, assisted by AYUSH pharmacists and nursing orderlies. This
reality must be confronted. If an AYUSH is doctor has been entrusted with the
responsibility of running a primary health centre, and found in shape to handle
the national programmes, the controversy over what AYUSH doctors can and cannot
do must be settled. The trend of AYUSH doctors working in as registrars and
second level physicians in private sector hospitals, clinics, and nursing homes
is wide-spread in states like Uttar Pradesh, Maharashtra, and Punjab; so also in
Delhi and Mumbai. The challenge lies in understanding what can be changed and
what cannot be changed, without getting intimidated by protests from Medical
Associations that will always protect their turf to retain primacy.
The Challenge of Retaining Doctors.
The most important concern by far is to decide
what kind of medical and public health cover is necessary and feasible to be
given to people living beyond the bigger towns and cities. If all general duty
doctors are making a beeline for post graduation- failing which opting for
management, administration and even banking jobs (because cities are better
places to live in,) the facts must be faced. Pursuing post-graduation, migrating
abroad and prospecting for jobs outside the medical sector cannot be stopped by
any Government. But fixed term requirements to stay bonded to the public sector
can certainly be insisted upon for state sponsored medical graduates. But
equally the working conditions, facilities and remuneration of such doctors
should be respectable. In the state of Jammu and Kashmir the compensation
given for working in more difficult areas has been graded. Such practical
solutions can greatly bolster doctor retention.
At the end of the day, the challenges of the
health sector can only be met if doctors, essential drugs and supporting staff
are available in the health facilities. The biggest transformation will come if
wriggling out of postings and manipulating things through political patrons
stops. The doctors will fall in line only if postings are notified through a
transparent and fair process and no exceptions whatsoever are allowed. Only the
state Chief Ministers and Health Ministers can make this happen. But will
they?
*
AYUSH refers to
Ayurveda, Siddha, Unami and Homeopathy medical systems supported by Yoga . The
status of Indian Medicine & Folk Healing can be seen in a publication by
the author at ;
http://over2shailaja.wordpress.com/category/a-report-on-indian-medicine/