People's Democracy

A Critical Look At Health Policy And Health Ministry Related Issues - II

Brinda Karat

A PROBLEM with the health policy is that of low or wrong prioritisation. For example, a most disturbing aspect of the national health profile is the widespread prevalence of vector borne diseases. Malaria continues to debilitate vast numbers of our population, particularly in tribal areas. Areas in the Northeast region are currently experiencing an increase in the numbers of malaria cases, including the more dangerous strains. A large number of deaths are taking place. Even the official figures, which are gross underestimates because most of the deaths go unreported, show that the incidence of malaria has increased in the last few years, as have the deaths. There were 1.8 million reported cases of malaria in the country last year but the blood examination rate was less than 10 per cent. The reported deaths which are a gross underestimate still show an increase from 963 in 2005 to 1441 in 2006, that is almost 4 people die every day of malaria. Incidences of all vector borne diseases like Japanese encephalitis, dengue and chikungunya are on the rise. The misplaced priorities of the government can be seen in lower allocations for disease prevention programmes over the last few years. Although TB was supposed to be eradicated we find from official figures that this is far from the case. Although the direct observed treatment (DOT) can claim some success, the incidence of drug resistant TB is still unacceptably high, requiring much more expensive drugs for treatment. The government has set up a national disease surveillance system to monitor the spread of epidemics and to take immediate measures. This is a welcome step; however, it is inexplicable why chikungunya and Japanese encephalitis have not been included in the list of diseases to be surveyed when in the last two years many states have been affected by these diseases.

The government appears to have set HIV/AIDS on high priority. It is indeed a matter of deep concern that only around 7 per cent out of an estimated 5.2 lakh HIV/AIDS affected persons are currently receiving treatment and the coverage should be expanded. But even as attention towards the prevention of HIV/AIDS is necessary, that attention should not come at the cost of the other disease control programmes. The allocation for the national AIDS control programme is Rs 720 crore in budget 2007-08, while the allocation for all the national disease control programmes taken together (which includes vector borne disease control programme, TB control programme, leprosy control programme, trachoma and blindness control programme, iodine deficiency disorders control programme, integrated disease surveillance programme and drug de-addiction control programme) is only Rs 884 crore. The international health agenda is dominated by the control of HIV/AIDS and major funding from international agencies like USAID and Bill Gates Foundation comes into that area, but surely it is for the Indian government to ensure that the other disease control programmes which are equally important for our country are not underfunded. Especially, the allocation for vector borne disease control programme needs to be much higher than what it currently is, if it has to make a difference.

Another example of lopsided prioritisation is the deteriorating record of the universal immunisation programme for children. At present, out of every 100 children who require immunisation only 47 are immunised under this programme. This clearly reflects a dismal picture. Researchers in public health as well as those working in the field have expressed apprehension that the pulse polio programme, which continues to be a vertical programme, has not only not succeeded in eradicating polio but has actually taken attention away from routine immunisation. The allocation for routine immunisation is only Rs 300 crore in budget 2007-08 while the allocation for the pulse polio immunisation programme is Rs 1289 crore. It is essential to give as much more importance to routine immunisation as the government is currently giving to the pulse polio programme.

JANANI SURAKSHA YOJANA

The Janani Suraksha Yojana is a new and important scheme of the union Health ministry under the NHRM. It is a welcome scheme to give incentives for institutional deliveries, which at present are only around 32 per cent of total deliveries. This is expected to bring down the MMR. However, there are two basic flaws in the scheme. Firstly, it is restricted to over 19 year old mothers only. While it is desirable to have a situation where the consciousness of the society is raised so that children are not born to mothers below 19 years of age and that the anti child marriage legislation is implemented, it needs to be recognised that the present realities are such that a large number of women between the ages of 16 to 18 do give birth to children. These mothers often do not have a choice, either in terms of their early marriage or in terms of childbirth. While initiatives to prevent child marriages and promoting later childbirth should be intensified, excluding pregnant women below 19 years from institutional deliveries is an unjust punishment to them. The scheme is restricted to the birth of only the first two children. This is another attempt to punish the mothers for circumstances which are often beyond their control. Denying institutional deliveries to mothers for the birth of the third child is another unacceptable measure of population control. Such a policy victimises women. These provisions need to be removed from the scheme if its main goal of lowering the MMR is to be achieved. Objectives like prevention of child marriage, underage pregnancy or family planning should be pursued through the existing channels and not by introducing unjust provisions in the Janani Suraksha Yojana.

When this issue was raised in parliament the minister assured the house that he would reconsider the scheme to make it more inclusive.

STATE OF THE PUBLIC HEALTH SYSTEM

The public health system comprises a three tier structure — the primary structure with sub-centres and primary health centers (PHCs), the secondary sector with community health centers (CHCs) and the tertiary sector with big public hospitals. These centers are supposed to be based on a certain population norm but shockingly the central government in many cases is still using the 1991 population norm to fund the sub-centres and the ANMs. The minister assured parliament that the norms are being changed and that the centre would increase funds for ANMs.

NORMS

Sub-centres 1 per 5000 population in general areas and 1 per 3000 population in tribal areas
Primary health centers: 1 per 30,000 population for general areas and 1 per 20,000 for tribal areas
Community health centers (hospitals) 1 per 1.2 lakh population in general areas and 1 per 80,000 for tribal areas.

Today all the three sectors are in shambles in most parts of the country. According to the rural health infrastructure bulletin 2006, there is a nationwide shortfall of 20,903 sub-centres, 4803 PHCs and 2653 CHCs. Moreover, 21 per cent of sanctioned posts for doctors are vacant, 39 per cent of PHCs had no lab technicians and 18 per cent had no pharmacists. In the CHCs, 54.4 percent of all sanctioned posts were vacant. In many places particularly in remote tribal areas the centers exist only in name.

The truth is that many of our trained personnel do not want to go and serve in the villages. We support the recommendations of various government committees that internships should include a mandatory term in rural areas as also other suggestions like incentives etc., for rural postings. The key to improve functioning of PHCs, however, is to ensure necessary infrastructure through proper buildings and availability of medicines and equipments. It is only through a combination of such steps that compulsory rural postings can be implemented. But equally important is the urgent necessity to increase the numbers of doctors, nurses and auxiliary nurse midwives (ANMs). This is an aspect that is ignored by current approaches by the government. It seems to have abdicated its responsibility of providing opportunities for medical education to the private sector.

Today 80 per cent of medical colleges are in the private sector, which are concentrated in 5 states. Students pay huge capitation fees to get admission. Someone who has paid 20 lakh rupees as admission fee is unlikely to be willing to go to a remote village to serve the poor. What is required is a huge investment to start government medical colleges. At the same time a separate legislative initiative is required to control the exorbitant fees being charged by private colleges. Similarly, in spite of the huge demand for nurses there are only about 200 odd government run nursing schools, the rest being in the private sector. The government needs to ensure affordable training for nurses in order to meet the gap. The third aspect is that of training schools for ANMs. At present if each sub-center is to have two ANMs we need at the very least one lakh ANMs. For this it is essential to have training schools at the district level. This will also encourage tribal or dalit women from the community so that they will stay on in the village and meet the health needs. They should also be encouraged to join nurses training. West Bengal has a positive experience in ANM training and recently 70 training schools have been set up to meet the demand. It is only through a conscious effort to increase the number of medical cadres at all levels that the public health system can be revamped.

We must extend our appreciation to all the doctors and medical personnel who continue to work in the government sector and in government hospitals in spite of the tremendous difficulties and drawbacks. Some of the finest doctors are practicing in hospitals like AIIMS taking on huge workloads and caring for their patients, whether they are the poor or affluent. It is necessary for the government to improve the working conditions and extend other facilities to all government hospital personnel.

Recently AIIMS has been in the news for the wrong reasons. It became a centre for the anti-reservation agitation. A recent report of the Thorat committee has highlighted casteist practices against dalit students. It is essential to take remedial action to protect the rights and dignity of dalit students. At the same time, the autonomy of the institution must be protected and as the Supreme Court which intervened in the matter commented ‘the minister and the director” should act in the best interests of the institution.

(To be continued)