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Book Review: Solving Healthcare Issues

The initial chapters deal with evolution of India’s health system, health financing and governance issues

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Even after nearly seven decades of Independence and a 8-9 per cent growth rate in the recent past, two-thirds of Indians do not have access to tap water and a clean toilet, over a third are malnourished, while a million-and-a-half children die before they turn five. Millions continue to die or suffer from communicable diseases such as tuberculosis, malaria, and other infectious diseases, which  are not only treatable but also at an incredibly low cost. Such systematic inequities necessitate the negotiating presence of a strong and assertive state.

The directive principles under Article 47, states, “the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”. Nowhere does India’s Constitution explicitly state health as a fundamental human right. Sujatha Rao, former Union Health Secretary, in her book, Do We Care? India’s Health System, has analysed the challenges facing India’s health system.

The initial chapters deal with evolution of India’s health system, health financing and governance issues. The second part of her book has a critical analyses of implementation of polices. The evolution of the health sector in India beginning with the Joseph Bhore Committee (1946) to the developments in the initial years after Independence and constituting the various Expert Committees to Alma-Ata Declaration (1978) and going on to the First National Health Policy in 1983 is appropriately described.

Rao argues that healthy people generate wealth and that ill-health and disease significantly impact the growth momentum. India’s 40 per cent young and productive population can be, and is, an enviable advantage, but only if they are healthy. Sick people do not produce wealth. Clearly, India’s tragedy has been its failure to provide access to fundamental public goods — clean air, safe water, sanitation, hygiene, nutritious food, and basic healthcare — and ensuring security to vulnerable populations from health expenditure shocks.

The cavalier manner in which health budgets were reduced by the Central government during the three years of the 12th Five-Year Plan (2012-17) exacerbates such apprehensions. Reduced public spending and the aggressive pushing of public-private partnerships can be a dangerous cocktail in these times.

The book also gives a vivid account of privatisation of medical education, as also nursing and allied services, which has grown exponentially since 1993 on account of three factors — liberalisation of the economy, fiscal crises and the insertion of Clause 10(a) to the Medical Council Act of 1956 that centralised all powers for the sanction of colleges, determining student strength, and introduction of courses in the health ministry. This reduced the role of the MCI to that of an advisory body.

In the chapter on primary healthcare, Rao highlights the need for both, Centre and the State, to expand their systems to co-opt talents and expertise outside the government, restructure their own organisations to meet the emerging challenges, and focus on laying down systems that provide stability and resilience to the organisation.

The author concludes that for two decades, India has been faced with an inability, bordering on paralysis, to take decisions and to provide a direction. The country’s public policy is confused and lost in its own rhetoric. On one hand, the government persistently denies any attempt at ‘privatisation’ of the health sector, while on the other, every policy helps in strengthening the private sector and weakening the public sector.

Rao is also quick to provide all the essential numbers in the book. For instance, she quotes that the 71st round of the NSSO survey estimates that the private sector provides about 58 per cent of care in rural and 68 per cent in urban areas and is growing at 15 per cent per year. The corporate sector is reported to constitute about 2 per cent of the private sector but provides three-quarters or more of tertiary care in urban areas and accounts for a sizeable amount of the money spent on healthcare. It is important to rein in the private sector to achieve the goal of improved health and reduced impoverishment.

Further, the government must ensure the Universal Health Coverage (UHC) to reduce impoverishment of individuals and families on account of medical bills. It has been argued that in the Indian context, efforts made so far to realise UHC have only strengthened the private corporate sector and the insurance industry. There is some truth in this assertion.

Having been associated as a medical professional with nearly four-and-half decades would no doubt like to endorse Sujatha’s study. However, if we were to improve the health status of the people of India, particularly, the impoverished, women and children, then we must put ‘systems’ in place in the healthcare delivery system in most of the states.

Making the community as partner in decision making will go a long way in addressing their health needs. A lot is being talked about against generic medicines by a section of the society. In fact, such strong decisions are required to reform healthcare in the country. There is no doubt that prescribing generic medicines instead of branded ones is a pro-people strategy. The bold move to demonetise the currency is an example for all of us to decipher. Let us not forget that over 70 per cent out-of-pocket expenditure by the people of India, particularly the impoverished section of society, goes to buy medicines and appliances, mostly branded.

Continued efforts by the governments, corporate houses, civil society and the people at large should be made to improve not only healthcare services but also the nutritional status of the women and children, water and sanitation, accountability, quality of healthcare and transparency of both public and private health institutions. More importantly, all this will fall in place once there is an overhaul of medical education system together with nursing as well as paramedical/technologists manpower development.

Disclaimer: The views expressed in the article above are those of the authors' and do not necessarily represent or reflect the views of this publishing house. Unless otherwise noted, the author is writing in his/her personal capacity. They are not intended and should not be thought to represent official ideas, attitudes, or policies of any agency or institution.

Ashok K. Agarwal

Agarwal is Academic Dean, International Institute of Health Management Research

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