People's Democracy

(Weekly Organ of the Communist Party of India (Marxist)


No. 22

June 03, 2007

A Critical Look At Health Policy And Health Ministry Related Issues


Brinda Karat




Every seven minutes, a woman dies in India in a maternity related death. Fifty children below the age of five die every half hour. These deaths are certainly avoidable. The UNICEF has calculated that there are at least a million avoidable deaths of under five year old children in India every year. There is something seriously wrong with a system, which has such a high rate of avoidable child deaths. Next year will mark the 30th anniversary of the International Conference on Primary Healthcare held in Alma-Ata, where a declaration was adopted to which India was a signatory. It made a commitment to adopt policies to achieve “health for all”. It defined health in the following terms: “health, is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity, health is a fundamental human right and the attainment of the highest possible level of health is a most important social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector.” Thirty years down the line, despite somewhat similar sentiments repeated in the National Health Policy of 2002, we have failed in practice to live up to that commitment.


Problems with Present Health Policy


In a recent debate in parliament on the health policy of the UPA government and a scrutiny of the working of the Health ministry several important issues were highlighted. After the debate the minister also made some assurances that need to be followed up. An important aspect that could not be discussed in detail was that of the high prices of drugs and the continuing defiance of any drug price control regime by big pharma companies assisted by certain sections in government. This is because the matter is under the jurisdiction of a different ministry. It will require a separate discussion.


Tame Delinquents in the Private Health care Industry


There are two basic features of the current health scenario in India. The first is the fast growing private sector in health including the entry of corporates, MNCs and the trend of big pharma companies setting up hospitals. On the other hand there is the highly inadequate, understaffed, public health sector.


Healthcare is increasingly going out of the reach of the poor. It has been assessed that 40 per cent of all patients admitted to hospitals have to borrow money or sell their assets including land in order to meet medical expenses. Next to dowry, health expenses are the biggest reason for debt. It is also estimated that 25 per cent of farmers are driven below the poverty line because of health expenses. India is one of the countries, which has the highest out of pocket expenditure on health, around 82 per cent of all health expenditure. Most people have to go to private doctors and hospitals to get treatment. The primary motive for the private players is not to make healthcare affordable for all but to reap profits. The slogan of health is wealth has been transformed into ill-health is wealth for a section of those providing medical services. Despite the mushrooming of the private players in healthcare, government regulation in the sector has been virtually absent. The healthcare institutions in the private sector get concessions from the government in the form of land, tax relief and lower charges for basic utilities and in return they are supposed to provide a percentage of free beds for the poor. However, none of the private hospitals implement this. An example is the PIL in the Delhi High Court resulting in a landmark judgement by Justice Qureshi. The top 20 private hospitals in the national capital had been given big concessions on certain conditions of providing free services to the poor. Not a single one of these hospitals, many of which were registered as trusts and charitable hospitals had complied with the conditions. The judgement made a sharp indictment and called upon the government to strictly ensure compliance. However this has not happened and on the contrary the health policies being followed are an abdication of responsibility of ensuring that the private hospitals live up to their commitment of serving the poor by setting some uniform standards for private hospitals without which no registration will be allowed. While exploitative commercial practices are rampant, there are no rules and laws to take action against the delinquents. This is a grave distortion in the present health policy, which needs to be rectified. The private sector in health needs to be tamed, to be made socially accountable but regrettably, the health policy in the name of public-private partnership actually protects and pampers the private health sector.


National Rural Health Mission


The National Common Minimum Programme (NCMP) of the UPA government adopted in 2004 took the NHP forward through a commitment to raise the expenditure on health to 2-3 per cent of the GDP. The following year the National Rural Health Mission (NRHM) was adopted, which was an important initiative to converge and coordinate the myriad health schemes through a process of decentralisation and increase in community participation thus replacing the vertically programmed model. It is too early to make a detailed assessment of the NRHM. There are surely some welcome aspects of the NRHM, especially the shift away from equating health with population control, an effort to bridge the urban-rural gap and the emphasis laid on building infrastructure for the public health delivery system.


However, there are some areas of concern like the issue of user fees for health services, which is sought to be imposed as a conditionality during the discussions with state governments over signing MoUs. Although in the course of the debate the minister made a categorical assurance that the RHM does not envisage the levying of user fees on any of the services, in reality this is what is happening. For example the main role of the Rogi Kalyan Samitis which was conceptualised as an avenue for community participation, has actually turned out in some states to be a committee to increase the financial viability of the Primary Health Centres (PHCs) and hospitals by suggesting the different types of user fees that can be levied! This goes against the interests of the poor. It is a travesty of the “health for all” concept to introduce user fees when the majority of those who use the public health system do so because they cannot afford expensive private healthcare.


Another issue that was raised in the debate was that of the role of ASHA (Accredited Social Health Activists). She is seen as the crucial link to provide community access to health services and also as a para-health worker. Although more community based health workers are needed, the conceptualisation of ASHA is problematic. She is at the bottom of the ladder after the ANMs and the anganwadi workers, themselves victims of exploitation. At the same time the role of ANMs is being neglected and ASHA is being posed almost as a substitute. It is essential to work out a mechanism for an integrated and comprehensive approach for ANMs as well as ASHAs. While she is expected to do a whole range of jobs, no allocations have been made for her remuneration by the government. Either it is expected that the ASHAs would provide free labour for the community or it is envisaged that she would collect user charges from those accessing health services. The burden of the entire community health sector is thus on the frail shoulders of an unremunerated ASHA! This is not only unjust but completely untenable. The minister in his reply did assure parliament that provisions had been made for the payment of ASHA but this is an aspect that needs to be checked in the different states. Reportedly 3.5 lakh ASHAs have been selected and 2.25 trained. It is necessary to make contact with this vast women workforce and help them in every possible way.


Another problem with the present health policy is that in the name of strengthening rural health services, urban health services have been completely ignored. A huge influx of migrant workers continue to take place from rural to urban areas, who are forced to stay in urban slums where access to health facilities is as bad as in rural areas. The present health policy has no separate plan for urban health, but it is put under the general allocation of flexible programmes. It is essential for the union Health ministry to plan proper schemes for urban health.


Neo-liberal Policies also Responsible


Besides the glaring problems with the existing health policy, there also exist a huge gulf between policy declarations and their implementation. While the official explanations of corruption and inefficiency of the public service delivery system is valid to a great extent, the basic problem lies elsewhere. The present policies, which in their origin and approach owe more to World Bank prescriptions of neo-liberal reforms than to the Alma Ata declaration on universal healthcare, has a built in bias towards withdrawal of the state from its responsibilities and reposing faith upon private initiatives to deliver the goods. Health is not just about disease, drugs and doctors but about ensuring the basic parameters of health linked to nutrition, food security, clean drinking water, housing, proper sanitation and a pollution free environment. The neo-liberal policies being pursued by the government are yielding outcomes, which far from meeting these goals are aggravating the situation. Rather than leading to health for all, neo-liberal policies are causing hunger and deprivation and therefore ill-health for a larger number of people. The recently released NFHS-III data show that one third of all women in India have a lower than normal body mass index. 56.2 per cent of all women and 58.2 per cent of rural women suffer from anemia. The number of pregnant women who are anemic has increased by 8 percentage points since the last survey to 57.9 per cent. When pregnant and lactating mothers suffer from high anemia, it is not surprising that the number of infants between 6 to 35 months who are underweight is also a whopping 79.2 per cent, up 5 percentage points since the last survey. The data also shows that the worst affected are tribal women, followed by dalit women and others from the backward sections. They constitute the poorest; most deprived and exploited sections of our people.


The union Health ministry is currently running a campaign to encourage breast-feeding for children that it is important for the health of the child. No one will deny this. However, the Health ministry should be asked how anemic mothers can breast-feed their children unless their anemic status, which is a direct outcome of malnutrition, is alleviated? Over and over again women are being made to feel guilty — you are not breast-feeding your baby, it is your fault that infant mortality rates are so high and so many babies are underweight. The main issue of food insecurity and malnutrition among women is conveniently bypassed. The maternal mortality rates in India are extremely high at 301 deaths per lakh live births, much higher than China at 56 and Sri Lanka at 92. But even these high MMR rates in India constitute just 11 per cent of deaths of women of the same age group. Most women die of other equally avoidable diseases related to anemia and malnutrition. It is a shameful reality that food subsidy is sought to be curtailed by successive union budgets in this backdrop of hunger and malnutrition and the public distribution system being dismantled rather than moving towards its universalisation as promised in the NCMP.


This is a prime example of how neo-liberal policies are creating a chasm between declared health policy objectives and ground realities. Without a sound universal food security policy one cannot ensure the prerequisite for good health. The same goes for the absence of drinking water. Stomach ailments, particularly diarrhoea, are among the worst fallouts of the failure to provide safe drinking water for people living in urban slums and in the poorer parts of rural India. Millions of people every day are afflicted with water related and water borne diseases. Children are particularly badly affected: of all the millions of children under 3 who require oral rehydration only 26 of every 100 children affected received the treatment last year. Inadequate resource allocations have prevented the government from ensuring access to drinking water for large segments of the population.


( To be continued..)